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Home My WebLink AboutApplication and WC ' � ' G3CL�C� Cop i � ► TOWN OF YARMOUTH BOARD OF HEALTH ' � � APPLICATION FOR LICENSE/P - 0 � �.. �. NOV ��0 20�15 .tfa . "'"' * Please complete form and attach all necess �,� �' er 1 S 201 S. ; ' Failure to do so will result in the return ' ��yo �i 'a o' � et. HEALTH DEPT. ' .�{c�u.Y�R€�i�RT C �W�C:��t�. �.; ; ESTABLISHMENT NAME: L--� � � '�i� TAX ID: I LOCATION ADDRESS: ( Z �M S\ l� •�` �J� TEL.#: � l CQ Cv� MAILING ADDRESS: �i--"�-+v'�L--�GC-- � �— t^� ✓�—' E-MAIL ADDRESS: ��=�� • c�✓�/� � OWNER NAME: 'C- � � � CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: �(�=��'�d� C^�- ` �`'� TEL.#:cjb '('�� C9Co Z� MAILING ADDRESS: '�S PbOL 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. ____ �€'.D.--v G �_,�_�� --_v. � r-c�.:_� - _ � _ - �------ - - � , _ _. i i 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. 1.' �'C�;��'� L�`,..��-z.-��. 2. ��`L �e� �►2-��-�� 3.� 1��J�'tL- �r- ��'7�� 4. �.CS-�s-�'-� �� v� w`J� 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 appli ation. The Health Department will not use past years' records. You must provide new copies and maintain file at your establishment. 1. 2. f PERSON IN CHARGE: I Each food establishme t have at leas ne P on In Char (PIC) on te during h s of operation. 1.�, _____—_ — - 2• - ALLERGEN CERTIF TIO All food service estab s ents require to have least on ll- ' e empl ee who has Allergen certification, as defined in the State itary Co for F d Servi Establi ts, 105 C 590.009(G)(3)(a). Please attach , copies of certification o is applic ion. e Heal Depart ent will not us ast years' records. You must provide new copies d aintain ile a your es blishm L HEIMLICH CERTIFIC IONS: All food service establi ents with 25 seats or mo must have at least one employee trained in the Heimlich Maneuver on the premis at all times. Please list yo employees trained in anti-choking procedures below and � attach copies of employee ertifications to this form. e Health Department will not use past years' records. You must provide new copies and maintain a file a our place of business. l. 2. ; 3. 4, � RESTAURANT SEATING: TOTAL# � _ _�__ n��rr+� 7rc� n�ri�,._ _ � v__�m-�-�-� - ---- __ --- - -- LODGING: � LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE P RMIT# _B&B $55 CABIN $55 �MOTEL $110 I�—OZ� _INN $55 CAMP $55 �SWIMMING POOL$1 l0ea. �0�� _LODGE $55 _TRAILER PARK $105 �WHIRLPOOL $ll0ea. _ FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# L[CENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 _CONTINENTAL $35 NON-PROFIT $30 _>100 SEATS $200 _COMMON VIC. $60 WHOLESALE $80 —RESID.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. $I50 _FROZEN DESSERT $40 _TOBACCO $1 l0 NAMECHArrcE: $is � � AMOUNTDUE _� � �� *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** i � �f � � 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 1NSURANCE ATTACHED � OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth t�es 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 � i 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 thirly(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. f 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 Iab, 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�vithin 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�orm 72 hours prior to the catered event. These forms can be � obtained at the Health Department,or from the Town's website at www.xarmouth.ma.us under Health Department, Downloadable Forms. � FROZEN DESSERTS: i Frozen desserts must be tested by a State certified lab prior to opening and monthly the�eafter,with sample results ! submitted to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen j � Dessert Permit until the above terms have been met. i OUTSIDE CAFES: I Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. I OUTDOOR COOKING: Outdoor 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. l ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: SIGNATURE: PRINT NAME& TITLE: Rev.10/O1/15 i 1 fA:t� i�ternationai io:t�K.'�I/Hol ly Iree for lown oF Yar�outh t�t:'t! 11/'t4/l5 tl Pg s-s Ctiern.#:97607 H�LlYTREEC I ACORD� CERTtFfCATE OF �IAB[L[TY fNSURANCE oarEfixee,r�roarvrvv� 1 U2M207 5 THIS CERTIFICATE fS ISSUE€3 AS A N44TTER OF INFORMAFtON ONLY AHD CONF£RS NO RIGHTS UPON THE CERTlFICA7E HOLDER.THIS CERT1FlCATE QOES NOT AFFIRMATIVELY OR NEGATIVfLY AMEND,EJCFEND OR ALTER THE COVERAGE AFFORDED BY THE POLICtES BE��fU.THIS CERTIFICATE OF IMSURANCE DOES NQT CONSTiTUTE A CONTRAC7 BETWEEAI TiiE iSSUING INSURER{S),AUTHORiZED REPRESENTATiVE 8R PftOQUCER,AND THf CERTlFICATE HOLUER. IMPORTANF:tf the certificate holcler is an AD[31TlONAL INSURED,tfie po3lcy(ies}must be endorsed.