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�/� ► TOWN OF YARMOUTH BOARD OF HEALTH ����0���
� APPLICATION FOR LICENSE/�"��✓II`�'� � ,
� � � A�� i '� �O16
'`°� * Please complete form and atta.ch all necess� c�o ` � s� � ;' i� ber I S 2015.
Failure to do so will result in the retu�tif y °�p� at on pa ketNEALTH DEPT.
ESTABLISHMENT NAME: �� r TAX D• -
LOCATION ADDRESS: �35' Rovt'2 �.5� i�`P,..j'4r►�tou�-l��MA'Z?2673.TEL.#: �00-33�-C�3SZ2 .
MAILING ADDRESS: �35 �o�t� 2s� Wea� ,�ar•�ou� MA-026�.,4
E-MAIL ADDRESS: -'T;�IQ we�-e r i3 S C�g�a��•co� .
OWNER NAME: ��Ar�r�c ��i9T�
CORPORATION NAME (IF APPLICABLE): H r T� �G-
MANAGER'S NAME��A R TFt `/?R 7' TEL.#:Q�-� gS 19 $'a3']
MAILING ADDRESS: �� �ttt'i•H S'�13(�4u�.,�•co� •
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.
l.�rvi5� �7'� 2. C.'HAR�.S �� ��{Gt.�.u.d1 �t�.
Pool operators must list a minimum of two employees currently certified in standard First Aid and Community
Cardiopulmonary Resuscitation (CPR), having one certified employee an 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. ��r�f /�r" TF� 2. Nic� ' Q.
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. ��rx T�T'�G ��P��( ��' 2.
PERSON 1N CHARGE:
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
___1_. t��RTH �.4T�� 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.
l. C�SA �As�.,,���� 2. ���,� ���5 .
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. '
�
1. � I ' 2. U ir�� �Cl�
3. 4.
RESTAURANT SEATING: TOTAL# ,
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE P RMIT#
B&B $55 CABIN $55 MOTEL $lI0
_INN $55 CAMP $55 �SWIMMINGPOOL$110ea. S 0(o(n '
_LODGE $55 _TRAILER PARK $105 _WHIRLPOOL $110ea. o �
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FOOD SERVICE:
T.l��NSF REQi TTRED FE�-- ItivlI�'-# I,ICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# i
( 0-100 SEATS $125 .���J�-(�� CONTINENTAL $35 NON-PROFIT $30 �
_?100 SEAT; $200 �COMMON VIC. $60 � _WHOLESALE $80 �
RE'I'AIL SER�ICE: —RESID.KITCHEN $80 �
LICENSE REC�UIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# '
<50 sq.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 �
<25.00Os .ft. $150 _FROZEN —
DESSERT 40
9 $ TOBACCO 110
-- $
— _ i
i
NAM�Cl-�ANGE: $�s AMOUNT DUE _ $ -rv t�j. �d �
*****PLEASE TURN OVEK AND COMPLETE OTHER SIDE OF FORM*****
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, ADMINISTRATION j
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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 '
i
CERT. OF INSURANCE ATTACHED �f
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
i
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MOTELS AND OTHER LODGING ESTABLISHMENTS �I
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 I,
an aggregate of not more than ninety(90)days within any six(6)month period. Use of a guest unit as a residence or I
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 II
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.
- 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.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.
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 ESTA$LISHMENT, MOTEL OR PUOL (i.e., ��Ir�-;-?'?F�' -_—
EQUIPMENT, ETC.),MUST BE REPORTED TO AND APP OVED BY THE BOARD OF HE,��.TH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY REQ �SITE PLAN.
nATE: '4��I � �G SIGNATURE:
PRINT NAME&TITLE: r�h � � ���
Rev. 10f01/15
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� The Commonwealth ofMassachusetts
Department oflndustrialAccidents
V Office oflrrvestigatior�s
�
t I Congress Street,-Suite 100
;
Boston, MA 02II4-2017
i www.mass.gov/dia
� Workers' Compensation Insurance Affidavit: General Businesses
� Annlicant Information Please Print Legiblv
Business/Organization Name: �A R� ►-�o SP ITi4L�T y �vL �8A CTi oF�w47E,�i,y,vJ
Address: t35 r`�o utp �,�
City/State/Zip: �esF r ou� HA- Phone#:_ �oo-- 3q�-6��
Are you an employer?Check the appropriate boz: Business Type(required):
1•�am a employer with�_employees(full and/ 5• ❑ Retail
or part-time).* 6. ❑RestaurantlBaz/Eating Establishment
2.❑ I am a sole proprietor or partnership and have no
employees working for me in any capacity. �• ❑ Office and/or Sales(incl.real estate,auto,etc.)
