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Home My WebLink AboutApplication and WC .. j � ► TOWN OF YARMOUTH BOARD OF HEALTH ��D�r�� APPLICATION FOR LICE ItT`;'=�(�1fi . ` '' �� -� � 2016 ' * Please complete form and attach all n� s o�ufn�nts b�:�ece ber� 2D�5. ' Failure to do so will result in th�tur�f�ur�p��ication p ' ket. '. LTH DEPT. � ESTABLISHMENT NAME: Ir1:S T a- TAX ID: I LOCATION ADDRESS: ._'ri 7oZ �YICLt�I. 5'�" _ �.L�� yaiit�w`�-. tila-TEL.#: �7�-o��'U-OqloS ! MAILING ADDRESS:`3 �e- V P � � �v '�-+�- i E-MAIL ADDRESS: , C Q��d��° ` OWNER NAME: T�— k CORPORATION NAME (IF APPLICABLE): !� A ' 1VTANAGER'S NAME: N p- TEL.#: MAILING ADDRESS: � 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. l. 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 2. 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. ; 1. ��'1 �T-D� 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. � 1. � 2. � ALLERGEN 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 �'I 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. � ; 1. �C�� C��T�-- 2. � ; HEIMLICH CERTIFICATIONS: i 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. � 1. �f� 2. I 3. 4. i RESTAURANT SEATING: TOTAL# ' OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $110 i INN $55 CAMP $55 SWIMMING POOL$i l0ea. i _LODGE $55 TRAILER PARK $105 WHIRLPOOL $I l0ea. ' FOOD SERVICE: I�I�ENSE REQUIRED FEE �� LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# i �0-100 SEATS $125 v _CONTINENTAL $35 NON-PROFIT $30 C >100 SEATS $200 _COMMON VIC. $60 WHOLESALE $80 i —RESID.KITCHEN $80 RETAIL SERVICE: ; LICENSfi REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq.8. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 =<25,000 sq.ft. $150 _FROZEN DESSERT $40 TOBACCO $110 - i NAMECHANGE: $15 U �TE _ $ �Z�.00 � �**�*PLEA E ��.'��'r; ��*�� S TURN OVER AND COMPLETE OTHER SIDE OF FORM i i I v I L �, 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 STATF 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 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 ESTABLISAMENTS 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 k obtained at the Health Department,or from the Town's website at www.Xarmouth.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: 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. 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. I DATE: ;�—(�-I—j e _SIGNATURE: i�I�� L_GU�� pR1NT NAME& TITLE: �(�►rl �� 1�ne� Rev.10/01/15 : � � � The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ` ' 1 Congress Street, Suite I00 - Boston,MA 02I14-20I7 ; www.mass.gov/dia Workers' Compensation Insurance Affidavit: General.Businesses A�ulicant Information Please Print Legiblv ; Business/Organization Name:�p,{�I n S �c��-�e� � �t�'hC S�Q a . ; Address: 5�� Gc.L.�) �fi r (�Q�Lf (� � '' � 6��3 City/State/Zip: 1- (Q�1 I'Y►Gv`�- mG� Phone#: �1�� ag`d -OQ(�5 ! Are you an employer? Check the appropriate boz: Business Type(required): j 1.❑ I am a employer with employees(full and/ 5. [�etail � or part-time).* 6. ❑ RestaurantlBar/Eating Esta.blishment 2.�I am a sole proprietor or pa.rtnership and have no �, � Office and/or Sa1es(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers' comp. insurance required] 8• ❑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 ha.ve 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.❑ 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#1. ' I am an employer that is providing workers'compensation insura.�zce for my employees. Below is the policy information. Insurance Company Name: Il�l� Insurer's Address: � City/State/Zip: I Policy#or Self-ins.Lic. # Expiration Date: j Attach a copy of the workers' compensation policy declaration page(showing the policy number and egpiration 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 Office of Investigations of the DIA for insurance coverage verification. I do hereby certify,under the pains and penalties of perjury that the information provided above is true and correct. Sienature: Il_F�_ �_0��1L--- Date• �" ��" �� Phone#: ��' ex0 0"(rl(D� Official use only. Do not write in this area,to be completed by city or town official 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 i � , o �-�""1 ROBIN-5 OP ID: LS � A�O�L.