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a TOWN OF YARMOUTH BOARD OF HEALTH
� � APPLICATION FOR LICENSE/P�T:.- 0 6� ' � MAY • � �'���
..�� ��� �' j�t, _
* P l e a s e c o m p l e t e f o r m a n d a tt a c h a l l n e c e s s a r}��c�c u i,e n t s b��e c e ra r 1 � �-� �•
Failure to do so wi l l resu lt in t he return�i f you�;a�c��b�p� .
� ESTABLISHMENT NAME: TAX ID: �!_
3
� LOCATION ADDRESS: Z � TEL.#:5��- 7l-0 l0
� MAILING ADDRESS: �o, �c 44�/ G�. �rr,�,.f� . 9N4_ oLl 7.3
' E-MAIL ADDRESS: o`�� , n�,�,,y,�.� ���` C,�,y,
� OWNER NAME:
� CORPORATION NAME( APPLICABLE): �-, _
! MANAGER'S NAME: TEL.#: `l? - --� �
MAILING ADDRESS: 0 !�� - u
� 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.
� 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:
iAll 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.
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' 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
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
B&B $55 CABIN $55 �MOTEL $110
INN $55 CAMP $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
_>100 SEATS $200 _COMMON VIC. $60 WHOLESALE $80
—RESID.KITCHEN $80
RETAIL SERVICE:
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 _ $ `�(�, QQ
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*****
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s ' The Commonwealth of Massachusetts
� Department of Industrial Accidents
O�ce of Investigations
� 1 Congress Street, Suite 100
� • Boston, MA 02I14-2017.
' www.mass.gov/dia
� Workers' Compensation Insurance Affidavit: General Businesses
� Please Print Legiblv
� A�nlicant Information _ -
; Buslness/Organization Name: �c ,, c,l���.�� l�'1 r-�����. ��� .s����- ��� � �`�-7"�"v��
�� �w
Address: `! �- �'1 a�1 1L ��
City/State/Zip: ���. � � � �� dY7� a zE, �..3 Phone#; `� ��' -3 7s�-�-yu z.-
Are you an employer? Check the appropriate bos: � Business Type(required):
1.� I am a employer with �3�� employees(full and/ 5• ❑Retail
a or part-time).* 6. ❑RestaurantlBar/Eating Establishment
2,❑ I am a sole proprietor or partnership and ha.ve no �, (] Offiae and/or Sales(incl.real estate,auto,etc.)
ennployees working for me in any capacity. g, �Non-profit
[No workers' comp. insurance required]
3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment
their right of exemption per c. 152, §1(4),and we ha.ve 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 %-{��•.f^�-�
' '"Any applicant that checks box#1 must also fill out the seetion 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 aa
organization should check box#1.
� I am an employer that is providing workers'compe�satdon Bnsurance for my employees. Below is the policy information.
Insurance Company Name:
Insurer's Address:
� City/State/Zip;
Policy#or Self-ins.Lic.# Expiration Date:
Attach a copy of the workers' compensation policy declaraHon page(showing the policy number and espiration date).
Failure to secure coverage as required under Section 25A of MGL c. 1 S2 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 a�id/or one-yeax imprisonmcnt,as well as civil penalties in the form of a STOP WORK 4RDER 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 enalt�es of perjury thal the information prov�ded above�ts true and correct.
�� /
re• ` Date: ��` l�
P ne#• — .S-S 4�'�- �
Official use only. Do not write in this area,to be completed by city or town offtciaL
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
a _
�
BERKSHIRE HATHAWAY • •�
01'1 8fl_d�d`'el� L�snuFs. a fs
���� OMPANIES Nor6UARp Ynsurance Com � „
Pa Y .A Stock Compan y
' Po�1cy Number Sq1A►C610831
�
��s��of SAUVC592556
P1� No. [25844],
I
; Poltcf►Information Page
[1lNarned lnsured anc!Matting Address
Sandbar Management Inc. A�en�Y
PO Box 481 CHOICE IiVSURANCE AGEMCY
West Yarmouth, MA 02673 376 Summer Street �
F��bur9, MA 01420 �
Foderal Employer's iD Agency Code: MACHOIIO
Risk ID Number I��� � Corporation
szsa�s
�ocations on Policy
��� 518 Rt 28, West Yarmouth, MA 02673
I f10/01/2015- 10/Q1/20I6)
i
[2� Pollcy Period
Ffiom October i, 2015 to October 2, 2016, i2;01 AM,skandard tlme at the Insured's mailing add�ess,
, [3J Covetage � .
a
R. Workers'Compensation Insurance_ p�rt One of thfs policy ap Iies to
� Law of the foJlowing states; Massa P the Wo �
chusetts Hcers Compensation
j �. ����Ye3 q abillty insurance -Psrt 7tivo of tl�is policy appNes to work In each of the states listed
� [ ] The Umlcs of our Itabtltty under Part Two are:
�a��Y I�tlury by Acctdent_each accident
Bod(ty Inju�,by Disease-each empioyee $1,000,000
Bodlly Infury by p��a�- po4ry timit ��,�0,000
$1,000,000
� Other g��s insurance-Part Three of thls poticy applies to ai!states,except any state listed{n
i! (tem [3jA. and the states of North Dakota, �hto, Washington,and Wyoming.
�. This policy tncludes these endorsements and
'; See Factension of Infermatlon pa �; �eduies:
g Schedule of Forms •�
��7 Premlum
The Premtum Bas�s and, there�ore, the premium wi(t be determined by our Ma
Classiftcaqons, Rates and Raqn Plans. .AlI
audlt, (CvnNnued on�another g ' �ual of Ru1es,
��e�• �qu�red �nformatlon is sub�ect to vertf�caCion and change by
Total lstier�ated Pollcy Premium
Total Sarchargee/q�nants $ '
Totai Est(mated Cost � -
fN7'FR11Le1 ' X: �
� :SAWC61�31
Date :09/11/2015 Pa9e- 1-
MANOTE Inforn'latbn Pagg
WC OOQpOlA '
Is�uinQ Offlce:P.O.Box A=N,18 S.Rtver Sb+�,Wqk�-Bsrre,PA 18703-0020.vYy�yv. �b
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