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Home My WebLink AboutApplication and WC ... _ � ,_.._.._.,.____ -�------ *� TOWN OF YARMOUTH BOARD OF HEALTH g=Au�w��I�ND . � ��., �013 � ,� APPLICATION FOR LICEN�F.� 'I�� ', .;_�; � 7 ' * Please complete form and attach all nec�s��,�>'� �� s , y � , e Fai lure to do so wi l l resu lt in t he r�t�rn ��e��p�licatio ' ESTABLISHMENT NAME: � T - LOCATION ADDRESS:_�� (�t�!, ^C. --'�.,_�\1��c+au�. TEL.#: �-4��1-�-(`'1 (�, MAILING ADDRESS: '` E-MAIL ADDRESS: . . OWNER NAME: . , CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: "C'�� a^^��t N, ' TEL.#: '�� -�g�$I 2 MAILING ADDRESS: ��«��.�""i :�-�R • V,1 °y��-�c�n n-��\�, �rn 4+ �- a'2�r t.,3 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 minimuxn of two employees currently certified in basic wat safety, standard First Aid and Community Cardiopulmonary Resuscitation(CPR),having one certified employee on premises at a11 times. Please list the employees below and�attach copies of their certifications to this form. The Health Department will not use past I years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: A�l 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 1N CHARGE: � Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. � J 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 em�loyee trained in the Heimlich j Maneuver on the premises at all times. Please list your employees trained in anti-chokulg 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# � _ _ . � OFFICE USE ONLY f LODGING: � LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE P IT# _B&B $55 CABIN $55 I MOT`EL $55 � I INN $55 CAMP $55 SWIMMING POOL $80ea. _LODGE $55 TRAILER PARK $105 `WHIRLPOOL $80ea. FOOD SERVICE: ' LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $85 _CONTINENTAL $35 NON-PROFIT $30 >l00 SEATS $160 _COMMON VIC. $60 WHOLESALE $80 —RESID.KITCHEN $80 RETAIL SERVICE: j LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# ' <50 sq.ft. $SO >25,000 sq.ft. $225 VENDING-FOOD $25 � —<25,000 sq.ft. $80 =FROZEN DESSERT $40 _TOBACCO $95 i NAME CHANGE: $15 AMOLTNT DUE _ $ 5�,d� ` *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** ' , 4 � � �� _ y � ADMINISTRATION � - � . � , � Under Chapter 152, Section 25C, Subsection 6,the Towri of Yarmouth is now required to hold issuance or renewa7 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 thiriy(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. a 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 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. .--- - _ - ------ _ _ _ _ _F��SE�ZVI�_ _--- - --- - - . - ---- ----- __ 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 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.varmouth.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. NOTICE: Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN i THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 13,2013. ALL RENOVATIONS TO ANY FOOD EST LISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED T N AP OVE THE BOARD OF HEALTH PRIOR TO CO ENCEMENT. RENOVATIONS MAY UI IT P A . � ��DATE: � � � SIGNATURE: � ; PR1NT NAME&TITLE: L. S'�'S� Rev. l0/08/13 '�� _��, t ,' J+ , I � " � � � � . � � CERTIFtCATE OF LIABILITY INSURANCE °"'�`"'""�°�"""' os/22/zaz3 .e2TIFICr4TE IS ISSUED AS A MATTER' OF lNFORMATION OI�iL.Y AND CONFERS NO RI(aHTS UPON THE C8R71FlCATE HOLDER. TNIS �pTE DOES NO't AFFIRMATIVELY OR NEGATiVELY AINEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES �{iy. 7'HIS CERTIFlCATE OF INSURANCE DOES P�T CONSTiTUTE A COMTRACT BfTWEEN THE ISSUINCa INSURER(S1, AUTHORIZED �+RESENTATIYE OR PROOUCER,AND THE CER77FlCATE HOLDER. ,pyi ANT: ff the certlflcate hoWer is an /�1'fiONAi_ INSURED. U�e policy(�) m� be endased. If SUBROGATION IS WAIVED, subjed to the terms a� conditions of ti�e policy, certain Polic�s maY re9uire an endorsemeM. A atadement on lhis t�rtificate does not confer rigMs to the certifiCate t�r in 6eu of suCh endorsement(s). r�x�x � PADL SCHLEGEL IITSDRANCE gc�wr.F.r_tr.r. INSIIRANCE BROI�RS INC rewt� �� 5U$—?71-8381 ��,�,508-771-0663 34 �lIN STE;BET � �, SCHLEGBI.INSDRANCB@VERI7A2t.NET NEST YA�TH �i 02673 , ��s. wsurte�tst n�wvEsaae e�a�c s �"S� a�u�enTRAVBLERS Bridge Over Corporation n�s: 1 3IDD8ARTH LANS aasur�c: WSFIt�R D: Halbrook, IIIl� 02343 aau�E: _ wsurtacF: C01tERACaES • CERTiFICATE Nl1MBER: - REVlSIOiN NUMBER: • SHIS !S TO CERTIFY THAT TNE POUCIES OF It�URANCE LISTED BQOW HAVE BEEN ISSUED TO THE INSUI�Q NAMED ABOVE FOR THE POtICY PER{OD INaCATED. P�TiMTHSTANDING ANY REQUIREMENT, TERM � CONDiTtON OF ANY CONTRACT OR OTHER DOCUMENT WfTH RESPECT TO NMICH THtS CERTIFICA7E MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORD� BY THE POLICIES DESGRIBED NEREIN IS SUSJEC'f TO ALL THE 7ERMS, EXCLUSIONS AJ�CONDiT10NS C�SUCH POUCIES.UIdITS SHOWN MAY HAVE BEEN�DUCED 6Y PAID CLAIMS. « Tr�� y� poucv►au�n �xworrrrY► �xa�erocnrYYr� �+� c�c w�rt,r �occ�ce s �ce�n�uneamr �cea aam�nea) s anu� �occ� e�owWnr«bv�) s . PER�lA1.8 ADN�Y E c,E�N.AGC�EGATE S. ' GEML/t6�GP.lE 49dt'T MPLIES POt: - PROOUC'fS-COYP/OP K3G S pOLICy � WC � i � ��,yqbp,Ry � CAA�SHJ[3LE LIANT = �� MK AUTO �Y IN,M2Y(P�Pxwn) i /1LLOVMI�D,AUTQS - - - BOaLY INJIMY(�r x.�fQ S- � S'CFiF-0UI.ED AUTOS . PROPER71'DAMAGE ; . f11fiED AtIT� �� NONAYYNED iAt7'OS . � � s . � S � �� OCCIR � . . EACH Of:Ct1�ICE - S . EXCESst.t16 �G1J11S-IAAOE � AGGI�CASE � S � � .. S RET9iT10N 5 S � ��. A �� C-000978043 05/22j20 05/22/2014 ��$ � __ nar arsov�rownNn*�o�xrnve ❑ M�� ..�nac�r s 100,d 00 �� 1�n��q e.�.a�nse.eno+�.ov� a 300.000 Myas,aesaAe unax �oFov�wrio►�u� e.�.aseasE-Pa.�cr�xnr s 500,000 � �oF�twNsiwcnnaa�v�aFs uu��c�o�n.��scneaw,��.�.m�.ai " CERTIFlCATE HOLDER CANCELLATION CPiPE TRAVBLSR , �g � stwin.o awr oF niE aeovE o�een �ouaEs eE cnHceum e�o� TME oc�w►now onre rs�, Noncs vau. sf oEuvert�o �N � r�►7r � srna acc�aaHce uwn+TMe roucv nRov�oNs. nunwaac� • HAZID DELIVERED _ 2009 ACORD CORPORATtON. Ail rights reserved. ACORD 25{2Q09/p9) The AGORD name and logo ave registered rks ACOR� t � r- � ; , � � The Commonwealth ofMassachusetts � � Department of Industrial Accidents ° Office of Investigations ' l Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legiblv Business/Organization Name: Address: �� • �� . S`�C, �1.. "�Q'�'��;�1� City/State/Zip: Phone #: 'S�j�.- ��.� .- �� 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).* 5. ❑Restai.::rrant/�ar/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]* 11.❑ Health Care 4.