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Home My WebLink AboutApplication and WC � � TOWN OF YARMOUTH BOARD OF HEALTH � � APPLICATION FOR LICENSE , �JVII�' -2013 �v�--��=t��Vl�� , o.... ��,-� .�jI� q 2013 �� * Please complete form and attach all necess �:" �x c ts;1� ber7'S'2e�. Failure to do so will result in the retu f y �' :��.' ` ke��fi�� ESTABLISHMENT NAME: S' � ��? 611�t�S TAX ID: � " � LOCATION ADDRESS: /'�` TEL.#• � 7 - � O MAILING ADDRESS: � S • OWNER NAME: �' (� PS � CORPORATION NAME (IF APPLICAB ): MANAGER'S NAME: �e /',S6 TEL.#: ✓�^�� a73 - �� MAILING ADDRESS: � � � Q r�'►o'� 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. �. .�,� l� s � _ z. . Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provid new copies and maintain a file at your place of business. 1. � l. �,^s��s 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. l. 2• PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC)on site during hours of operation. 1. 2. i 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-chokmg 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. 3. 4. RESTAURANT SEATING: TOTAL# � � i OFFICE USE ONLY � LODGING: � LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# ( B&B $55 _CABIN $55 _MOTEL $55 � INN $55 _CAMP $55 �SWIMMINGPOOL $80ea. ��'L�� LODGE $55 TRAILER PARK $105 _WHIRLPOOL $80ea. � FOOD SERVICE: i LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# ' 0-100 SEATS $85 _CONTINENTAL $35 NON-PROFIT $30 i >100 SEATS $160 _COMMON VIC. $60 _WHOLESALE $80 � —RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.8. $50 >25,000 sq.ft. $225 _VENDING-FOOD $25 , _<25,000 sq.ft. $80 —FROZEN DESSERT $40 _TOBACCO $95 NAME CHANGE: $15 AMOUNT DUE _ $ 43��aU *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** I i , I � ; ADMINISTRATION � . Under Chapter 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 i AFFIDAVIT MUST SE COMPLETED AND SIGNED, OR I � 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 �i I APPROPRIATELY IF PAID: ; YES_� NO I I MOTELS AND OTHER LODGING ESTABLISHMENTS � I i 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 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 OPE1vING: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 i 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 closin .. g 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 forms can be obtained at the Health Department,or from the Town's website at www.yarmouth.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 COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. ' I NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETIJRN � THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15, 2012. 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 COMMENCE ENT. RENOVATIONS MAY RE IRE A SITE PL . DATE: � JP a��.3 SIGNATURE: ' PR1NT NAME& TITLE: � � c�/',S'a� ,f Rev. 10/09/12 f r ,�coRfl� CERTIFICATE OF LIABILITY INSURANCE DATEiMM/DDlYYYY) ��, fl6J1912013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UFON THE CERTIFIGATE HOLDER. THIS ; CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND, OR ALTER THE COVERAGE AFFORDED BY THE POUGIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT GONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATNE OR PRODUCER,AND THE CERTiFICATE HOLDER. IMPORTANT: if the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate dces not confer rights to the certificate hoider in lieu of such endorsemeni(s). PRODUCER O47Z'I -OO'I NAME� James E SuOivan Insurance P�NN.