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Home My WebLink AboutApplication and WC� 1 �� ' TOWN OF YARMOUTH BOARD OF HEALTH '��O�IC�DD � �• . � � APPLICATION FOR LICENSE/P��VI� `� 1��2 �A�1 Q� zO16 ..... ' * Please complete form and attach all necessar�docu en by Dece er 1 S 201 S. ' Failure to do so will result in the return ofyour applicafion pa ket. EPT. E�TABLISHMENT NAME: � T ID: � LOCATION ADDRESS: �J�,pqDc/ T� •Z�,.��IC�t/1- TEL.#: � ��J- �� -�/�/ 1VIAILING ADDRESS: • E-MAIL ADDRESS: �� C .Z �l/C� • L ' OWNER NAME: ��C C�L r7 �l1"r� 1�t'� CORPORATION NAME (IF APPLICABLE): �N� . N�ANAGER'S NAME: ./��f� C�'L'� TEL.#: - }�l MAILING ADDRESS: PbOL 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. i L 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 witl not use past years' records. You must provide new copies and maintain a file at your place of business. 1.' 2. � 3. 4. i 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. i You must provide new copies and maintain a file at your establishment. ! 1. ./��i �C� D ,�l/f� l/!� 2. ��v� � yO (�� PERSON 1N CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. .�.�/�' C�� r/r� �/� 2. ,�9�� ¢ �L/v e/� 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.: /��i�� /l/C� (�� 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. 1, 2. : 3. q,. RESTAURANT SEATING: TOTAL# c510 OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&B $55 CABIN $55 MOTEL $110 —I� $55 CAMP $55 SWIMMING POOL$I l0ea. _LODGE $55 _TRAILER PARK $105 _WHIRLPOOL $110ea. FOOD SERVICE: L�CENSE REQUIRED FEE P RMI # LICENSE REQUIRED FEE PERM[T# LICENSE REQUIRED FEE PERMIT# i 0-100 SEATS $125 F _ CONTINENTAL $35 NON-PROFiT $30 _>100 SEATS $200 �COMMON VIC. $60 �� =WHOLESALE $80 RETAIL SERVICE: —RESID.KITCHEN $80 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: $is AMOUNT DUE _ $ 18S od E � *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** � i � . : __ � r y � } 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 Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE 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 lir�itations 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 mare 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 inspected and opened. I 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 obtamed 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. j 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 j TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. � 7 SIGNATURE: �- �'�� DATE: / �` � � � PRINT NAME&TITLE: ��1 �'E' � O lI/d �C� � O �/�/� � � Rev.10/O1l15 a a F � � The Commonwealth ofMassachusetts � Department of Industrial Accidents ; Office of Investigations ± ` ' 1 Congress Street, Suite 100 ' Boston,MA 021I4-2017 � www.mass.gov/dia , Workers' Compensation Insurance Affidavit: General Businesses : � Apulicant Information Please Print Le�iblv Business/Organization Name: , Address: � � City/Sta.te/Zip: Phone#: Are you an employer? Check the appropriate boz: Business Type(required): 1.❑ I am a employer with employees(full and/ 5. ❑Retail or part-time).* 6. ❑ RestaurantlBar/Eating Establishment 2.❑ I am a sole proprietor or partnershig�a.nd have no �, � 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 a 152, §1(4), and we have 10.0 Manufacturing no employees. [No workers' comp. insurance required]* 11.� Health Care 4.❑ We are a non-profit organization,staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.0 Other *Any appiicant that checks box#1 must also flll 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: 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 ezpiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lea.d to the imposition of criminal penalties of a 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 certify,un r the pains and penalties of perjury that the information provzded above is tru and correc� �. � � Si ature: ` Date: Phone#: Official 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 f 6.Other � { Contact Person• Phone#• i www.mass.gov/dia ; � � --'""�"1 M8�PSUBS-01 SWAINWRIGHT A��9 CERTIFICATE OF LIABILITY INSURANCE DAT�(MM/DD/YWY) 1/6/2016 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 certi�cate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Rogers&Gray Insurance Agency,IIIC. PHONE Fnx 434 Rte 134 �uc No E,a: ac No South Dennis,MA 02660 E•MAIL ADDRESS: INSURER�S)AFFORDING COVERAGE NAIC# iNsuReRa:Norfolk 8�Dedham Group INSURED INSURER B: M&P Subs,IIIC. INSURER C: 40 Virginia St. iNsuReR�: West Yarmouth,MA 02673 INSURER E: 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. NOTIMTHSTANDING 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 7ypE OF INSURANCE POLICY EFF POLICY EXP �TR INSD NND POLICYNUMBER MM/D�VYYW MM/DQNYYY LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ ��OOO�OO CLAIMS-MADE � OCCUR R7473744A 12/10/2015 72/10/2016 pREMISES Eaoccurre�ce $ MED EXP(My one person) $ rJ,�� PERSONAL&ADV INJURY $ ��OOO�OO GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ Z�OOO�OOO X POLICY�jE�T � LOC PRODUCTS-COMP/OP AGG $ Z,OOO,OO OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea acciderrt ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY Per accident $ AUTOS AUTOS � ) NON-0WNED PROPERTY DAMAGE HIRED AUTOS AUTOS Per acciderrt $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSAT1pN PER OTH- AND EMPLOYERS'LIABILITY �,�N STATUTE ER A ANYPROPRIETOR/PARTNER/EXECUTIVE WE145863A 12/09/2015 72/09/2016 E.L.EACHACCIDENT $ ��0�� OFFICER/MEMBER EXCLUDED? ❑ N/A r �Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ �,OOO,OOO If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POUCY LIMIT $ ��OOO�OO DESCRIPTION OF OPERA710NS/LOCATIONS/VEHIC�ES (qCORD 101,Additional Re�rks Schedule,may be attached�more space is required) CERTIFICATE HOLDER CANCELLATION i SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE ' Town of Yarmouth THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN � 1146 Route 28 ACCORDANCE WITH THE POLICY PROVISIONS. � South Yarmouth,MA 02664 � AUTHORIZED REPRESENTATNE j �� /� Ei f �O 1988-2014 ACORD CORPORATION. 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