❑ We are a non-profit organization,staffed by volunteers, 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: � � �,�� -'L, SU�A�l C_-� ' �"�c1�+��1 V , Insurer's Address:_ �� 'C`4\�`�1 , -�"'-�� . City/Staxe/Zip: y�-�'C`C\d'��' "6�'� - O"�-'6 r� Policy#or Self-ins.Lic. #_ �.0 �pC�O�'�� 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 Ni��,a 152 can l�ad 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 e pa d Ities ofperjury that the information provided above is true and correct. ' � i Si ature: \ Date: , 'ij� 1� i , Phone#: �i�� •��'� '�� Official use only. Do not write in this area,to be completed by city or town officia� City or Town: ��,f1 Vy� Permit/License# I ng ut o ' ircle one): � 1.Board of Hea t 2. Building Department 3. City/Town Clerk 4.Licensing Board 5.Selectmen's Office ; . ; i � Contact Person• Phone#• �D8 �22 3( �i Z�'( � www.mass.gov/dia , � �x� ,�; Cn ° �' �� + CERTIFICATE OF LIABILITY INSURANCE �� ' 05/22/2013 � {�p �RT1F(CATE 13 ISSUED AS A- MATTER OF INFORMATION ONLY ANIO COMFERS NO RK'aHTS UPON THE CERTIFICATE HOLDER. FHIS � ',�riCATE DOES NOT AFFIRIIRATNELY OR NEGATNELY AIII�ND, EXTEND OR ALTER THE COVERAGE AFFQRDED BY THE POLICIES ��ly, THIS CERTtflCATE OF INSURANCE DOES NOT CANSTITUTE A CQNTRACT BE7IMEEN THE ISSUING INSt�R(S), AUTHQRiZED ,rPREgENTATNE OR PRODUCER,AND THE CERTIFICATE HOLDER. . `1MPORTANT: If tl�e certificate hotder is an ADDITIONAL INSURED. tfie Pa+�YI�I m�t be endorsed. IE SUBROGATWN IS WAIYED. subject to the tenns aru! canditions of U�e poiicy. certain polic�s may require an endorsemeni A stabement on tfiis ce�be doss not co�er NgMs to the certificate hoider in Iiew of sueh e�s}. �� ; PAUL SCHI.EGEL SNSIIRANCB SGffi+EGEL INSIIRIRNCE B120�RS INC �� 508-771-838I ��i508—T71-0663 34 MAIN STREET SCHLEGELINS�RANCE@VERI80N.NET ao�ss: �EST YAR2�lDDTH !�, 02673 ��, wsunEn{sl nFwl�IriG covErtacE Ha�c r iNStqtED _ 9iSURER A QRAVEIiBRS Bri�@ OV'22 CAIpOSdt10A � NSURHiB: 1 SmD�� + - WSUI�iG: � � - MSlAt6t D: � Ho].Y�rook, �+i 02343 x�e: eat�rt F: GOVERAGES CE4tTiFiCATE NUMBER: REVISION NUMBER: THfS IS TO GERTIFY THA7 THE POLICIES OF ►NSURAPICE USTED BELQW HAVE BEEN ISSUED TQ THE iNSURED NAMEO ABOVE FOR THE POL{CY PERIOD INDICA7ED. NOTYtATHSTANDING AW7 REQUIREMENT. TERM OR CONDiT10N Of ANY CONTRACT OR OTHER DOCUMENT VNTFi RESPECT TO WHICFi THIS CERTIFICA'fE MAY B£ ISSUEO OR MAY PERTAIN. THE INSURANCE AFFORDED 8Y THE POLIClES UESCRiBEL1 HEREIN IS SUBJECT TO ALL THE TERMS, D(p.US10NS AND CONDtTiONS OF SUCH POUCIES.11MffS SHOVMI MAY HAVE BEEN REDIiCE�BY PAIO CLAIMS. �� "�^� a�e vwo �� {�t�unorcYvrt prNouirrvv� � c�n��rtt �o�� s CNAA�iCIAL GENERAL LW8M171' � PRE�ISEu(Ea oaurrence) S CLMAASdAAOE �OCtxkt I�D�WiY�Pe�? S - �1Pd.8 AOV 6JJURY S - . �ALAQGREGATE S GFPtL AGGt�a7E t�YT A�L�S P�: � atOIXJCTS-COIiPIOP AGG S POUCY ,� tAC � S . At1T'OAtGBfl.E I.IABq.lTY C01IBIt�SINGL.E LHiUT ; lEs��xrt) M!Y AUTO . BO�Y flANMY{P�Pxaa�) S ALL OYV�AUTOS � �� B�ILYlNJURY�v� S �AtlT0.S PROPERTY DMtAGE S MIffiD AUTOS (�� . WON-0YMbI@ P1llTOS $ �. S �� Ot�l1R EACH OCCtK2RENCE S � EXCESB LY1B � � �� s . �1CT�LE � 5 . �r�on� s . s A ��TM WC-000978043 05/22/20 05J22/2di4 .�y ^� °� rra �� ❑ NiA �-�+�� : ioo,000 ; ��+► ��.�,�� s ioo,000 ' a�.�� oEsa�wraNOFor�n�se�w �.�asense-aoucY�r a 500,000 o�nar oF ov�n�s��ounoNs�vaKxFs WmU�acoao,m.we�am�sa�.u a�e�e��r.d� CERTIFICATE HOLDER CANCELLATION _ TdWN OF YA�DTS RODTE 28 SHOULD ANY OF TNE ABOVE DESCi�BED POUCIES BE CANCELLED BEFORE 'fHE D�RATION DATE THEREOF. NOTICE IMIL BE DEWERED M WEST YARMOUTH, MA 02673 ��E WITH THE POUCY�OV�N3. AUTHOR�D REPRESENTATNE HAND DSLIVERBD � r ACflRD 25(2009/09) The ACORD name a�d logo are �1988-2069 ACORD CORPORAi70N. Alt rigMs reserve� ►eg�.sa aco� _ i �