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Home My WebLink AboutApplication and WC , « b' V Woo a • TOWN OF YARMOUTH BOARD OF HEALTH ��. Q��C��I(�D � � APPLICATION FOR LICENSE/PERMIT��O'�� S� D�` .� � �01� `°' * Please complete form and attach all necessary docutri�nt�y Ilecent�i�r,:: S 2015. Failure to do s will result in the return of yc��ap�1ic�tr�ri pac et. HEALTM DEPT. W 061 �N�B IUNt, ESTABLISHMENT NAME: �'hcs.�`e-s l� ` TAX ID: - � LOCATION ADDRESS: ` c�. s'c O TEL.#: - �� 3 MAILINGADDRESS: �3C� _otr�rc�c��L��2o.\�-h �� 4Or� '`�,� ��1\\5 E-MAIL ADDRESS: ��C�,c�,�ve��zor � � OWNER NAME: Ch CORPORATION NAME (IF APPLICABLE): (' �C:,.�c �. ��e �,�(10,'�.Z�c, ' MANAGER'S NAME: � �\c� o�ssc� EL.#: , MAILINGADDRESS: 3�6 Cc�r��<s�,\ � �'� C''��\�� ', 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. �� , , _. � �� . � , � _ _ _. _� _� ��__-�. _ � c�r�� s-a� l �._ � y Pool operators must list a minimum of two employees currently certified in standard First Aid and Community li 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 I, y�ars' records. You must provide new copies and maintain a file at ur place of business. � I� 1. � � e ��J'y 2. Cr/1/�1�vi .�y � 3. 4. F�OD 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. N � �C i PERSON 1N CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. , 1. � � � 2. � , - - - - - - _-- ..R _ _...�—__�-___.— . _ I AL�,ERGEN CERTIFICATIONS: I All food service establishments are required to have at least one full-time employee who has Allergen certification, r as defined in t�ae 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.' N V'c 2. N � � � � 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 j attach copies of employee certifications to this form. The Health Department will not use past years' records. E You must provide new copies and maintain a file at your place of business. 1. �� I �� 2. �} l �. 3. 4. � , � RESTAURANT SEATING: TOTAL# ; f --- nFFTCF._U�E_QLYI.�--- - ___ _ -- ----- --- — _ I ------------------ � LODGING: � LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $110 � _[NN $55 CAMP $55 �SWIMMING POOL$ll0ea.�(o _LODGE $55 TRAILER PARK $105 WHIRLPOOL $110ea. 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: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED F PERMIT# LICENSE REQUIRED FEE PERMIT# � _<50 sq.ft. $50 >25,000 sq.ft. 85 VENDING-FOOD $25 <25,000 sq.ft. $150 _FROZEN DESSER $40 TOBACCO $110 NAME CHANGE: $is AMOUNT DUE _ $ !!0•OO *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** � ,_ � � � � , . _ ... ' S i� � � 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 Warker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE GOMPLETED AND SIGNED, OR CERT. OF 1NSURANCE 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 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 inspect�d 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 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.Xarmouth.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 COMMENCEMENT. RENOVATIONS MAY RE UIRE A SITE PLAN. DATE: (¢/�d �I S SIGNATURE: � PRINT NAME &TITLE: /�C�. Rev. 10/O1/15 a i � The Commonwealth ofMassachusetts _ Department of Industrial Accidents Office of Investigations ` 1 Congress Street, Suite 1 DO Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly ; Business/Organization Name: ("�rl Q s C.A�h:`�� (l c'q Q Y�� ' Address: ?�?� (�c�c�c��Y��.\�� City/State/Zip: S p \ Phone#: �\�-- �(o� '��-�3 Are you an employer?Check the appropriate boz: Business Type(required): , 1.❑ I am a employer with employees(full andl 5. ❑ Retail ; or part-time).* - 6. ❑ RestaurantBar/Eating Establishment � - --- -____ __ _ __ � _--� _ -- --- _ _ -- — - 2. I am a sole proprietor or partnership and have no - - - - 7.�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.❑ Manufacturing � no employees. [No workers' comp. insurance required]* 4.