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Home My WebLink AboutApplication and WC , �-�1'�`^�v�`�`��"W1JE _ , � TOWN OF YARMOUTH BOARD OF,HEALTH ; , J � � r� APPLICATION FOR LICENSE/PERMIT - 20�6 r r� r� ;t� .� �1►��; � � �� `"'` * Please complete form and attach all necessaky doc�men.tss b�Z?ec ' ber 1 S 201 S. Failure to do so will result in the return of your application pa ketH�;qLT3-I DEPT. ESTABLISHMENT NAME: ' TAX ID: - LOCATION ADDRESS:�a,1�� (��c.a.& � TEL.#: 5pt�-3� - MAILING ADDRESS: 'Z Cc.�rt-�� S�- S. �c�Src�r� �,� d a.�-t�- E-MAIL ADDRESS: wv.�. OWNER NAME: ` � e. CbRPORATION NAME (IF APPLICABL ): MANAGER'S NAME: �'�aw� ��,��,g n TEL.#: 50�-a,'�d-�_ MAILING ADDRESS:'LC.e,rt-�o�� -r-.� ��kS�con,�,� p�3Z�- POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. I. ��,___o,`�b ��:��\�fL. 2• Pool operators must list a minimum of two employees currently certified in standard First Aid and Community Cardiopulmonary Resuscitation (CPR), having one certified employee on premises at all times. Please list the employees below and attach copies of their certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. l.��a►��b)U\ h� • _ 2. ( .A a�.p�c._�� `Q 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years'records. You must provide new copies and maintain a file at your establishment. L 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. i _ _ _L t�LL,�RGEN CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who has Allergen certification, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.009(G)(3)(a). Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment. l. N�� 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. L 2. 3. 4. RESTAURANT SEATING: TOTAL# __ _-- - --- __ _ _ __ __._____ _ - - - _ _---_ _ _------ - _ OFI+'ICE USE ONLY"- --- - LODGING: LICENSE REQUIRED FEE PERMIT# L[CENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE P RMIT# _B&B $55 CABIN $55 �MOTEL $110 6—d�- _[NN $55 CAMP $55 �SWIMMING POOL$110ea. � _LODGE $55 _TRAILER PARK $105 WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 _CONTINENTAL $35 NON-PROFIT $30 _>100 SEATS $200 _COMMON VIC. $60 WHOLESALE $80 —REStD.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 =<25,000 sq.ft. $150 _FROZEN DESSERT $40 _TOBACCO $110 NAME CHANGE: $�s AMOUNT DUE _ $ 22.-0•OO *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** ADMINISTRATION � Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR i � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED V Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES �� NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be limited to the temporary and short term occupancy,ordinarily and customarily associated with motel and hotel use. Transient occupants must have and be able to demonstrate that they maintain a principal place of residence elsewhere.Transient occupancy shall generally refer to continuous occupancy of not more than thirty(30)days,and an aggregate of not more than ninety(90)days within any six(6)month period. Use of a guest unit as a residence or dwelling unit shall not be considered transient. Occupancy that is subject to the collection of Room Occupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient. POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. Contact the Health Department to schedule the inspection three(3) days prior to opening. PLEASE NOTE: People are NOT allowed to sit in the pool area until the pool has been inspected and opened. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, and submitted to the Health Department three (3) days prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE SEASONAL FOOD SERVICE OPENING: All food service establishments must be inspected by the Health Department prior to opening. Please contact the Health Department to schedule the inspection three (3) days prior to opening. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health Department,or from the Town's website at www.varmouth.ma.us under Health Department, Downloadable Forms. FROZEN DESSERTS: Frozen desserts must be tested by a State certified lab prior to opening and monthly thereafter,with sample results submitted to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. OUTDOOR COOKING: O��tc�oor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. NOTICE: Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 15, 2015. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROV THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE IT N. DATE: 3-3- \�o SIGNATURE: PRINT NAME & TITLE: � e-ti- Rev. 10/O1/15 '4�� CERTIFICATE OF LIABILITY INSURANCE °A�`M""°°""�", 3/3/2016 THIS CERTIFICATE 15 lSSUED AS A MATTER OF INFORMATION ONLY AND CONF�RS NO RIGHTS UPON THE CERTIFICATE HpLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMENO, EX7ENb OR ALTER THE COVERAGE AFFORDEU BY TNE POLICIES BELOW. THIS CERTIFICAT� OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHaRIZED REPRESENTATlVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies)must be endorsed. If SUBROGATkON IS WAIVED,subject to the terms and conditions of the policy,certain poficies may require an endorsement. A statement on this certfficate does not confer rights to the certificate holder in lieu of such endorsement(s. PRODUCER NAME: JUd1 March Risk Strategies Company PHONE - - '�B1 961-0325 �� _lAl4.Ha.