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Home My WebLink AboutApplication and WC + � ' CD � TOWN OF YARMOUTH BOARD OF HEALTH �r, �! �� APPLICATION�FOR LICENSE/PERM�T �` b, �' � �� DtC "�� a 2C�t5 � * Please complete form and attach all necessary docu�,nts. �' e` er �"� EPT. Failure to do so will result in the return o�'your app'�°ication p N��R�lN�Yt- 1�oTolzc.AO C� E�TABLISHMENTNAME: �'1� Cr�4`��FTRZ MARIhICR LL � TAXID: LOCATION ADDRESS: .r'�� R�UTE 2 g ,l�t,^��('Y�12�'`�011'il'i �ME}--O�EL.#: �i0g-^�`�I��g$'� 1�AILING ADDRESS: g�3 R? 2& , �C-�3( �Pt��''l�(17f� ,M ��D26�-3 E-MAILADDRESS: mct�si'ne�smo�'a��od4� � 4.mctiL •c-arr� OWNERNAME: r'l�/� Cs�AYfF7�21 MAR�nt[�K LLC CORPORATION NAME (IF APPLICABLE): 1V�ANAGER'S NANtE: �CntrllS ��1-7e=L- TEL.#: �D�-��8'�� 1VIAILING ADDRESS: 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. _ _ 1. �i;►�tv`�-n�'f �'"��T C"� _:__ _ _ _ 2 �ar��l� ��(� _ —_ 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., D�N N l S f��`C��- 2. `�I P(K+A Pv�nt P�}`CCL 3. 4. F40D PROTECTION MANAGERS - CERTIFICATIONS: I� 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: Fach food establishment must have at least one Person In Charge (PIC) on site during hours of operation. _1. --__._ - -- - _ -----_ -- - -�-_____.�� - _ 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 pxovide new copies and maintain a file at your establishment. 1., 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich 1Vlaneuver 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. 4, RESTAURANT SEATING: TOTAL# ----_ -- -- — � — - - _ � _ ___ _. LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE P RMIT# —B� $55 —C�P $55 �MOTEL $110 _LODGE $gg $55 SWIMMING POOL$110ea. �07s _TRAILER PARK $105 �WHIRLPOOL $110ea. .. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE P �IT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 ,LCONTINENTAL $35 /(o�- 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: $15 AMOUNT DUE _ $ �7S•O O *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** . � ..�_, < ADMINISTRATION Under�hapter 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 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 sha11 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�or 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 fhe 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 fortns 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. 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 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 SITE PLAN. DATE: �T�/ � SIGNATURE: � � PRINT NAME&TITLE: 1��f/��S ��7�� Rev. 10/01/15 � � The Commonweadth of Massachusetts Department of Industriad Accidents Office of Investigations ' l Congress Street',Suite 100 Boston,MA Q21I4-2017 ' : � : www.mass.gov/dia � Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Le�iblv Business/Organization Name:_ M� G�R7f� R 1 i''i�R t/��i� [-L� Address: �'�3 RoUTC 2�� r,c��3T Y/4R+�ouTht, r'1�} -0 Z��-3 City/State/Zip: u��3'[ YA-I�Ma�N�M,�}-D26��,Phone#: h�4's-��1'—�$$� Are you an employer? Check the appropriate boz: Business Type(reqaired): 1.❑ I am a employer with employees (full and/ 5• ❑Retail - or part-time).*_�_ _ � _ 6. 0 Resta.urantBar/Eating Establishment __ __ - -- -- — - - - 2.Q I am a sole proprietor or partnership and have no �, � Office and/or Sales(incl.real estate,auto, e t c.) 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 10.0 Manufacturing no employees. [No workers' comp.insurance required]* 4.❑ We are a non-profit organization,staffed by volunteers, 11.� Hea1th Care with no employees. [No workers' comp.insurance req.] 12.�.Other d�(e�t (� *Any applicant that checks box#1 must also fill out ttie section below showing their workers'compensation policy' ormation. **If the corporate officers have exempted themseives,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#1. - - - I am an em.ployer that is providing workers'compensation insurance for my employees' Below is the policy information. � . �� Insurance Company Name: i _ I Insurer's Address: I � 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 a 152 can lea.d to the imposition of criminal penalties of a --�me up to I;3�6:��an�one-year impnsonmen,as wetl as civi pen ies�e o�rm o�a ER-and�a�ia�- � 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 f Investigations of the DIA for insurance coverage verification. I do hereby certify,under th pains and penalties of perjury that the injormation provided above is true and correc� Si ature: Da#e: 1 l �`� Phone#: ��`�-�"��.�� Official use only. Do not write in this area,to be completed by city or town offacia� City or Town: Permit/License# IssuingAuthority(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 �� DATE(MMiDD/YYYY) �,.. CERTIFICATE OF LIABILITY INSURANCE �,5 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND COPIFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVE�Y OR NEGATIYELY 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 hoider is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain poGc�s may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT �� V�� G.H.Dunn insurarxe Agency,Inc. - 64 F�rha�en Road �o►'� . (�)�-3248 �,q c,No�:(508)3�2-3243 e-ra� PO Box497 a�Ess: 1��@9�'►•� M8tt�0ISP.tt,MA 02739 INSURE S AFFORDING COVERAGE rWC g iNsu�A: NORFOLK&DEAHAM 2396,5 INSURED Maa Gayatri MarinPx LLC iNsu�s: dba Mariner Motor l.odge 573 M ai n St iasuR�rx c: Route 28 INSURER D: VUest Yarmouth,MA 02673 �asuR�e: . INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY il-IAT THE PaLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSLIED TO THE INSl�2ED NAMED ABOVE FOR THE POLICY PERIOD INDIGATED. NO'TWITHSTENDING ANY F�QU�MENT, TERM OR CONDITION OF AN1'CCN�lfRACT OR OT}�R DOCIAu�NT WI7H RESPECT TO WFqCH Tl-IIS CERIIFICATE MAY BE ISSUED OR MAY PERTAIN, Th� INSURANCE AFFORDED BY'IHE POUCIES DESCPoBED HEF�IN IS SI�JECT TO ALL 7HE lERMS, EXCLUSIONS AND CONDI110NS OF SUCH POUCIES.LIMITS SHOWN MAY HAVE BEEN REDl10ED BY PPJD CLAIMS. L�R TYPE OF INSURANCE POLJCY NINABER MMUCD/YYYY Mu/DD/YYYY LJMITS I GENERAL UASILITY FACH OCCURRENCE S COMMERCIAL GEt�RAL L64B�fTY O D PREAMS S Ea ocwrtence $ CLAIMSMADE �OCCU2 N�D E�(An one person) $ PERSON4L&ADV WJURY $ GENERALAGGREGATE $ GEPlL AGGREGATE LIMIT APPLIES PER: PRODUCTS-CONPJOP AGG $ ' POLICY �o- LOC $ I AUTOMOBILE LIABILITY ��nD SkJGLE L�AAIT ANY AlfiO BODILY IWURY(Per person) $ ALL ONrtJED SCF�DUI.ED BODILY INJURY Per accident $ AUTOS AUfOS � � NOPFOIM�ED PROPERTY DAMAGE � HIRED AUTOS q�pg Per accident $ I uM BRELLA uae OCCUR EACH OCCl�2RENCE $, F�(CE33 UAB C��E AGGREGATE $ OED RETEhITION S g A VYORKERS COMrlN9A710N V4E15850QA 0722/2015 07/22/2016 ��TATLL oTr+ AND EMPLOYERS'IJAdILJN Y/N � ANY PROPRIETOR/PARiNER/D�CUTNE r�� N/A E.L.EACH/�CIDEM $ SOO,OOO OFFICERlMEMBER E�LUDEDT L_� (Mandatory in NHj E.L.DISEASE-EA EA�PLOYEE $ �.� DYESCRIPTION OF OPERATbNS below E.L.DISEASE-POL�Y LIMIT $ SOO,OOO i �ESCWPTION OF 4PERAilONB/LOCATIONS/VEHICLES(Attach ACORD 707,Additional Remarlw 9chedule,ff more apace ia reqWred) FEIN 474285788 CERTIFICATE HOLDER CANCELLATION Fax#.(508)�0836 SMOULD ANY OF TME ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Yarmadh rHe EXPIRATION DATE THERE�, NOTICE WILL BE DELNERED IN 1146 Rt 28 ACCORDANCE 1MTH THE POLICY PROVISIONS. Saith Yarrrbuth,MA 02664 NJTHORI�D REPRESENTA7NE �� ` �.�y�..'....M.—�.....r+ � O 798&2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD narne and logo are registered ma�ks of ACORD