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Home My WebLink AboutApplication and WCC ac�� o �o � ► TOWN OF YARMOUTH BOARD OF HEALT v x- � � APPLICATION FOR LICEN�:�� «T�� P y : At ��; `; S ��r ""� * Please com lete form and attach all nec�;�ary .F��r� �ce ber S 2015. ' Failure to do so will result in the rc�t�rn o�yar'i�application pa EPT. ESTABLISHMENT NAME: o Z Crn+M T ID: �� LOCATION ADDRESS: � TEL.#: O�-6/9 33��- 1VZAILING ADDRESS: E-MAIL ADDRESS: � ��'r� O�UNER NAME: 1-�. CQRPORATION NAME (IF APPLICABLE): a MANAGER'S NAME: TEL.#: l�t�� - O MAILING ADDRESS: r P�OL 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 Cardiopulmonaty 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 y�ars' records. You must provide new copies and maintain a file at your place of business. 1.I 2. 3. 4. ' 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 IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) 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 and maintain a file at your establishment. i i 1.'' 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' r�cords. You must provide new copies and maintain a�le at your place of business: 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# ' LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $110 I� $55 SWIMMING POOL$110ea. _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 >IOO 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 $11-0 d NAME CHANGE: $IS AMOUNT DUE _ $ 2lp0.OO *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** �, __ ., 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 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 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 inspectecl 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 Departrnent prior to opening. Please contast�th�- 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.yarmouth.ma.us under Health Department, Downloadable Forms. FROZEN DESSERTS: � I 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 REQUIRE A SITE PLAN. DATE: r�� ( � "�� SIGNATURE: �� PRINT NAME & TITLE:��;�'�,..n�. f`c� ld-Q►�t�� Rev. 10/O1/15 � The Commonwealth ofMassachusetts '' ` Department of Industriat Accidents Office of Investigations ' I Congress Street, Suite I00 Boston,MA 02114-2017 . www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information ' Please Print Legiblv Business/Organization Name:��C.(�.� � (a(� �'TO'7� Address: � � �� City/State/Zip:��- � 6�� Phone#: cSQ 8= ��" Are you an employer?Check the appropriate boz: Business Type(reqnired): � 1.❑ I am a employer with_�_employees(full and/ 5. �'Retail ___ _ Q�art=tune).* _ _ _ _ __ _ 6. ❑RestaurantJBaz/Eating Establishxnent _ � _ _ � -- —_ _— _ _- -- _ - -- -- -- -- � _ 2. I am a sole proprietor or partnership and 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 ha�e 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 aze a non-profit organization,staffed by volunteers, 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 organization should check box#1. I am an employer that is providing workers'compensation insurance for my employees Below is the policy infarmation. Insurance Company Name:�I,+�,�G� �'Y�.SL(� G�� Insurer's Address:�c�7 �t�1sf Q� ��YI�EII A�! q�;� � �V cr�yiv �/��/()(cx�� 9a ,.� City/State/Zip:H�cfZ'11'1�" .� 1�� ' � �°2�O� Policy#or Self-ins. Lic. # �D/�/P ��3� ��w��c�� Expiration Date: � �r '� �d�� Attach a copy of the worke csr ompensation policy declarai�on page(showing the policy nnmber and egpiration date). -----__._ Failure to secure coverage as required under Section 25A of MGL c. 152 can lea.d to the imposition of crimina.l penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civi p'I—ena7t�es m e orm o a 1�K�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,under the pains and penalties ofperjury that the information provided above is true and correc� Si�nature: 17� 1� Date• t�^ ��'�� Phone#: �-�`LI� �6�' �.