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Home My WebLink AboutApplication and WC r : ., � � w��.,s V�sL� ' °� ► TOWN OF YARMOUTH BOARD OF HEAL ' � � APPLICATION FOR LICENSE%PER1�1'I�`�'�# � � '`�, ��y�' �' �' ��'�� `"'� * Please complete form and attach all necess do h� e t's,b n �a�m er �1��EPT. , �', �� .�' � Failure to do so will result in the return of your application pac cet. ESTABLISHMENT NAME: o TAX ID: � LOCATION ADDRESS: S � TEL.#: J' 1VIAILING ADDRESS: � S � � � 6 ! � �E-MAIL ADDRESS: OWNER NAME: � ��v��_�`�l��til�N , CORPORATION NAME (IF APPLIGABLE): � � 1VIANAGER'S NAME: TEL.#: MAILING ADDRESS: V � � 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. 1. 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. 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 CHARGE: Each food establishment ust have at least one Person In Charge (PI ) 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 a�d m�aintain a file at your establishment. 1. 2, HEIMLICH ERTIFICATIONS: 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. i 1. ��(�',�n� �. , T�'M�Y� ��1�� 2. � 3• 4. ; RESTAURANT SEATING: T�TAL# �� i OFFICE USE ONLY LODGING: � LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $110 INN $55 CAMP $55 SWIMMING POOL$110ea. _LODGE $55 TRAILER PARK $105 WHIRLPOOL $I l0ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# ! 0-100 SEATS $125 CONTTNENTAL $35 NON-PROFIT $30 { �>100 SEATS $200 �(o / COMMON VIC. $60 � c f =WHOLESALE $80 j —RES[D.KITCHEN $80 � RETAIL SERVICE: LICENSB REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq.ft. $50 >25,OOt�sq.ft. $285 VENDING-FOOD $25 � =<25,000 sq.ft. $I50 =FROZEN DESSERT $40 _TOBACCO $110 � i NAME CHANGE: $15 AMOUNT DUE _ $ 2(00_O� j *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** ' s � � ADMINISTRATION ` k 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 ' Cornpensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, Oit CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior ta 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 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 j 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 � I closing. i 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 obtamed 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. � 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 CONIMENCEMENT. RENOVATIONS MAY QUIRE A S TE PLAN. D �° SIGNATURE: PRINT NAME & TITLE: �� Rev. / 1/15 � I f a �,,.: �.�� s�„�� ,'� The Commonwealth of Massachusetts �Y=- � ; Department of Industrial Accidents v Office oflnvestigations ! ' I Congress Street, Suite I00 , ; Boston, MA 02114-2017 www.mass gov/dia Workers' Compensaflon�Insurance Affidavit: General Businesses - A licant Information Please-Pri t Le 'bl � Business/Organization Name: ' Address: � �. � � Y�(/ � Ci /State/Zi � '� . tY P� (��:-EC Phone #: !� � r�� / Are you an employer? Check the appropriate boz: Business Type(required): 1.❑ I am a employer with�L_employees(full and/ 5. ❑ Retail 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.) I 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.❑ Manufacturing ' no employees. [No workers' comp. insurance required]* 11.❑ Health Care ' 4.❑ We are a non-profit organization,s.taffed by volunteers, with no employees. [No workers' comp. insurance req.J 12.