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Home My WebLink AboutApplication and WC . ' Q '_ s-r� � ► TOWN OF YARMOUTH BOARD OF HEALTH ° o � � APPLICATION FOR LICENSE/I'� f I�'` (�t� � l� 20�5 `"� * P lease comp le te fortn an d a t tac h a l l nece5s �� ° u�m�en t y D "em er 1 S 2 0 1 S. Failure to do so will result in the re t t�i�tn o o"a�"ap' ic�i pa et.HEALTH DEPT. E�TABLISHMENT NAME: T ID: LOCATION ADDRESS: �' TEL.#: O � - �S MAILING ADDRESS: E-MAIL ADDRESS: ru �` OWNER NAME: CORPORATION NAME (IF APPLICABLE): i 1ViANAGER'S NAME: �32aA-t� PE'c12.�cc.1 TEL.#: � 1VTAILING ADDRESS: ; PdOL 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 1., � .(-r ��-e 2. I t f Pool operators must list a minimum of two employees currently certified in standard First Aid and Community i Cardiopulmonary Resuscitation (CPR), having one certified employee on premises at all times. Please list the I 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. ; i 1. �2 r !?/� 2. �i � U l/' 3. ' 4. �r � ; i � - FbOD P�t�T�.G��I MA ArTFR��CERTIFICATIONS: _ ___ _ _ --. All food service establishments are required to have at least one full-time employee who is certified as a Food I 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. 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 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. 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. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# � _ ____ _ ___ __ f3��-�JSE-f3N�� --_ -- -- _ _ _— ---_ _---- � LODGING: I LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# i B&B $55 CABIN $55 MOTEL $110 ' _INN $55 CAMP $55 J�SWIMMING POOL$110ea. � — � �p� _LODGE $55 _TRAILER PARK $105 _WHIRLPOOL $110ea. , I� 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 —RESID.KITCHEN $80 RETAIL SERVICE: LICENSfi REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sy.ft. $50 >25 000 sq.ft. $285 VENDING-FOOD $25 =<25,000 sq.ft. $150 _FROZEN DESSERT $40 TOBACCO $110 NAME CHANGE: $is AMOUNT DUE _ $ Zzo•O O � *****PLEASE TURN OVER AND COMPLETE OTHER S1DE OF FORM***** 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. O F INSURANCE 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 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 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. POOLS i 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 I required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be ; obtamed at the Health Department,or from the Town's website at www.yarmouth.ma.us under Health Department, ! Downloadable Forms. FROZEN DESSERTS: j 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. ! i OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. OUTDOOR COOHING: 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. j I 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 COMMENCE ENT. RENOVATIONS MAY UI SITE PLAN. DATE: Id'"C 3 Z� SIGNATURE: ( � n t PR1NT NAME & TITLE: '��►� ��'�ct�� Unku�� 4 � Rev. 10/O1/IS j � �' ` The Commonweadth of Massachusetts I�I � I _ Department of Industrial Accidents ; Office of Investigations ' 1 Congress Street, Suite I00 _ Boston,MA OZII4-2017 ; www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses A licant Information i� S -%�� Please Print Le 'bl ; i Business/Organization Name: ; � I Address: yl >' % �,�� ; � P� a� 7.5 �..Q�'-3(�� - 3S 35 Ci /State/Zi � �i Phone#: � Are you an employer? Check the appropriate bog: Business Type(required): 1.� I am a employer with employees(full and/ 5. ❑ Retail � i or part-time).* 6. ❑ RestaurantBar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no �, � Office and/or Sa1es(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 o�cers 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]* ', 4.