�ro DATE(MAAlDD/YYYI� �,,,,., CERTIFICATE OF LIABILITY INSURANCE oin�ois ; THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFfCATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFlCATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTA7IVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy{iesj must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on thls certlflcate does not�nfer righffi to the certificate holder in lieu of such endorsement(s). PRODUCER Np�E CT Larry Spilker ext 203 Pro Insur,lnc.dba PHONE 31�-848_90�5 F Campbell Risk Man ement nic wo �e: � �:317-848-9093 9595 Whitley Drive,�suite 2oa ppDR'E�,IspilkerC�3campbeilrisk.com Indianapolis,IN 46240 Larry Spiiker ext 203 INSURER(S AFFORDING COVERAGE NAIC# �r,suReR a:Capitol Indemnity Corporation 10472 INSURED Robin's ToffeE by the Sea INSURER B: P O Box 323 Uxbridge, MA 01569 INSURER C: tNSURER D: INSURER E: INSURER F: i COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTIMTHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT iMTH RESPECT TO WHICH THIS CERTIFICATE MAY BE iSSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICfES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ', INSR TypE OP INSURANCE CY E F LICY P LIMITS � LTR INSD WVD POLiCYNUMBER M MM/D i A X COMMERCIAL GENERAL LJABILITY EACH OCCURRENCE $ ��OOO�� CLAIMS-MADE �OCCUR X CP02492797 02/17/2016 02/17/2017 pREMISES Ea occurtence $ 100,�Q . MED EXP(My one person) $ 5r00 , PERSONAL 8 ADV INJURY $ ��OOO�OO GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ �L�OOO� X POL.ICY� PR� � LOC PRODUCTS-COMP/OP AGG $ Z�OOO, JECT OTHER: $ AUTOMOBtLE LIABILITY COMBINED SINGLE LIMR $ : Ea acciderd ANY AUTp BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per acadeM) $ AUTOS AUTOS NON-0WMED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident ' $ UMBRELLA LJAB OCCUR EACH OCCURRENCE $ ; EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ � WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y�N STATUTE ER ANY PROPRIETOR/PARTNERlEXECUTIVE E.L.EACH ACCIDENT $ �� OFFICERlMEMBER EXCLUDED? �N�A (Mandatory in NF� E.L.DISEASE-EA EMPLOYE $ i If yes,desaibe u�der � DESCRIPTION OF OPERATIONS below E.L DISEASE-POUCY LIMIT $ � DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be atiacF�ed if more space is required) �` Those usual to the insureds operations.Blanket additional insured applies f per coverage for CGL 421. ;. i CERTIFICATE HOLDER CANCELLATION ; EVIDENC � SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE ; THE EXPIRATION DATE THEREOF, NOTICE WILL BE DEUVERED IN EVICI@t1C@ Of 111SU�811C@ ACCORDANCE WITH THE POLICY PROVISIONS. i 4 I AUTHORIZED REPRESENTATiVE t��`�- O 1988-2014 ACORD CORPORATION. AII rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD t s . j �,,...�+� ROBIN-5 OP ID:LS � '`��`'�� CERTIFICATE OF LIABILITY INSURANCE DAO�(��0� � THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS [ CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES G BELOW. THIS CERTIFlCATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED � REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certiflcate hoider is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBFiOGAT10N IS WAIV�D,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate hoider in lieu of such endorsement s. PRODUCER NpMEACT Larry Spilker ext 203 Pro Insur,inc.dba PHONE 317-848-9075 � N,:317-848-9093 Campbell Risk Management � � �: 9595 Whitley Drive,Suite 204 A oREss:Ispilker@campbellrisk.COm Indianapolis,IN 46240 Larry Spilker e�203 INSURER(S)AFFORDING COVERAGE NAIC# wsuReR a:Capitol Indemnity Cor ration 10472 INSURED Robin's Toffee by the Sea INSURER B: I U b tlge,MA 01569 INSURER C: f INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: ' THIS IS TO CERTIFY THAT THE POLICIES OF WSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD . INDICATED. NOTIMTHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR AAAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OF INSURANCE DDL BR ��Y NUMBER MM/uDCY�� MM�Y�P LJMITS A X COMMERCIAL 6ENERAL LIABILITY EACH OCCURRENCE $ ��OOO�OO I CLAIMS-MADE �OCCUR X CP02492797 �2/17�16 02/17/2�17 pREMISES Ea occurrence $ 100�0 MED EXP(My one person) $ 5r� PERSONAL 8 ADV INJURY $ 1�OOO�OO GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ Z�OOO,OO X POLICY❑ PR� � LOC PRODUCTS-COMP/OP AGG $ 2�000,00 JECT OTHER: $ AUTOMOBILE LIABILiTY COMBINED SINGLE LIMIT $ i Ea accideM ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY�NJURY(Per accideM) $ � AUTOS NON-0WNED PROPERTY DAMA(� $ HIRED AUTOS AUTOS Per accident $ UMBRELLA LIAB pCCUR EACH OCCURRENCE $ ' EXCESS UAB CLAIMS-0AADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSA'f10N PER OTH- AND EMPLOYERS'LIABILITY y�N STATUTE ER ANY PROPRIETOR/PARTNEWEXECUTIVE ❑ E.L.EACH ACCIDENT $ ��' OFFICER/MEMBER EXCLUDED? N�A �'� (Mandatay in NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHIC�ES(ACORD 101,Additional Remarks Schedule,may be atfached'rf more space is required) Raynham Flea Market is an additional insured. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Raynham Flea Market 480 S St.W Raynham,MA 02767 AUTHORIZED REPRESENTATIVE ��C�f-C_.� OO 1988-2014 ACORD CORPORATION. AU rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD