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Home My WebLink AboutApplication and WC ,� ` � ► TOWN OF YARMOUTH BOARD OF HEALTH ��D � � APPLICATION FOR LICENSE/PEitI��T �:2;01 :� MAY , 6 ZQ16 ..,, `'' � ' ' � * Please complete form and att�ch all necessa �o � e�' t�t'1��IS H DEPT ' Failure to do so will result in the return�yc��p�ic�oi �c E�TABLISHMENT NAME: � 'T U ' N"� TA ID: — LOCATION ADDRESS: ��7� �oU'�'E Z j� �ov YN �R-R Il0(TfI� n� oZ6G4TEL.#: S0�`�Cf�"�O 1VZAILING ADDRESS: n�(, �"1�Z� S��`�'K / ,�2 Ylrvt(� , 1'�A ��j E-MAIL ADDRESS:__ Y g A� t 1�I°'E�c �.��-�1 pC� e �D h OWNER NAME: t �I! t CORPORATION NA E (IF APPLICABLE): � (1 IV �� (°� S' LL G MANAGER'S NAME: V�S � N 1� � TEL.#: O — —�" 40 MAILING ADDRESS: Z 0�TG( p 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. 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 will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 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. 2. - P��or�mT c��: - _ _ _ _ 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. L 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. , � l. 2_ i 3. 4. i RESTAURANT SEATING: TOTAL# 3U ; i OFFICE USE ONLY LODGING: ' LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&B $55 CABIN $55 MOTEL $110 ' �� $55 SWIMMING POOL$110ea. _LODGE $55 =TRAILER PARK $]OS _WHIRLPOOL $110ea. I FOOD SERVICE: LICENSE REQUIRED FEE P RMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# I 0-100 SEATS $125 �((0-163 CONTINENTAL $35 NON-PROFIT $30 � _>100 SEATS $200 1 COMMON VIC. $60 � —WHOLESALE $80 RETAIL SERVICE: —RESID.KITCHEN $80 � LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUtRED 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 _ $_/H S. OO *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** i a. , ' ADMINISTRATION ' $ ; Under Chapter 152, Section 25C,Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal I, 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 ' i 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 i 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 i 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. i '� 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. '� i 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 RETLTRN 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: SIGNATURE: PRINT NAME&TITLE: Rev. 10/01/15 i 1 � � �� '`�' ,� The Commonwealth of Massachusetts � `� a,:�- �r. °_ Department of Industrial Accidents " Office of Investigations , ` 1 Congress Street, Suite 100 Boston, MA OZll4-2017 - - www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Le�iblv Business/Organization Name: �/11 t3 � ti� � pR i s� LL� Address: I O�6 )�QVT� �$ City/State/Zip: �(�U�K R I�� M��Z�� Phone #: So�— �4 $'= S6 �Cg Are yqu an employer?Check the appropriate boz: Business Type(required): 1.�I am a employer with�employees(full and/ 5. ❑ tail or part-time).* 6. Q"RestaurantBar/Eating Establishment 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] 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.❑ Manufacturing no employees. [No workers' comp. insurance required]* 4.❑ We are a non-profit organization, staffed by volunteers, 11.❑ Health Care with no employees. [No workers' comp. insurance req.] 12.❑ 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 information. Insurance Company Name: �,'�{�� NO t/ f /U Sv �1V CE �} ('y��/ �°�/C I Insurer's Address: � y '�� f�v��Q.s Q� 0 �r��' S 7 � �,�� City/State/Zip: �.� � � �� s � � � � � 2� .