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Home My WebLink AboutApplication and WC ► , .; aC�C��M�D � � TOWN OF YARMOUTH BOARD OF HEALTH � � APPLICATION FOR LICENSE/PE�� 1 (��; � . �;�� ``"' * Please com lete form and attach a11 necess �doCu' s=,��l3ece �ber 1 S 201 S. P �' , Y ' Failure to do so will result in the return�f 3�ou�.p�lication p ,,l�etNEALTH DEPT. ESTABLISHMENTNAME: (�!) eY �P rl TAX D: - LOCATION ADDRESS: 0 U f e !n�' 4 rM th �'! 4Zi?3I'EL.#: -?� -S' p MAILING ADDRES�S: a+�t� qS Lo a on E-MAIL ADDRESS: t�1�O ti�n��vS a vPP�Mo�- • Co M � OWNER NAME: A�m R�,�J PaT Ft- I CORPORATION NAME (IF APPLICABLE): JV � MANAGER'S NAME: (,J2V 1 S A� T TEL.#: � ' D„�� j MAILING ADDRESS: V I 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. � l. Pv�zv��_s��a-r�-� 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. ��t��5�P ��4? �L 2. T ��L , 3. �v �c� ie n��ii.ey 4. r i FbOD 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 1N CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. 2. � I ALLERGEN CERTIFICATIONS: i 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. � HEIIVILICH 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. Pleaselist 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# --- — - ------- OF�'ICE USF, nNT.Y � LOUGING: � — - — — LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PE MIT# ' _B&B $55 CABIN $55 �MOTEL $110 6-03�i _INN $55 CAMP $55 _(.,SWIMMING POOL$i l0ea. — _LODGE $55 _TRAILER PARK $105 �WHIRLPOOL $110ea. 7 FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# L CENSE REQUIRED FEE P RMIT# LICENSE REQUIRED FEE PERM[T# 0-100 SEATS $125 �CONTINENTAL $35 (o�12-e NON-PROFIT $30 _>100 SEATS $200 _COMMON VIC. $60 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-F`OOD.$25 • —<Z5,000 sq.ft. $150 _FROZEN DESSERT $40 _TOBACCO � $110 NAMECHANGE: $ts AMOUNTDUE _ $ 3�5•OO *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** r � ! � r _ , 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 Campensation Insurance. THE ATTACI�ED STATE -WO�ZKER'S COMPENSATION INSURANCE ' AFFIDAVIT MUST BE COM�LETED A�ND SIGNED,OR . � CERT. OF 1NSURANCE ATTACHED. . OR � /' WORKER'S COMP. A�FIDAVIT.SIGNED AND ATTACHED V 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 sha11 be i 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 tran,sient. 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 axea until the pool has been inspected and opened. POOL WATER TESTING: T'he 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. I POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of f closing. i ---- . � �,__ �-r_ , �- . - - 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.varmouth.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. ,I � 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 f 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 i TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. I DATE: � � �fl � �e�'��S SIGNATURE: � f � PRINT NA�VIE&TITLE: U V J � �EI' Rev. 10/O1/15 i ; f � � ; � � The Commonwealth of Massachusetts ` Department of Industrial Accidents � � - Office of Investigations ' E � I Congress Street, Suite I00 ' � Boston, MA 021I4-2017 :._:� ` www.mass.gov/dia ; • . . . � - . . . �.