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Home My WebLink AboutApplication and WC � ► TOWN OF YARMOUTH BOARD OF HEALTH ° ��N � � � � APPLICATION FOR LICEN��P , �� (� Z ZO�S `"°" * Please complete form and attach all n �j�s.� �,.,.� � �u ��n �y� e em � Ol S. ; G .. ' Failure to do so will result in the�returr�of your�pp�ica�io T ; ,._., i ESTABLISHMENT NAME:�"A�.T L�� Nl�-r r-r TAX ID: � LOCATION ADDRESS: � 2 G �Reca-l-r�2& W• �tng�.a�.�•- nt.l�F TEL.#: zip�-771 -�2`l9 MAILING ADDRESS: ' E-MAIL ADDRESS: OWNER NAME:�i(' l�c PQF� '�I CORPORATION NAME (IF APPLICABLE): ; MANAGER'S NAME: 1�('�.c Pn�ea TEL.#: SoSI-�j�'� -�'A6y MAILING ADDRESS: ? 2� �-��_�,.1 �i.is.�n�,�L- ;+tiA �'�-�, 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. ' __ _---- ---- _ _ __ . _ _- - - .�. _ 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. 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. 2• ': PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. ' � i 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 fortn. 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# ' ------ --------- --- n��ir� rrc� n�Tr v LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PF,�ZMIT# B&B $55 CABIN $55 #�(,-O'3fj INN $55 CAMP $55 �SWIMMING POOL$110ea. _LODGE $55 TRAILER PARK $105 WHIRLPOOL $I l0ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# �CENSE REQUIRED FEE P��vt[T 3 LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 CONTINENTAL $35 �#- tn 6 NON-PROFIT $30 _>100 SEATS $200 _COMMON VIC. $60 WHOLESALE $80 ' —RESID.KITCHEN $80 I RETAIL SERVICE: LICENSfi 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 — i rramE caArrcE: $i s AMOUNT DUE _ $ /�S,p O � � *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** �, � I i i � ; � ADMINISTRATION a ` � 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 � 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 Np MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy sha11 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. ��._�___ _ a:._.. � , _ _ _ __ _ . FOOD SERVICE ` - SEASONAL FOOD SERVICE OPENING: All food service establishments must be inspected by the Health Department prior to opening. Please contast th� 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.yarmouth.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. ' - 4 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 RE IRE A SITE PLAN. 4 DATE: i9 ��(�„� SIGNATURE: PRiNT NAME & TITLE: ��1�/l, Rev. 10/O1/15 i , � � � � The Commonwealth of Massachusetts ` _ Department of Industrial Accidents � Office of Investigations � ' 1 Congress Street, Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses � Applicant Information Please Print Legiblv j Business/Organization Name:�'�C�P C u.� rnv �-� Address: � 2C� Q_�,�-Pr�- - 2fk City/State/Zip: Phone#: �cn � - � � � - ��y Are you an employer? Check the appropriate boz: Business Type(required): 1.❑ I am a employer with employees (full and/ 5. ❑Retail k or part-time}.* 6. ❑RestaurantlBar/Eating Establishment � - - _ _ _ _- ---- I 2. I am a sole proprietor or partners�iip anT�ve 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 have 10.0 Manufacturing ' no employees. [No workers' comp. insurance required]* 11.0 Health Caze 4.❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.0 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 organizadon should check box#1. ; I am an employer that is providing workers'compensation insurance for my employees. Below ds the policy information. Insurance Company Name: Insurer's Address: City/State/Zip: � Policy#or Self-ins.Lic.