� Poticy#or Se�f-irts��,��-#�— — - E xpiration Date: Attach a copy of the workers' compensation policy declaration page(showing the policy number and ezpirat�on 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-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 cer ,under the pains and penalties of perjury that the information provided above is true and correct. Si ature: �� Date: J� � v Phone#: ��0�G �� 5G �p 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 � 6.Other Contact Person: Phone#: � www.mass.gov/dia l � I � i � -- ---- -____------ ' '`�c�� CERTIFICATE OF LIABILITY INSURANCE °�'�`�"�°'"�'"' 5/12/16 T RTIFICATE IS ISSUED AS A MATTER OF II�ORMATION OI�Y AND CONFERS NO WGHTS UPON THE CERTIRCATE HOLDER TFRS ! FICATE DOES NOT AFFIRMA7lVELY OR NEGATIVELY AAAEI�, E)CTEI� OR ALTER TFE COVERAGE AFFORDED BY THE POLIqES �� LOW. TF�SS CERTIFlCATE OF INSURANCE DOES NOT CONSTITU7E A CONTRACT BETWEEN THE ISSUING INSURER(S), AUiHORIZED PRESENTA7NE OR PRODUCER,AND THE CERTIFlCATE HOLDER. ' �►VIPORTANT: If the certificate holder is an ADD1710NAL INSURED,ihe policy(ies) must be endorsed. If SUBROGA710N IS WAIVED,subject to ! the terms and con�itions ofthe policy,certain policies may rec�ire an endorsement A sta�errferrt on tMs certificate does not conkr righfis bo tl�e ' ? certificate holder in lieu of such endorsement(sy. % PROqJCER + NAIY�: R3 Travers Chagnon Insurance Agency, Inc. P�E . (�jOE) 771-1660 �'X N ; (508) 775-1135 � PO Box 355 AD��; raytraners@ciai.nsurance.net � 411 Route 28 INSURE S AFFORDINGCOVERAGE NAIC# West Yarmouth, 1� 02673 �r�R�a:Harford Insurance �Co �ratat� INSURER B: YI� Enterprises LLC i�Re�c: dba Big Al's Breakfast and Lun i�R�p: 1074 Route 28 INSURER E: So Yarmouth, 1+�. 02664 �NSURERF: COVERAGES CERTIFICATE NUMBER: REVtSION NUMBER: Tti1S IS TO CERTiFY THAT THE POLIC�S OF INSURANCE LISTED BELOW HAVE BEEN (SSUED TO THE INSIk�ED NAMm ABOVE FOR THE POUCY PERIOD INQICATm. NOTiMTHSTANDMG AN`f REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WI'i'H RESPECT TO WHICH THIS CERT�ICATE MAY BE ISSUED OR MAY PERTAW,THE WSURANCE AFFORDED BY TFE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDIT40NS OF SUCH POLICIES.LAVIffS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. �LTR TYPEOFINSURANCE A�L� POUf.1f NUIIBER M�KEFF ��d�Y u�� A ��i4L1-1A'B��TM BEING ISSUED 5/18/16 5/ie/i� �cHoccuw�ce s 1 000 000 X COANNERCIALGENERALLIABII.ITY � DAM4GETORENTED $ lOO OOO CLAIMS-MADE �OCCUR . _. MED EJ�(Ary one persm) $ rj �0� r�SOw�La aoV IwURY $ 1 OOO OOO ceNEwu.AGCREcare $ 2 OOO OOO 6EN'LAGGREGATELMITAHPLIESPER PRODUCfS-CflIV�/OPAGG $ Q OOO OOO POLICY PRo- �p� S AUTOMOBILELIABILITY C IrBINED W L LIMR a axidert g ANY AU'Ip � - • BODILY INJURY(Per person) $ ALLOWPED SCHEDULED ' BODILYINJURY Peraccident $ AUTOS AUTOS � ( 1 HIREDAUTOS NON-OWNED PROPERf`f DAMAGE _AUTOS Peracciderrt � ' $ UNBRELLA uA6 Q��R EACH OCCURRENCE $ -" EXCESS LIAB CLAIMS-MA� AGGI�GATE $ DED RETENTION$ '�_ $ A uwRKERS coMPENsaTlow BEING ISSUED 5/18/16 .5/18/17 1Nc STaTu- pTH_ AND EMPLOYERS'LIABILII'Y Y/N �. _.a�nr�x�aiFrowaatn��cu-rn�.____. _ __500 OQOA___ �FI�RIN�MBER IXCLIAED? � N%A _ __ __ .__ _-- - - -- - '.- G.L.EACH ACqOEWr — .__ -g- (AAandaeory in NH� E.L.DISEASE-EA 9uPLOYEE $ 'Jr��,�� If Yes describeunder DESG�RIPTION OF OPERATIONSbelow EL.�ISEASE-POUCY L9�AR $ rJOO,OOO OESCRiPT10N OF OPERATIONS 1 LOCAT10N5/VEF9CLES (,4ttaeh pCpRp�p1,pdaho�al Rertarks gq�ed�e,if more apace is requ rad) Breakfast and Lunch Restaurant �. __ - <-a" CERTIFICATE NOLDER CANCEi.LAT10N ' SNOULD ANY OF THE AHOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DA7E THEREOF, NOTICE WILL BE DELIVERED IN i TOWn of Yarmouth ACCORDANCE WI7H iHE POLICY PROVISIONS. � Rt 28 � ; So Yarmbuth Ma. 026, Aun�or��r+�s�rn � i � �