� � �' Workers' Compensation Insu�ance'Aff da�it: General Bt�sine"sse� � : , ; - �p. �' �. � Applicant Information _ _ _ Please Print Legiblv ,. . _ . Business/Organization Name: �('� }�°V�s �r2 �°n /�I D f-P�_ i ; Address: J�Jt 3 ��l, �"� �� City/State/Zip: �' �I Q�N1 o c�1 Li l/1'J�I'�Oa 6�3 Phone#: SD� - 7 7 J�- ,S�� ' Are you an employer?Check the appropriate boz: Business Type(required): 1.�I am a employer with 1 I$ employees(full and/ 5. ❑ Reta.il _ or part-time).* -- -_ — _ -- 6.-{��es�aurantIBar�a'ting-�sta�is�r�er�---_ - 2.❑ I am a sole proprietor or partnership and have no �, � Office and/or Sales(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 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]* 1 LQ Health Gare 4.❑ We are a non-profit organiza.tion,staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.�Other � �� 1� '' � *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#L _ . ,, _ � _ I a�rs�n employer that is providing ryorkers'compensation insurance for my employees. Below is the policy informdtion � ''� .. _ . . � . .,.. , _ , Insuran��-Company Name: . . ' I � � � � 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. --_ --- � fine up to$1,500.00 an or one-year impnsonment,as-weI�'as civi�'pen t�Ta ies iri tTie form o�a S'TaP W�RK�Ki3EI�an a e -- of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Of�'ice of 't Invesrigations of the DIA for insurance coverage verification. I I do hereby certi nder the pains and penalties ofperjury that the information provided above is true and correct. Si ature: �C�" Date: O 7� ��J � Phone#: � � 1 —O � � — U �� ', _ _ , Official use only. Do not write in this area,to be completed by city or town officiaL ! E � City or Town: PermitJLicense# � Issuing Authority(circle one): 1.Board of Health 2. Building Department 3. City/Town Clerk 4.Licensing Board 5. Selectmen's Office j 6.Other � � Contact Person: Phone#: ! �.��s.go�ia�a � `�� CERTIFI ATE F LIABILITY INSURANCE DATEIMM/DD/YYYY) �� ,�,� O 04/14/2014 THIS CERTIFICAT6:IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS VPON THE CERTIFICATE HOLDER. THIS � CERTIFICATE DOES NOT AFFIRRAATtVELY OR NEGATIVELY AMEIVD, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE�F INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(SI.AUTMORIZED 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 oertificate does not confer rights to the+ y certificate holder in lieu of such endorsement(s). � PRODUCER : � CONTACT � PAYCHEX INSURANCE AGENCY INC a�C,NNo.Ext1: s7713s2-s�e5 Fa,r►o: an�sn-oaa� 150 SAWGRASS DR E- AIL ROCHESTER, NY 14620 : chox�troveiers.com (877) 362-6785<= PRODUCER � • 1572G5185 SV996 7OA INSURER(5)AFFORDINCa COVERACaE NAIC# � INSURED INSURER A:THE TRAVELERS INDEMNITY COMPANY OF CONNECTICUT � SHRIM INC INSURER B: ; DBA HUNTERS GREEN MOTEL INSURER C: � 553 MAIN STREET ROUTE 28 INSURER D: VtfEST YARMOUTH, RRA 0267� (NSJii'cR E: i $ INSURER F: < i COVERAGES CERTIFICATE NUMBER: 568491406�1�401 REVISION NUMBER: � THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE USTED BELOW HAVE BEEN ISSUED TO THE INSURED NAWIED ABOVE FUR THE PIILICY PERIOD ' Ib INDICATED. NOTWIitiSTANDING 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 TME POUCIES DESCRIBED HEREIN IS SUBJECT TO ALl THE TERMS, EXCLUSIONS :i AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. `? NSR ADDL SUBH POUCY EFF POUCY D(P . TR TNPE OF INSURANCE INSR POLICYNUMBER MM/DD/YYYY MM/DDM'YY UMITS GENERAL UABIITY EACH OCCURRENCE $ �. COMMERCIAt GENERAL LIABILITY DAMAGE TO RENTED . $ � CiAIMS-MADE �OCCUR . t MED EXP(An one erson) $ � � PERSONAL&ADV INJURY $ ' i��' — ENERAL AGGRE AT S � ��' GEN'L AGGREGATE�IMIT APPLIES PER: PROD T -COMP P A S �� PRO- 'f POUCY JE T LOC � S � � � AUTOMOBIIE LIABILITY � COMBINED SINGLE LIMIT $ (Ea accident) .�� ANY AUTO BODILY INJURY(Per person) $ � ALl OWNED AUTOS � BODILY INJURY(Pei accident} $ '� SCHEDUIED AUTOS HIRED AUTOS �e�acR tle DAMAGE $ 'T $ NON-OWNED AUTOS ' S `t UMBRELLA LIAB''' OCCUR EACH OCCURRENCE S i IXCESS UAB CLAIMS-MADE AGGREGATE $ � '` � �DEDUC718LE � $ �. � FiETENTION $ $ ;� .� WORKERS COMPENSATION WC STATU- OTH ; rilA ,U8-9D848415-14 03/27/2014 �3/27/2015 X �kuur�Ts €s __, AND EMPLOYERS'UABIUTY �Y/N � - �� I ; ANY PflOPRIETOR/PARTNER/EXECUTIVE ❑ E.L EACH ACCIDENT $1 OO,OOO f � OFFICER/MEMBER EXCLUDED? � > (Mandatory in NH) E.L.DISEASE•EA EMPLOYEE $'I OO,OOO :- if yes,describe under . �°�� SPECIAL PROVISIONS below E.L.OISEASE-POLICY LIMIT $SOO,OOO 3 I � � � 1 DESCRIPT70N OF OPERATIONS/LOCAiIONS/VEHICLES(Attech ACORD 101,Additional Remarks Schedule,it rtwre space is requirad) � i _CERTIFICATE HOLDER CANCELLATION _ . € SHFttM INC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELIED BEFORE THE DBA HUNTERS GREEN MOTEL EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE 553 MAIN STRF�T ROUTE 28 WITH THE POLICY PROVISIONS. WEST YARMOUTH, MA 02673 �� AUTHORIZED REPRESENTATIVE � • ��, . j '; ° 1988-2009 ACORD CORPORATION. All rights reserved. � ; ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD :3 f . � NOTICE N � � NOTICE �. � TO W TO � �, ; � a � =� EMPLOYEES �� EMPLOYEES T �W / y� O,�M Sv� � ��- The Commonwealth of Massachusetts � DEPARTME�IT OF IN�USTRIAi. �CCI�E�tTS 600 Washington Street, Boston, Massachusetts 02111 � 617-727-4900 — htt : www.mass. ov dia ; p // g / � As required by Massachusetts General Law, Chapter 152,Sections 21, 22&30, this will give you notice that � I(we) have provided for payment to our injured employees under the above mentioned chapter by ; � ., msuring vv�th: � THE TRAVELERS INSURANCE COMPANIES : � NAME OF INSURANCE COMPANY � � P.0. BOX 1450 MIDD�EBORO. MA 02344-1450 � ADDRESS OF INSURANCE COMPA�TY � � , (IEUB-5E70975-7-15) 03-27-15 TO 03-27-16 ' � POLICY NUMBER EFFECTIVE DATES � _ � � Q� AUTOMATIC DATA PROC INS 1 ADP BLVD MS 325 � � � R05ELAND NJ 07068 � � NANIE OF INSURANCE AGENT qDDRESS PHONE# � �� i i � o� SHRIM, INC. 553 MAIN STREET ROUTE 28 ; � � DBA HUNTERS GREEN MOTEL o� WEST YARMOUTH '—� MA 02673 "� EMPLOYER � m_ ADDRESS — o_ f � � � o� EMPLOYER'S WORKERS COMPENSATION OFFICER (IF ANY) Dp� �.' — � �= MEDICAL TREATMENT � �� "� The above named insurer is required in cases of personal injuries arising out of and in the course of ` °= employment to furnish adequate and reasonable hospital and medical services in accordance with the ; � °'� provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the ` � °� injured employee. The employee may select his or her own physician. The reasonable cost of the services � � provided by the treating physician will be paid by the insurer, if the treatment is necessa and reasonabl � "— connected to the work related in'u . In cases re uir' � y � � ) ry q ing hospital attention, employees are hereby notified ` that the insurer has arranged for such attention at the `4 �♦ @ � " NAME OF HOSPITAL ADDRESS � � 0�2� ,�oP,�o2 TO BE POSTED BY EMPLOYER � � � � �: ,