�� Official use only. Do not write in this area,to be completed by city or town offaciaL City or Town: PermitlLicense# 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 Client#:7618?S 2p'rp21 ACORQ,. GERTIFICATE OF LIABILITY INSURANCE DA�(�� 1?,/n9rt015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERIIFICATE HOLDER.THIS CERTIFICATE DOES NQT AFFlRIAA7IVELY OR NEt3AT1VELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELpW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTIT'UTE A CONTRACT BETWEEPI THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND TME CERTIFICATE HOLDER. IMPORTANT:If the certlficate holder is an ADDITIONAL INSURED,U�e poiicy{bsj muat be endorsed.lf SUBR0�3ATION IS WAIVED,subject to the terms and conditbns of the pofky,certafn paikks may requh�e an endoreemerrt.A atatemeM on th(s certificate dces nat confer rights to the cerNfk�te hotder M Ibu of such endoraem�t(s). a�ucEa Na�: Dbwlit�&O'Neil Msurance Ag " ;Spg 7�rr1g2p No:5p877$1218 973 lyannough Rd,PO Box 1990 e.�uu� Hyannis,MA Q2601 " 508 775-1620 u�►� ��aaNa cov�e►cc� w►�c s �e�,r�e A:�Y Inclemnity �"su�� u�sue�r►s:Guard InsurenCB Group Poojanery Inc.DBA A to Z Convenience 88 Constance Avenue INSURER C: West Yarmouth,MA 0�'JS �Msur�o: INSURER E: INSURER F• COVERAQES CERTIFICATE NUMBER: REVISION NUIIABER: THIS 13 TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEM ISSUEQ TO THE INSURE'D NAMED ABOVE FOR THE POLICY PERiOD INDICATED. NOT4VITHSTANDING ANY REQUIREMENT, TERM OR CONDITIONI OF ANY CONT'RACT OR OTHER DOCUMEM' WITH RESPECT TO WHICH THiS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY Tl� POI.IC{ES DESCRlBED HEREIN IS SUBJECT TO ALL TFfE TERMS, IXCLUSIONS AND CONDRIONS OF SUCH POI.ICIES. LIMITS SHOWN MAY HAVE BEEN REDtK;ED BY PAID CLAIMS. �R IYPE OF INSURANCE 1 � POLICY NUMBER � u�rrs q °�ER^�u"siun' BMA0023631 5/2015 05h 5r201 EACH OCCURRENCE $ Opp ppp X COMMFACIAL CiENERAL LIA�LITY PRENASES Ee oc�ai er�ce $�OO OOO CLNMS-MADE �X OCCUR MED IXP A one } ��Q�QQQ PERSdNAL$AOV INJURY t {IOQ OO(� QENERALA�Cif3qECiHTE $4(�Q� dEN'L ACiQRECiATE t1MIT APPl1ES PER: p��.�P��Q $ �0� POUCY P� lOC g AUTOMOB�LE LJABILITY t;pM�NED SNVCiLE L1MIT !Ea aoeider�tl ANY AUTO BOpILY IN,�JRY(Per person) $ AILOWNED SCHEDULED .. . AtlTOS AUTOS BODILY INJURY(Per accident) y HIFiED AUTpS q��ED PROPERTY DAMAf�E $ � S � UMBRELLA LJAB �� EACH OCCURRENCE $ r EXCE88 UAB f�/UMS-MADE . aOCiREdAh $ DED RETEMION $ B wor�eQes oaM�r�►T� POWG863386 2r2015 02/1?1.201 X wc srA�ru- oTM- AND EMPLOYEFiB'LIABILITY • ANY PROPR�TO(�ARTNER/EXECUTiVE Y/N E.L.EACH ACCIDENT S� � OFFICEWMEMBEREXCLUDED? a N/A ff�� E.L.DISEASE-EA EMPLOYEE SSOO OOO DESCRIPT10P1 OF OPERATIONS bebw E.L.DISEA�-POUCY LIMIT Sr WQ . ��RIPTION�CPERAT�I IOCATIONS/VEHICLES(Attseh ACORD 101.Addi�ia�ai Rrmsrks SehatlW0.H mon spseo b roelui►ed) Irisurance crn►erage is lim�ted Uo tt�e terms,c�nditions,exclusions,�limitatbns and endorsements. Nothing contained in the c�tificabe of insurance shaii be de�med to ha+re aftered,waived,or extended tt� ��erage provit�d aY�e paicY i�visions. CERTIFlCATE HOLDER ��.n� Town of Yarmouth s�+ou�a arnr oF rHe�sovE o�scr�o Paaaes ee C�uEu s�oRE 1146 Roube 28 "�+e �w►noN w►� rr��, � vwu. ee oeuv� ia accor�„wcE wrrH TMe �ouc�r �+ovis�s. Sot�itf Yarmouth,MA 02664 11U7NORI�D REPRESENTATIVE �198&201 O ACORD CORPORATiON.AII righlas reserved, ACORD 25(201Ql�5) � pi� The ACORD name and logo are registered rna�ks of ACORD �5162209VM162206 CBD