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a TOWN OF YARMOUTH BOARD OF HEALTH
� � APPLICATION FOR LICENSE/PERMIT -2016 I��'K�� 18 1��� '
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"'"' * Please complete form and attach a11 necess�ar����c���nt�y��J ��� ber
Failure to do so will result in the return your�pli,�ation.�3a = - EPT.
,
E�TABLISHMENT NAME: 1 TAX ID: ;
LOCATION ADDRESS: Z TEL.#:�D 9' � �
MAILING ADDRESS: � � C� �
E-MAILADDRESS: � c'-� '�C� �f�C• CO
OWNER NAME:
CQRPORATION NAME (IF APPLI ABLE): � v! � / I
MANAGER'S NAME: �'�'l f � � TEL.#:� 6�i
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MAILING ADDRESS: ! � � ' /t � '
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POOL CERTIFICATIONS: i
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.
1. 2. ;
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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
y�ars' 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. c�"" � � 2.
PERSON IN CHARGE: �
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1
1. LI"1�' t.J���� 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. � L---I�`N �'�^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.
;
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3. 4.
RESTAURANT SEATING: TOTAL# �`��
OFFICE USE ONLY I
LCENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# `
B&B $SS CABIN $55 MOTEL $I10
INN $55 CAMP $55 SWIMMING POOL$110ea.
LODGE $55 TRAILER PARK $105 WHIRLPOOL $I IOea.
FOOD SERVICE: �
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# ;
0-100 SEATS $125 CONTINENTAL $35 NON-PROFIT $30 �
L>100 SEATS $200 � �COMMON VIC. $60 �3 _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. $150 �FROZEN DESSERT $40 �� _TOBACCO $110 (
NAME CHANGE: $15 AMbUNT DUE _ $ �00.O� I
_ �
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** f
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CERTIFICATE OF LIABILITY INSURANCE DATE(MMlDD/YYYY�
U1i12/Ztl16
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
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)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 this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER CONTACT pavid Schofieid
8chofield Insurance Services PHONE 5EIH 376-�J��'t$ F'0'� . 508 376-5468
11Q2 Main Street E'�"A�� . dsehofiefd schofieldinsuranceservices.com
MtIIlS I�EA QZOS� INSURER S AFFORDING COVERAGE NAIC#
INSURER A:
INSURED INSURER B:
Beachview Enc.DBA The Skipper Restaurant iNsuReR c:
152 South 5hore Drive INSURER D:
5outh Yarmouth NiA U26B4 INSURERE: �A R@�31I M@CCE18t1tS WC GfOt! ,Inc.
INSURER F:
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. NOTWITHSTANDWG ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY 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.
INSR TypE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP
L POLICY NUMBER MMlDD/YYYY MM/DD/YYW LIMITS j
GENERAL LIABILITY EACH OCCURRENCE $
COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $
. CLAIMS-MADE �OCCUR MED EXP An one erson $
PERSONAL&ADV INJURY $
GENERALAGGREGATE $
GEN'L AGGREGATE LIMIT APPUES PER: PRODUCTS-COMP/OP AGG $
POLICY PR� LOC $ '
AUTOMOBILE LIABILIN COMBINED SINGLE LIMfT
ANY AUTO BODILY INJURY(Per person) $ '
ALL OWNED SCHEDULED BODILY INJURY(Per accident) $
AUTOS AUTOS
HIRED AUTOS NON-OWNED PROPERTY DAMAGE $
AUTOS
$ '
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS UAB CLAIMS-MADE AGGREGATE $
DED RETENTION$ $
WORKERS COMPENSATION X WC STATU- OTH-
AND EMPLOYERS'LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIV Y�N E.L.EACH ACCIDENT $SOO�OOO '
� OFFICER/MEMBEREXCLUDED? � N�A 014005032678198 01l0112416 01/01t2017
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $5a�,a��
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $5{}QrQaO
DESCRIPTION OF OPERATIONS!LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required)
G��S���i'i�D
M�� � 8 2n16
HEAL7H DEPT.
CERTIFICATE HOLDER CANCELLATION
Town of Yarmoufh SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
1146 Route 28 ACCORDANCE WITH THE POLICY PROVISIONS.
South Yarmouth,MA Q2&fi4-4492
AUTHORIZED REPRESENTATIVE <MS>
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J�.
�O 1988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD
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NOTICE N�TICE
TO TO
EMPLOYEES EMPL�YEES �
�
�
The Comm.on�vealth of Massachusetts
DEPART�NT OF IlrTDIJSTRIAL ACCIDE;1rTTS
1 Congr�s Stree� Suite 100,BQsto�,M�s�aGhus�ts 02114-2417 �
61?-?27-4900 -httpJlvvww.sta�e.m�a.usldia
As requu+od try Masga�hus�C,a�a1 I.a�w,t'hap�r 152,Sa�io�2l,22 Bt 38,tms w�l�ve y�rarice
t3�t I{we}have�rarvidod for po�yme�nt tio a�r injinod mnployees tu�er�e abovc-�c�r b9
�� �
MA R�eta7 Merchant�WC Group Inc. -
NAME OF IN4[3RANCE(X}MPANY �
PU�c 85922,'L-9222 Brainfiree,MA 02185 ;
ADDRESS OF INSURANCB COMPANY i
0140050326'78115 1lOU2015 - 1�UU20i6 �
�LICY NtJMBER � EFF�3CTNB DATES �
Schofield I�Seavic�es, 1102 Main Stre�Millis,MA 02054 508-376-54E
NAN�OF INSURANCB At�BrTf �DDRBSS PHONE# !
The Skipper R�ta�nt 152 South S�o�e Drive South F�,MA U2664 �
EIv�LOYSR ADDRESS
IIVIPLOYER'S WORKEIt�S'COI��Il'FNSAITON OFFICEat{!F ANY) � DATE
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MED�CAL TF�EATMENT ;
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� -���wo�s����r. A�y��F����►�u���� ;
'mjin�ea amployee. Tlue�ployee map s�t lr�a�her o�vvn pl�►s�u;isa Tl�e i+easonable cost of�e ser- I
vic�as p�+ovidod bY f1�e tc'�in8 p�ry�wlll be paid trp thc�,if�h+e�o�at is�ry and
reasonably cc�ocbod to ti�c wa�lc rr�a�ad�jury. Yn c�s i'oq�rin8 i�itai at�io4 et�playees tu+e .
luxdry.�th�the insu�l�s arrangod for sach�at the
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NAME OF HOSPTrAL A�RBSS
TO BE POSTED BY�LO�i''ER