�n: t � _;�aC,NO); (7B1)336-4420 15 Pacella Park Drive E-MAII �rch@risk-strate $ult.�3 24O ADDRE$S;�_ __ Q;63.COm {NSURER(S1AFFORDINGCOVERAGE � NAIC# . . ._._.— ---"- .......---.._s Randolph I� 02368 __ INSURERA:Travelers Indemnity Co 25658 --------- �-----------... .. . , INSURED INSURER B:We3CO IAS. CO. _._ -..._..... _ —. --- 1261 Bass River Realty LLC INSURERC: _....�----...... _ ... ; _ dba Yaratouth Beach n' Towne Motel INSURERD; i ._,_...---- - _.... Rt9 28 INSURER E: I ----._. _----.. --- W. Y$TIDOLittl MA INSURER F: COVERAGES CFRTIFICATE NUMBER:CL763309256 REVISION NUMBER: THIS tS TO CER7IFY THAT THE POLICfES OF INSURANCE USTED BELOW HAVE BEEN ISSUED TO 7HE INSURED NAMED ABOVE FOR THE POLICY PERIOD INOICATED. NOTIMTHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY COWTRACT OR OTHER DOCUMENT WI7H RESPECT TO WHfCH 7H15 CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICfES DESCRIBED HEREIN IS SUBJECT T4 ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LlMITS SHOVYN NlAY HAVE BEEN RE�i10ED BY PAID CLAIMS. INSRj `---- --......... ...A�OLSUBTY . ._. —_ . . ........ . .._---. LTR 7YPE OF INSURANCE POLICY NUNBER MMlLI7�1'EFF PMIICY EXP «��TS � X �COMMERCIAL GENERAL LtABIUTY EACH OCCURRENCE ,$ 1,000,000 _., ; i DAMAGE 7Z?RENTEb A ; I CLAIMS•MADE : X � OCCUR pREMISES(Ea ocwR@ncel_ �„S 300,000 i 6608609N4G7+TCT15 i 8/3/20I5 j 8/3/2016 MED EXP(My one�erson) i� 5�000 .� .. . ____.... I ' i ! PERSONAL 8 ADV INJURY 'S 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER' I � - `� _._._....__--- __.... � GENERALAGGREGATE $ 2,000,000 PRO- i ' ----. . ... �,X PaLICY I !JECT .„___ �4C ' ' � PRODUCTS-COMPlOP AGG $ 2,000,000 OTHER: ---�--- $ AUTOMOBILE IIABILITY BINED SINGLE LIMIT s (Ea accider�t) _ —... . _ _..._... ANY AUTO 60OlLY INJURY(Per p6Bon} $ ' ALL OWNED SCHEDULED - "'�-----'-� ---��•� � �-� �._.,AUTOS AUTOS BODILY INJURY(Per acci6eM) S � HIREO AUTOS p�N g�E� ' PROPERTY DAMAGE S f i � ; .(Per x�ident). -------._..._.. S UMBRELLA UAB � OCCUR � I ' ; EACH OCCURRENCE 3 � EXCESS LIAB ; ......-------.. ..._ .. ___ I CLAIMS-MAOE � AGGREGATE S i . . ....._. -----.._............ .. DED RETENTION S ' E W�RKERS COMPENSATIQN PER O H- ;AND EMPLOYEFt,S'LIABILITY Y!N � : STATUTE__...... .ER IANY PROPRIE70RfPARTNERrEXECUTIVE � � - -� B �OFFICERlMEMBER EXCLUDED? ;N I A. f.l.EACH ACCIDENT _$ 100�000 (Mandabry in NH} WWC3Q98440 B/6/2U15 8/6/2016 E.L DISEASE-EA EMPLOYEE S 100,008 1f yes,describe under ... �DESCRIPTION OF OPERATIONS below E.L.OISEASE-POLICY LIMIT $ SOO O00 I � I I DESCRIP710N OF OPERA710NS!LOCATI�NS!VEHICLES (ACORD 101,Additional Ranarlce Sehedula,rnwy be attachod H more space Is requlrad) Re: Yarmouth Baach n'Towrse Motel, Rte 2B, South Ysrmouth Ma CERTIFIGATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POIICIES BE CANCELLED BEFORE Board of Health THE EXPIRATION DATE FHEREOF, NOTiCE WII.L BE DELIVEREO IN South Yarmouth, MA ACCORDANCE WITH THE POLICY PROVISIONS. AUTHOfi1ZED REPRESENTATIVE Michael Christian/JUM -�'"-'"�-^�"-� <'_'...d'-j��.-.�':'-�=, 01988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(20�4107) The ACORD name and logo are registered marics of AGORD INS025�zo,eaiy � . � The Commonwealth of Massachusetts Department of Industrial Accidents � Office of Investigations ' ' I Congress Street, Suite 100 Boston,MA 021I4-2017. www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Auplicant Information Please Print Le�iblv Business/Organization Name:�� <<,��Q,t,�t �_� � �4ddress: �� b u.rc.._ �&. City/State/Zip: Phone#:�-��39$—�3 l� Are you an employer? C eck the appropriate bo�: Business Type(required): 1.� I am a employer with�employees (full andl 5. ❑ Retail or part-time).* 6. ❑ RestaurantBarBating Establishment -- _ 2. I am a sole proprietor or partnership and have no �. � Office and/or Sales(incl.real estate, auto,etc.) employees working for me in any capacity. [No workers' comp. insurance required] g• ❑Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4),and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]* 11.❑ Health Care 4.❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.�I Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#L I am an employer that is providing workers'compensation insurance for my employees Below is the policy information. Insurance Company Name: G.-1- � �^rs�►�� T•;_��n Tn� ('�� Insurer's Address: 1,'S' 't'q,C.��Q �k, � c�� ,��i rt-e ��.(� City/State/Zip: �l�o�,n�e� �� n� la Sc- � � �--- Policy#or Self-ins. Lic. # W3��'�� t,1(1 Expiration Date: �!�- I(n Attach a copy of the workers' compensation policy declaration page(showing the policy number and ezpiration date). Failure to_secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the O�ce of Investigations of the DIA for insurance coverage verification. I do hereby certify,under thepai enalties ofperjury that the information provided above is true and correct. Si ature: Date: - ) Phone#: Official use only. Do not w te in this area,to be completed by city or town officia� City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2. Building Department 3. City/Town Clerk 4.Licensing Board 5. Selectmen's Office 6.Other Contact Person• Phone#: www.mass.gov/dia