[f SUBItOGATEON IS WAIVED,subject to the terms and condltions of Ehe policy,certain policies may requ3re an endorssmetrt.A statement on this cert�cate does not confer r}ghts to the cer#lficate hotder in lieu of such endorsemen#{s}. rrsoouce� Na�rE: HUB Intemational New England FfUB Mternatianat New Engiand P��:g78 657-5100 �: 978-988-0038 299 B�lardvale St nee.certificates�,►hubintema#ional.com wlmingto�t,MA 018$7 nooaEss: 978 657-5100 fN3URER{S)APFORDING COYERAGE wn�c u �suReaa:Granite State Ins Co x�su�o Hoily Tree Condo[WC} �S�RER B: AtEn: Brian M.0'Heam NiSURER C: 4f��1I1.SitfL�t lNSURER 6: West Y�rmauth,MA 42673 �iS�RER E: INSURER F: ��S CERTIFICATE NUMBER: REVi$!ON NUMBER: THIS IS TO CERTlFY THAT THE POLICtES dF INSURANCE LISTED BELOW HAVE$EEN iSSUED TO THE tiVStSRED NAAAED ABOVE FOR THE PdtICY PERIOD INDICATEd. NOTWITHSTANDING ANY REQUIREMENT, TERM O€? CONDlTIOlQ OF ANY CONTRACT OR OTHER DOCUMfNT WITM 12ESPECT TO WHICH THIS CERTIFICATE MAy BE ISS[1ED OR MAY PERTAIN, THf INSURANCE AFFORDE� BY TNE POL�CIES DESCRlSED HERElN IS SUBJECT 70 HLC THE TERMS. EXCLUSIONS AND COND!'FIONS OF SUCH POLICIES. LINflTS SFl�WN MAY HAVE SEEN i�EDUCED BY PAID GtAiMS. �� FYP£8f NJSURANCE D� 8 P�pY fFF P�OL��Y EXP �,p�tT3 IMSR WVD POLICY NUMBER GEkERAL LIABFLtTY EACH OGCURRENCE $ CflMMERCIAL GEN€RAL LIABFLITY f�R�W��E�$ R€aT�E�� $ E� CtA1MS-MA6E �OCGUR MEa EXP�any a�e person} $ PERSONA�&ADV{NJURY E GENERALAGGREGATE $ GEN'L/�GGREGATE LIMIT APPLtES AER; ARODtlCFS-COMF/4R AGG $ POIfCY PRO- JECT LOC g AUTOMOBtLE LIABFLITY MBlN£€J StN6LE LEMfF Ee accideM $ ANY AUTO 90DILY tN3URY(Pet personl $ Al:L OWN£D SCH£DUtED AU70S AUT4S SODELV INJURY{per accident} $ HIREQAUT6S NOhLOWNED AROPERTYQAMAGE $ AU70S Per aCCident $ tJMBRELLAlfAB � OCCUR . EACNOCCURREPICE �� $ .� EXCESS LIAB CLAipAs-p�ADE AGGREGATE S DED RETENTfON 5 S A WORKERS COMPENSATION WG003fi�3399 8l01l2015 08/fl1t201 Wc s�"T�_ °T"- ANO EMPi0YER3'LU46€LITV RY tT ' ANY PkOPRiE70R/PARTN�RlEXECUFIVE Y�� E.L.EACH ACCS�NT $.�100 OOIJ � OFF CERlMEMBER EXCLUDEO? � N 1 A (MoRdatary in NH) E.L.DISEASE-EA EMPlOYEE $JW)UOO ( ff yes.desctibe uixler 6ESCRlPTtON OF OPERATIONS beicw E L DISEASE-POLICY LlMtT $rJ{IE}OOO � i OESCRIPTtON OF OPERpTlONS t LOCATIONS!VEHICIES[Attach ACOR0191,Additlond Remarka Schedule,if mon apsce fa requ€red� �� No.of Days; 10 i i f ! CERT[FICATE HOLDER CANCELLATION i Town of Yarmouih SHOULD ANY OF 7ME A80V£DESCRIBED FOtIClE8 BE CANCELLEQ 9EFORE 'I'I�R017�@ 28 T�E £iCPIRATION DATE THEREOF, NOTICE iNILL BE DELtVERED C�! ACCO#tDANCE WiTH YIiE POL(CY PR�VISIONS. South Yarmouth,MA fl2664-0000 AUTHORIZED REPRESENFATIVE O 1588-2018 ACORD CORPORAT[ON.All rights reserved. ACOItD 25(2070t45} � p�� The ACORD name and lego are reg€stered marks of ACORD #S1498898/IIA1496895 CW049 � � � � The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ` 1 Congress Street, Suite 100 Boston,MA 021 i4-2017 www.mass.gov/dia ' Workers' Compensation Insurance Affidavit: General Businesses Applicant Information - Please Print Le�iblv � Business/Organization Name: HOLLY TREE CONDOMINIUM TRUST dba HO .i.Y TR F. RF.S(1RT Address: 412 Main Street, Route 28 f City/State/Zip: West Yarmouth, MA 02673 Phone#: 508-771-6677 Are you an employer?Check the appropriate boz: Business Type(required): l.� I am a employer with 20 employees(full andl 5. ❑ Retail i _ or art-timep.*p - p — p - - - — 6. ❑ Office an�Salesn ncls rea1 estatetauto etc. . � 2. I am a sole ro netor or artnershi and have no � � � � 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 10.0 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.� Other Homeowners Assn./Timeshare *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#1. I am an employer thaf is providing workers'compensation insurance for my employees. Below is the policy information.' Insurance Company Name: HUB International New England, LLC Insurer's Address: 299 Ballardvale Street City/State/Zip: WilminQton, MA 01887-0000 Policy#or Self-ins.Lic.# WC 003-60-3399 Expiration Date: 8/1/16 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 fne up to$I,30��r one-year imprisonrrierit�as we11-as civiTpena�fiesin the�orm of a STDP�ORI�DI�EK a:nc�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 Office of Investigations of the DIA for insurance coverage verification. I do hereby c ify,under the pains and penalties of perjury that the information provided above is tr e and correct. Si ature: Date: `� � � ` Phone#: �� Q,� 1 Official use only. Do not write in this area,to be completed by city or town offacial 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#: I www.mass.gov/dia 4 i