❑ Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensadon policy information. ' **If the corporate officers have exempted themselves,but the corporadon 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 insurance for my employees. Be[ow is 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' compeusation 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 j 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 ce �`ify,under the pains andpenalties ofperjury that the information provided abo is ue and correc� � Si ature: Date: �t� i l� ' � � Phvne#: � Officia[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#• wwwmass.gov/dia � � �� Fax:(877)816-2156 To: 15083980836@rcfax.cc Fax: +15083980836 Page 2 of 2 04lDS12016 5:0�PM �� ROURTOP-01 DRUST j�� CERTIFiCATE OF LIABILfTY INSURANCE DpTE(MMIDD/YYYY) ;�i ' 4/Sf2016 ,2TIFlCATE IS 15SUED AS A Ml1TTER OF INFORMATlON ONLY AND CONFERS NO RlGHTS UPON THE CERTIFICATE HOLDER.THlS �� ;CATE DOES NOT AFFlRMATfVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES � �V. THiS CER7IFICATE dF lNSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE lSSUiNG INSURER(S),AUTHORlZED �;ESENTATfVE OR PRODUCER,AND THE CERTIFlGATE HOLDER. '� ' = ORTANT: If the certiticate holder is an ADDfTIONAL lNSURED,the policy(ies)must be endorsed. if SUBROGATION IS WAlVED,subject to �± ,; terms and canditians af the policy,certain policies may reguire an endorsement A statement on this certificate does not confer rights ta the � '. �rtificate holder in lieu of such endorsement(s). 'I i ; �ODUCER CONTACT I - NAME: I ogers 8t Gray Insurance Agency,I[1C. PHONE 134 Rfe 134 p/C No Exc: �Aic,Noa:(877)816-2156 �� 5outh Dennis,MA 02660 aDOREss:�►'�at(�rogersgray.com ; INSURER(5)AFFORDINGCOVERAGE NAIC� I! I INSURERA:NOCGUARDEt1SUC3t1CACOttlPfln3/ Ij ' INSURED ; INSURERB: j' ' Raurke's Top af the Cove LLC iNsur�Rc: 183 Main Street iNsuReRo: Sauth YarmcruEh,MA 02673 INSURER E: INSURER F: I� COVERAGES CERTIFECATE NUMBER: REVISlON NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TOTHE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERNI OR CONDffION OF ANY CONTRACT OR OTHER DOCUNIENT WITH RESPECTTO WHICH THIS i' '; CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN ISSUBJECT70ALLTHETERMS, I i EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. �LTR TYPE OF INSURANCE INSD YYVD POLICY NUMBER POLICY EF POL CY EX � (MM/DD/YYYY) (MM/DD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ �' ` CLAIMS-MADE �OCCUR PREMISES(Ea occurrence) $ ' MED EXP(Any one person) $ i PERSONA�&ADV INJURY $ � GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ � � POLICY ❑PP.O- � JECT LOC PRODUCTS-COMP/OPAGG $ i OTHER: $ � AUTOMOBILE LIABILIT' COMBINED SINGLE�IMIT $ I, � Ea accident � ANYAUTO BODILYIN.AJRY(Perperson) $ i ALL OWNED SCHEDULED BODILY INJJRY(Per accidenq $ I AUTOS AUTOS HIREDAUTOS NON-OWNED E Y AMAG AUTOS (Per acddent) $ I $ I UMBRELLA LIAB OCCUR EACH OCCURRENCE $ � i EXCESS LIAB I � CLAIMS-MADE AGGREGATE $ � � DED RETENTION S i WORKERS COMPENSATION $ � AND EMPLOYERS'LIABILIT' X STATUTE ER I A ANY PROPRIETORlPARTNER/EXECUTIVE Y f N ROWC750389 04/05/2016 O4/Q5/ZQ'I7 E.L.EACH ACCIDENT $ 'IOQ OOO I I' ' OFFICERlMEMBER EXCLUDED? Y❑ N/A , (Mandatory in NH) y If yes,describe under E.L.DISEASE-EA EIviPLOYEE $ '�aQ,�Q� � ,: DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ SQO,Q�Q � " ' . . �-'! ��.i..: ��. j:' DESCRIPTION OF OPEF2ATIONS/LOCATIONS/VEHICLES (ACORD 1U1,Addidonal Remarks Schedule,may be attached if more space is required) �.' tescaurant ,�, i � � ' CERTtFlCATE HOLDER CANCELl.ATfON � ' SNOULD ANY OF 7HE ABOVE DESCRlBED POLICIES BE CANCELLED BEFORE Town of Yarmouth TkE EXPIRATlON DATE THEREOF, NOTlCE WiLL BE DELlVERED tN 1146 Raute 28 ACCORDANCE WfTN THE POLICY PROVISlONS. �' South Yarmouth,MA 02664 AUTHORI2ED REPRESENTA7IVE �� O 1988-2014 ACORD CORPORATfON. All rights reserved. 4CORD 25(2014/01) The ACORD name and logo are registered marks of ACORD : � s