[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]*
4.❑ We are a non-profit organization,sta.��ed by volunteers, 11.❑ Health Care
with no employees. [No workers' comp. insurance req.] 12.❑ Other
*Any applicant that checks box#1 must aiso 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 am an employer that is providing workers'compensation insurance for my employees. Below is the policy information.
Insurance Company Name: �t�AyC,H£X �NS URA �1C-"� , �n►�.
Insurer's Address: /JTD �JA�.1("�I�A S S ��/4/V'� .
City/State/Zip: ��GN F,S T�'� A�Y /46 �2� .
Policy#or Self-ins.Lic.# U� q F 3 o i c 5 A Expira.tion Date: 3 I Q����7 .
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 and/or one-yeaz imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certi ,uri er the 'ns and penalties of perjury that the information provided above is true and correct.
� Si ature: _ _ Date: � d /6 .
i .
� Phone#:
Official use only. Do notwrite in this area,to be completed by city or town offuial ,
City or Town: Permit/License# ',
Issning Authority(circle one): ,
1.Board of Health 2.Building Department 3. City/Town Clerk 4.Licensing Board. 5.Selectmen's Office ,
6. Other
Contact Person: Phone#:
www.mass.gov/dia j
�� CERTIFICATE OF LlABILITY INSURANCE o3iio o°Mis`""
HIS CERTIFICATE IS ISSUED AS A MATTER OF INFdRMAT10N ONI.Y AND CONFERS NO RKiH'f3 UPON TFtE CERTlFICATE HOLDER. THIS
CERTIFICAtE DQE3 NOT AFFIRNIATIVELY OR NEGATIVELY AMEN�, EXTEND OR AITER THE COVERA(iE AFFORDED BY THE POlICIES
BELOW. TI�S CERTIFlCATE OF INSURANCE OQES NOT CONSTITUTE A CONTRACT BETWEEN THE tSSUiNG INSURER(S), AllTNORIZED
REPRESENTATIVE QR PRODUCER,At�THE CERTIFICA'i'E HOIDER. ',
IMPORTANT: if the certiflcats hoider fs an ADOITIONAL INSUf�D,the poticy(ies)must be endorsed. If SUBRO(3AT10N IS WANED,subject to �
the tem�and co�diUons of d�e policy,cerfain policies may raqWw an�dorsamaot A sqitement on this cartiticafe does n�confer rights W the !
certlficate hoider tn lieu of such endo s. �
PRODUCER '� . PaY�ex in8uranee A9encY.Inc. ,..,'�..
Paychex Insurance Agency, inc. • �—
150 Sawgrass Drive �� �����"�� "'�
Rochester,NY 14620 '
877-266-6850 � �O�N°�OV�"Gf �*
. ���A: THE TRAVEL£RS INDEMNITY COMPANY OF CONNECTICUT zN�Bz
INSURED . � MISURERB: .
HARI HOSPITAl17Y, INC. ���.
DBA TIDE WATER INN
135 ROUTE 2$ "�"�tOt
WEST YARMOUTH,MA 02673 "'�'�E'
Hsur�F•
COVERAGES CERTIF{CATE MJMBER: REVtS�ON Nt�AQER:
THIS IS TO CERTIPY THAT THE POLICIES OF INSURANCE USTED BEIOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOO
INDICATED. NOTWITMSTANDING ANY REQUIREMENT,TERM OR CONDITIO�J OF ANY CONTRACT OR QTHER DOCUMENT VNTH RESPECT TO WHICW THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,TNE INSURANCE AFFORDEO BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO AlL THE TERMS,
EXCLUSlONS AND CONOITIONS OF SUCH FOLtGES.UMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CWMS.
fN8R E IYPE OF INSURANCE NUYBER' M LIMITS
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(tMyam,labry IntNiy E.L DISEASE•FA EMPLOYE S t00.4o0
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DESCRIPTfON OF OPERATlON8 I LOCATIONS/VEHICLES{Atboh ACORD 101.Additlond R�marq SolyduM�M mo�sp�os h�quk�d)
CERTIFICATE MOIQER CANCELLATION
SHOULD ANY OF THE ABOYE DESCRBED POIICiES BE CANCELLED BEFORE THE
C LI E NT (�QOO��9X4H EXPIRATiON DATE THERE��,NQTICE NALL BE DELIV6RED IN ACCORDANCE NfITH 7HE
POLICY PROVISIONS.BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPQSE NO
OBLIGATION OR LfABIiITY OF ANY KIND UPON THE COMPANY,ITS AGENTS,OR
REPRESENTATIVES.
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1588-207Q AGORO CORPORA I . Ai rights reserved.
AGOR47 25{20l0105} The ACORD name and iogo are regis�red marks of ACORD
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