# Expiration Date: 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 � - -- iirie up to$T;S�U:tiII anci7or one-year imprisonin��as weii��iv�ilp n�`�in tlr�-f6rri��i f a�n�- �' of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify,un the pains and penalties ofperjury that the information provided above is true and correct. Si ature: Date: � 2' �:) Phone#: ' Officdal use only. Do not write in this area,to be completed by city or town officiaL ', City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2. Building Department 3. City/Town Clerk 4.Licensing Board 5.Selectmen's Office ' 6.Other Contact Person: Phone#: www.mass.gov/dia � Dec, 2. 2015 10:38AM No, 1910 P, 1 � '`�� CERTIFICATE �F LIABII,ITY INSURANCE �iz�a�zo� � 7Ht3 CERTIF[CATE IS ISSUED AS A AMATTER OF)NFOii{VIA71�N ONLY AND CONFER3 NO RIGHTS UPON THE G�IiTIFICAT� HQL6ER. TNI5 CERTIFICATE DOES NO7 AFFiRMATNELY OR NEGATIVELY AMEND, EXTENb OR AL.7�1� 7HE COVERAGE AFFORDED BY THE POLlG1E5 B£LDW. THIS CERTIFICAT� �F INSURANC� pQE$ NOT CON3TITUTE A CONTRACT �E7WEEN THE ISSUING IN3URER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,ANU THE CERTIFICA7�HOLDER IMPURTANT: If the certificate holder is an ApdITIO1dAL INSURED,the policy(ies}must 6e endorsed. if 5U�1iQGATION IS WAIVED,subject to fhe terms and conditlons oF the policy,cettain policies may raqulre an endorsement. A statement on this certiF3caEe does rlok Confar rlghts Eo the certificats holder in lieu aF such sndorsemenqs). PRODUC�R �NT'�DTOrah MCcoYm3.ok McCormick & Sons insurance Agenay, znc PHONe , (509)586-2973 F ,(508)587^66T9 B00 Reet btain Str�et ��g:nmccormick@mccormickinsuxanoe.aom � INSUR S AFFOROING COVERAGE MAIC fF � � Avon D� 02322 � _ ��ryp{�p F7eatern World Insurance C4111 AI3 ; iNsuaeo INSURER 0:Llo 's oE Lowdon � CaQtle Dawn D4nte1, Sainaath Co., SiadeVang Co. INSURERC: _ 226 YZoute 28 INSUI�RO: tNsur�s E_ OP6Bt Yarmrn�tll M�: �28�3 INSURER�: � COV�RAG�S y CEF�TI�ICATE NUMBER:�1512202490 Fi�VISIdN NUMBER: ' TH]S lS TO CER"fIFY 7HAT THE POI.ICIES OF IltSURANCE LISTED BELOW HAVE BEEN ISSUED TO TH�INSUREp NAMED A84VE FOR THE P4LICY PERIOD fNPICATED. N{lTWITHSTANDING ANY REQUIREMENT,7ERM OR CONDITI4N OF ANY CONTRRCT OR OTNER bOCUMENT WI7H RESPECT TO WHICH THIS C�R1"IFICATE MAY BE ISSUED OR MAY PERTAIN, THE IM1ISURRNCE AFF�RD�Q BY 7HE POLICIE3 D�SCRI�ED HERE�N IS SUBJECT TO ALL TH�TERMS, FJ(ClUSIONS AND CONDITI�NS OF SUCH pOLIC1ES.LIMl7S SHOWN MAY HAVE BEEN REDUCEd BY PA[D CLpIMS. �� iYPE OF INSUkANCE POIJGY NUMb�R MM7D�� E� L[MITS ]C COMMF-RCiAI,GENEw►t uaBiuTY EACH OCCURRENC� S 1,000,000 A CWMS-MAOE �OCCUR PREMISES E ; SU0,004 NPP62d606$ 5f2/2015 5/2I2016 p�EDEXP M ane ereon S 5,000 PERSONAL&ADViNJURY t 1i004,000 ' G�rPL MiOAE(3ATE LMI7APPLIES P�R: GENERAL AGGREGA7E s 2�000�000 X P4LICY�JEC ❑�oc PRODUCTS-CAMPJOP ACiO f �.ciuded OTHFR: i AUTONOBILE LIABILITY COMBINEO IN LE LIM a �A�� fiODILYWJURY(Perpefaonj S ��D 8AC�ME�sULED eODILY IMIURY(Per eaidenp i NOk-4WD1ED PROPER s HIR�D q�Jrps p,�'(OS i ' UMBR�+►LWB p�C�fR �A,(;Hp�RENCE S 2040000 A x E][CESS LJAB C�S�#AAOE AGGREGHTE S pEp ��bN NPPB266088 5/2/2015 5/2/2016 � � WORICER9 COMPENSATION PER OTH- ANo�MPtAv�s'uae�urr �A�� AN`!PROPRIETORfRARTNERf�(ECUY'IVE Y�N 1A EL EACN ACCIDEN7 S OfFIC�RMIEMd�R E%�Lu0Eo7 �x�anaawry m NH) EL O�aEasE-EA EMP�OYE g N ys�s desa�unQer bESC�RIP110N QF OP6RA710NS b�w EL D�&F�Se.pOUCY LIMR S � H 9059d 5/2J2015 5/2/2016 BUILUIkG LIMIT 9,0OOOOD � DESCRIPTION OF OPERl4TlOt�1 LOCATION51 V�fYC1.F.S(ACOR010�,pdditianal Remuks ScheOule,may be attachetl 1I mora sppco Is requl� CERTIFICATE HOLOER CANCELLATION SHBULD ANY OF THE A60VE DE3CRIBED POUCIES b�C/�iCELLE�BEFORE 'TOWN OF YARMOU�H 7HE eXPIRATION PATe rH�aF, woncE wn�� eE b�LJVEREU iN BUILDING DEPT ACCORDANCE WITH TH�POLICY PROVISION$. YARMOU'�ET, MF► nurHor�xm HFr�s�NTnml� Norah Nlccormick/DJM �1888-241d ACOR�CORPOlZATI4N. All rights reserved. pCOItD 26(201a107) The ACO�tD name aod logo are regEstered marks of ACORb IN3025�2o4�ot