❑ We are a non-profit organization, staffed by volunteers, 11.0 Health Care , 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 organizaUon should check box#1. I am an employer that is providing workers'compensation insurance for my employees. Below is the poldcy information. � Insurance Company Name: � i Insurer's Address: � City/State/Zip: � I Policy#or Self-ins.Lic. # Expiration Date: � Attach a copy of the workers' compensation policy declaration page(showing the policy nnmber 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 C fine up to$1,500.00 and/or one-year impnsonmerit,—as weII-as ci�en t�tTie form o a ' �t�ana a�ne "- "" 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 certi ,under the ains and enalties of perjury that the information provided above is true and correct. I Si ature: Date: 10 Phone#: �! i � i Official use only. Do not write in this area,to be completed by city or town officiaL � City or Town: Permit/License# I 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 i ! —�'�'� CHARWHI-03 JLOOMIS j ��Y DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 10/31/2015 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 CERTIPICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED I REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. i ; IMPORTANT: If the certifcate 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 certiflcate does not confer rights to the certificate holder'sn lieu of such endorsement(s►. PRODUCER NAME'CT Jane K Loomis,CISR�CIC ' The Corcoran&Havlin Insurance Group aHONe -- Fa�c -- 287 Linden Street �ac ruo�exq:�781)235-3100 �ac,No�:(781)235-1622 Wellesley,MA 02482 E-Ma� — ADDRESS: �' INSURER(S)AFFORDING COVERAGE � � ' NAIC#� ._. _.____ _ . —_—___... ._ ; __ wsuReRa:Rockhtli Insurance Company i28053 ___ _ , �INSURED . . __.._. .__ __. ._..__ � � INSURER B HartFord Fire Insurance Company _ . _ .19682 _-- i Charles White Management Company iNsuReR c: f _ �-;��emm3^•.�aFlth Avenue wsuReR o: � BOStOI1�MA 02115 INSURER E: � � INSURERF:.. _. . .. ..._... . ..._.. _._.. .. .._ . _I.—.. . _. ;' 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. NOTWITHSTANDING 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'�. -�---�---��--��- ��-� ADDLSUBR �� POLICYEFF POLIOYEXP �� - � �7R NPE OF INSURANCE INSD WVD POLICY NUMBER �� I MMfDDIYYYY � MMIDDIYYYY ,� IIMITS A X'��,COMMERCIAL GENERAL LIABILITY '��. ' ', '��. , '��.EACH OCCURRENCE '�..$ 'I,OOO,OO ..�bAMAGETOR��D �- � �� J. � I � PREMISES(Ea_occurrenceZ__ $ � �� '�' _.. ... ...... ,, ,. . .. __.__._ ci.a,iMs-Mnoe X occuR RCGLPG01685-00 01/08/2015 01/08@016 _ I �� MED EXP(Any one person) $ 5,�� __ '� '�. � '� � �,PERSONAL&ADV INJURY �$ ��OOO,OOO � ,, .... .. .. --. i I ., .... _. . .. _ N'L AGGREGATE LIMIT APPLIES PER: � i �GENERAL AGGREGATE $ 2 OOO�OO __, — GE. POLICY PRO- -- ...- _ ._. JECT �LOC PRODUCTS-COMP/OP AGG $ Z OOO,OOO __ __- _... __._. � � OTHER: �, '�, � ,, .,', '� . . ,$ � AUTOMOBILE LIABII.ITY ', I, '�, � .COMBINED SINGLE LIMIT ��.$ � � . .. ., �,. I�.: Ea accident) _... . . .. _._._... ._.____. �'�,ANYAUTO � . . �, 'BODILYINJURY(Perperson) $ � �'�..ALLOWNED �'SCHEDULED j , I. BODILYINJURY Peraccident� $ �, 'AUTOS JI AUTOS � ) , HIRED AUTOS AUTOS I PROPERTY DAMAGE -�$ ��Perecudent) � + ...�NON-0WNED .,. . I''I ,',. �, ,,. - '.$ �. I '�,UMBRELLA LIAB � OCCUR . ', '�, ��EACH OCCURRENCE $ �. ��,EXCESS LIAB .. . ., � , .___ ... .._ ._.... . .____._ . ._. .. . ..._.. . ---1CLAIMS-MADE��. ..., �i, . ', AGGREGATE $ � .. ... , , -. .. ,, ,, �.. �.. , .. ._.____. .__.. . .. ._ .- ---- ..DED �'� �RETENTION$ '. '� �� .'. '. �'.,$ ��. 'WORKERS COMPENSATION Y,N ' I I X �.STATUTE '. I ORH- ' OFFCER/MEMBER EXCBL1U D? ❑ N/A � ,OY/OY/YO'IG E.L EACH ACCIDENT � $ �$OO�OOO ANYPROPRIETOR/PARTNER/EXECUTIVE �OHWBLDBYS3 '��OZIOY/YO'IS � �(Mandatory m NH) - ��. E.L.DISEASE EA EMPLOYEE $� � rJ0�,000 �� y ___ , _ ___ ji �If es.descnbe under �,,. i ... ..-- DESCRIPTION OF OPERATIONS below � �E.L.DISEASE-POLICY LIMIT'�.$ SOO�OO � �i �� . � . _._. _ ....____. . . . i ''. j �,, ',, . . ��,., . '. � DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES�ACORD 101,AtltlHional Remarks Schedule,may be attachetl i(more space is required) , CERTIFICATE HOLDER CANCELLA i ION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of YBmlouth THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN , YeIT110Uth,MA ACCORDANCE WITH THE POLICY PROVISIONS. � AUTHORIZED REPRESENTATIVE . �,��,.:4�,��1'r �nr J O 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD PDF created with pdfFactory trial version www.pdffactorv.com E