❑ We are a non-profit organiza.tion,stafFed by volunteers, 11.0 Hea1th Care 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 coiporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is reqirired and such an � org9^:.�a4r:v^^-sheuld-chgcl�bAx#�- I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: i � ��a� CO� Insurer's Address:�D I�U,��, !!�?,�PrnQfJan�/�/�LLG' a99 �t//,YG�I/ /�� City/Sta.te/Zip: G�(/I�IYI J✓l4.��}t a�� Policy#or Self-ins.Lic.# ��r,`L�/�� c3� �O`��Expiration Date: �� /v 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 Office of Investigations of the DIA for insurance coverage verification. I do hereby certify,un e pains and penalties of perjury that the information provided above is true and correc� Si ature: ��r �► Date: (l � ( Phone#: S�� 3�� " 3 S3� i Official use only. Do not write in this area,to be completed by city or town officiai 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 �� CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) , IFICATE 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 BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to he terms and conditions of the policy,certain policies may require and endorsemeM. A statement on this certificate does not confer rights to he certificate holder in lieu of such endorseme s. PRODUCER CONTACT NAME: HLJB INTERNATIONAL NEW PHONE FqJ� 299 BALLARDVALE ST (A/C,No,Extk (MC,Noy: WII.MINGTON,MA 01887 E�� ' ADDRESS: 2939R INSURER(S)AFFORDING COVERAGE �C g ', INSURED INSURER A: TRAVE[ERS IIdDIINN1Ty COMPANY OF AMERICA KINGS WAY CONDOMINIIJM TRUST INSURER ec : INSURER C: C/O PROPERTY MANAGEMENT AT 64 KINGS CIRCUIT �NSURER D: INSURER E: I YARMOUTH PORT,MA 02675 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: ( TH TO CERTIFY THAT THE PO ES OF INSURANCE LISTED BELOW HAVE BEEN ISSUEp TO THE MISURED NAMED ABOVE FOR THE POLICY PERIOD INbICATED.NOTYYITHSTANpNG ANY REGUIREMENT,TERM OR CONDRION OF ANy CONTRACT�t OTHER ppCUMENT WRH RESPECT TO WIi1CH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAM.TFIE INgURANCE AFFORDED BY THE POL�IES DESCRIBED NEREM IS SUBJECT TO ALL THE TERMS,D(CLU�ONS AND CONDITIONS OF SUCH POLIC�S. LMRS SHOWN NAY HAVE BEEN REDUCED BY PA�CWMS. I INSR, ADD SUB POLICI'EFF DATE 'POUCY D(P DATE ' ! LTR TYPE OF WSURANCE � R POLICY NUMBER (MA11DD1YYYl� (MMIDD\YYY1� LIMRS GENERAL LWBIL�T1f CH OCCURRENCE $ ; COMMERCIAL GENERAL LIABILITY ��,. CLAIMS MADE �OCCUR. AMAGE TO RENTED REMISES(Ea axurrence) a � ,..r..�..��..�. ; ED EXP(Arry one person) $ � GEN'L AGGREGATE LIMIT APPLIES PER: ERSONAL 8 ADV INJURY $ ENERALAGGREGATE $ POLICY �PROJECT�LOC RODUCTS-COMP/OP AG6 $ AUTOMOBILE LIABILITY . ANY AUTO COMBINED SINGLE a UMIT(Ea aocident) ALL OWNED AUTOS BODILY INJURY * $ SCHEDULE AUTOS Per person) HIRED AUTOS BODILY INJURY a NON-0WNED AUTOS P�a��M� PROPE TY DAMAGE $ (Per aocideM) UMBRELLA LIAB OCCUR EACH OCCURRENCE a EXCESS LL4B CLAIMS-N44DE GGREGATE a'"��"�"'" DEDUCTIBLE a'"....."�' RETENTION a $ �""' A WORKER'S COMPENSATION AND WC S7ATuroRY oTHER � EMPLOYER'S LWBILITY Y/N UB-0175N69&15 02l26/2015 02/26/2016 X uMITS � nNvwtOr�wTOwPaRrr�wexecurn� tv 7 N/A $ 500,000 f OFFlCERIMEMBER EXCWDED? 7'J E.L.EACH ACCIDENT (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 n res,des«tbe under � DESCWPT�OM OF OPERATIOn�below E.L.DISEASE-POUCY UMIT $ 500 ppp II DESCRIP710N OF OPERATIONS/LOCATIONS/VEHIC�ES/RESTRICTIONS/BPECWL ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO Tf�CER1'IN7CATE HOLDER AFFECTING WORKERS COMP COVERAGE. I i CERTIFICATE HOLDER CANCELLATION TOWN OF YARMOUTH SHOULD ANIf OF TNE ABOVE DESCRIBED POLICIES BE CANCELLED j�Aj,TH DEpARTMENT BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DEWERED IN ACCORDANCE YViTH THE POUCY PROVISIONS. 1146 ROtTTE 28 AUTHOftI�D REPRESENT E � � SOUTH YARMOUTH,MA 02664 ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD 1988-2010 ACORD CORPORATION. Ail Nghfs reserved, '