�: (978)861-9600 nAic.No.: 885 Main Street EMAi� Tewksbu�y,MA 01876 A°°REss: N APFORDIN O C . A.I.M.Mutual insurance Company 33758 . INSURED INSURER B: Bass River WaterirontTownhouses _ _ _ _ N�t1R�_C:_— ,_ _ — 111 North Main Street R p: South Yarmouth,MA 02664 1NSURER E: GOVERAGES CERTIFICATE NUMBER: REVISION NUMBER: , -- �ffS i� FO GERTIFY TMAT-THE P�LICIES-OF lNSSJRANCE_L[SIED��nw Ha� BEEN ISSt1ED TO THE INSURED NAMED ABOVE FOR 7HE POLICY PERIOD INDICATED. NOIWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACP OR OTHEFF D�UNfENI�TR"RESPECT TO iNN�ChtiHl3 , � CERIIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE B�EN REDUCED BY PAID CLAIMS. '�! ��TR TYPE OF INSURANCE ��Bp POUCY NUMBER MfDD� MMfD�DY1YY�Y`P! LIMtTS GENERAL LIABIUTY EACH OCCURRENCE S COMMERCIAL GENERAL UABIUTY PREM SES Ea occurre�ce $ CLAIMSMADE �OCCUR MEO IXP(Any one person) S PERSONAL&ADV INJURY $ GENERALAGGREGATE S EN'L AGGREGATE LIMIT APPLIES PER: , Pi20DUCTS-COMP/OP AGG $ LICY �j OC AUTOMOBILELIABILITY C�OM�&�eDSINGL UMIT $ ANY AUTO BODILY INJURY(Per person) 3 ALL OVMIED SCHEDULED BODILY INJURY(Per accideni) $ AUTOS AUTOS HIRED AUTOS NON-OWNED �OPa��T�Y DAMAGE $ AUTOS s UMBRELLA LIAB OCCUR EACH OCCURRENCE S EXCESSLIAB CWMSMADE AGGREGATE T S DED RETENTION 5 T � AND EMPLOCYERB'LIABILRY X TORY LIMT9UTS �ER Y�N E.L.EACH ACCIDENT 5 'IOO,000.00 p o��C��n+��CZ��r��{vE� N!A AWC-d00-7029102-2013A 6I1I2093 6/1i2014 E.L.DISEASE-EAEMPLOYEE S 1d4,000.00 {NNandaMry in NH) ��s �o�r El.DiSEASE-POL�CY LIMIT s 500,000.00 9G�1�'�ON OF OPERATIONS bebw DESCRIPTION OF OPERATIQNS I LOCATIONS I VEHICLES tAttach ACORD 101,Additional Remarks Schedule,if more space is required) ' , �_ :=��i�D ��j�1 2 I 't013 HEALTH DEPT. CERTIFICATE HOLDER CANCELLATION Town of Yarmouih - _ Attention:Phiilip Renaud,Health Depaftment S�io'J'.:.D Rt�Y-�F THE Afi4VE_DESCRIBED POUCIES BE CANCELLED BEFORE 1146 Rt 28 THE EXPIRATION DATE THEREOF; FiOTii.E L::Li R�-nELIVEREQ •IN S Yarmouth,MA 82664 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZ�REPRESENTATIVE � � �� O 1988-2010 ACORD CORPORATION.Ali rights reserved. ACORD 25(2010/05} The ACORD name and logo are registered marks of AGORD r � The Commonwealth of Massachusetts ' � Department of Industrial Accidents Office of Investigations - - -- --- ' 1 Congress Street,Suite l00 ' Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses ' A licant Information Please Print Le ibl Business/Organiza.tion Name: ,JGl SS 1 rU�" a�fi t►'6�� /-�/�`J�� pS Address: / J� � ` � City/State/Zip: S� ��/'�du � `"r /��-� Phone#: � 0� �3 l�^ 7 0 �� Are you an employer?Check the appropriate bog: Business Type(required): 1.❑ I am a employer with employees(full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/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 *Any applicant t6at 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 organizarion should check box#L ' I am an em,ployer that is prov g workers'compensation insurance for my employees. B low is the policy information.� Insurance Company Name: �S SC'�C-I� (Pe �K��t'f�'J E"S c�� c.I �u� ( �1/�S. ri Insurer's Address: City/State/Zip: �llf l i� /�o l � � Policy#or Self-ins.Lic.# /( � 70� J��i J�� Expiration Date: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration 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,SOQ.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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi ,under the pains a d pena[ties of perjury that the injormation provided above is ue and correc� Si ature: Date: � Phone#: � 7 ' y � Official use only. Do not write in this area,to be completed by city or town officiaL City or Town:�V,A�--Iti101rTt� Permit/License# circle one): 1.Board of Health .Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office 6. er Contact Person: ` Phone#: ;5Z�8�3Q -,30�31�GI Z`F� www.mass.gov/dia ��:�< � � EMPLOYERS LIABILITY INSURANCE POUCY � �T' � INFORMATION PAGE ��,�� } � � Associated [ndustries of Massachusetts Mutuat fnsurance Company �� 54 Third Avenue,Burlington,Massachusetts 09803 �- (800)876 2765 NCCI NO 26158 POLICY NO. AWC 7013063012012 PRIOR NO. AWC 7013063012011 ITEM 1. The insured Joily Captain Motor Lodge Condominium � Mail Address: �o Philip R Pierce,Treasurer South Yarmouth NW �2664 111 N.Main St Street No. Ta�wn or Cily County State Zip Code FE1N � ