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a TOWN OF YARMOUTH BOARD OF HEALTH
� � APPLICATION FOR LICENSE<P I�IT�� RECEIVED
�"° * Please com lete form and attach all nec,e�s � m „ s em 0
P ���� t �'�.
Failure to do so will result in the���rn��r�l�t� pac . �6
E�TABLISHMENT NAME: w o o � � TAX •
LOCATION ADDRESS: �- � TEL.#: a � -��I
MAILING ADDRESS: 1- � �1-
E-MAIL ADDRESS: G � �! t.,, Gow(
OWNER NAME: ow N N � L�-�.
CORPORATION NAME (IF APPLICABL ):
1VIANAGER'S NAME: w �J TEL.#: '�iZ -�
MAILING ADDRESS: A � n�c:� t. ' �
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.
�. � w�e� p,�� Ic 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.
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 atta.ch 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.
PERSON 1N 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.
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.
1. 2. '
3. 4.
RESTAURANT SEATING: TOTAL# I
OFFICE USE ONLY Na� OP€�vr�t� 0��002 f ooLS, !
LODGING: Lt c�►S��G iN�002 t W�D��POO LS.
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# I6��;
_B&B $55 CABIN $55 �MOTEL $110
_INN $55 CAMP $55 v' SWIMMING POOL$110ea. f � '
_LODGE $55 TRAILER PARK $105 ��-WHIRLPOOL $110ea.���03Z!
FOOD SERVICE: �1�O�0C�6��t�-081
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
0-100 SEATS $125 _CONTINENTAL $35 NON-PROFIT $30
_>l00 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 �
I
NAMECHANGE: $�s AMOUNT DUE _ $ ��O.00
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** �
t
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!
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 C MPENSATION 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 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 shall generally refer to continuous occupancy of not more than thirly(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.
POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate coua�t '
by a State certified lab, and submitted to the Health Department three (3) days prior to opening, and quarterly �
thereafter.
E
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
obtamed at the Health Department,or from the Town's website at www.yarmouth.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 COOKING:
Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited.
NOTIC'E: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 i
EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY REQUI ITE PLAN.
DATE: �,p'��6�(l,, SIGNATURE: ,
i
PRINT NAME & TITLE: w
Rev. 10/O1/15
6
INFORNlATION PAGE RENEWAL AGR£EMSNT
Insurer: PRODUCER: Agent# 13?
MA Retail Merchants WC Graup Inc. Boynton Insuarance Agency Inc.
PO Box 859222-9222 72 River Park St
Braintree, MA 02185 Needham, MA 42394
(Carrier �ode_ 34355) Carrier Policy #: Q14�Q5033479�16
, Carrier Prior Policy #: 014005033479115
1. The Insured: Dockside Hotel Group Inc
Mailing Address: 4�6 Main Street
West Yarmouth, MA 02673
Fein:
Other workplaees not shown alaove: Type of Business: Corporation
S7sE SCHEDL}'E.E OF OPERATIOAFS - Risk ID s
2. The policy period is from 12:01 a_m. on 1/Q1j2016 to 12:OI a.m. on 1/�1/20Z7
at the insured's mailing address.
3. A. Workers Compensation Snsurance: Part One of the policy applies to the Workers
Compensation Law of the states listed here:
MA
B. Employers Liability Insurance: Part Two of the po].icy applies to work in each
state listed in Item 3.A. The limits of our liability under Part Two aree
Bodily Injury by Accident $ 1,000,004 each accident
Bodillr Injury by Disease $ i,000,000 poli.cy limit
Bodily Injury by Disease $ 1,000,000 each emplo�ee
C. Other States Insurance:
D. This policy includes these endorsaments and scheduies:
wcoa0000c(�i/ls) WC000310(OaJ84) WC000406(08/84) wc0004i4to�/sa} wcooa4aas(oi/is>
WC200301(Q4/84) WC2003d2(OS/86} WC204303B{p7/99} WC200306B(06/13j WC200405{p6/Ol)
WC20060I.A(d7/08)
4. The premium for this policy wi.7.1 be determined by our Manuals of Rules,.
Classifications, Rates and Rating Plans. All information required below is subject
to verification and change by audit.
elassifications Code Premium Basis Rate Per Estimated
No. Total Estimateci $l00 of Annual
Annual Remuneration Remuneration Premium
SEE SCIiEDt7LE OF OFSRATIONS
Total Estimated Annual Premium $ 14,596.00
M��i�tum Premium $ 349_Oa Expense Constant _Q0 Depasit Premium .00
SCHEDULE O�` OPERATIONS FOR: PP,GE: Z .
Dockside Hotel Group Inc Carrier Policy #: 014d05033479116 .
476 Main Street Fein: .
West Yarmouth, MA 02673
DIV #: Q0000 EjL Nurnber: 0000000001 .
OTHER WORKPLACES:
The Point LLC Fein: .
Cape Point Hotel
476 Main Street, Route 28 Eff date: 01/01/16 .
West Yarmouth, MA 02673 NAICS: 721110 ,
DIV #- 00001 .
E/L Number: d040Q00401 .
The Mariner Motor Lodge LLC Fein: .
Mariner Motor Lodge .
573 l�tain Street. Route 28 Tsff date: Ol/O1/16 .
West Yarmouth, MA II2673 NAICS: 72�1i0 .
DIV #: 00002 .
Mailing: EjL Number. 004Q000001 .
573 Main Street
�1est Yarmouth, MA Q2673 ,
Cape Town & Country Motor �Lodge LLC Fein: .
Town 'N Country Motor Lodge ,
452 Main Street, Route 28 Eff date: O1/01/16 _
West Yarmouth, MA 02673 NAICS: 721110 .
DIV #= 00003 .
Mailing: E/L Number: OOOOOOOQOI ,
476 Main Street, Route 28 ,
West Yarmouth, MA 02673
WC 00 00 D1 B �
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�,�� �.� �,�. .�,,:
,� The Commonwealth ofMassachusetts �=�� ��� R.
Department of Industrial Accidents
" Office of Investigations
' 1 Congress Street, Suite I00
Boston,MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Apulicant Information Please Print Le�iblv
Business/Organization Name: �"�X;�S/ t=,' �'- � y��,1
Address: �� � //I� �� �.- � ` O� � ��-�,'
City/State/Zip: 1�`:S� � �'l Jv f' �`�P one#: � � '�
►� G � � fS' a��t7 l�6 ] r�'�f-`1�t•-���1�-.
Are ou an employer?Check the appropriate boz: Business Type(required):
1.'� I am a employer with `�.1� employees(full and/ 5. ❑ Retail
or part-time).* 6. ❑ RestaurantBar/Eating Establishment
2.❑ I am a sole proprietor or partnership and have no �, � Office and/or Sales(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]* 11.❑ Health Care
4.❑ We are a non-profit organization,staffed by volunteers,
with no employees. [No workers' comp. insurance req.] 12.� Other � �"t,'��
*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 insuran e for my employees Below is the policy information.
Insurance Company Name: � - /�- � - �� �y�Q"��
Insurer's Address: • V< �
Ci /State/Zi � � � �
ri p: 4���v��`R��- � 1��111 �.t K�
Policy#or Self-ins. Lic. # �l��t ��7 ����i 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 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 certify, d th ains andpenalties ofperjury that the information provided above is true and correct.
Si ature: Date: �
Phone#:
Officia[use only. Do not write in this area,to be completed by city or town officiaL '
City or Town: Permit/License# j
Issuing Authority(circle one): �
1.Board of Health 2.Building Department 3. City/Town Clerk 4.Licensing Board 5. Selectmen's Office '
6.Other j
I
Contact Person• Phone#• �
www.mass.gov/dia
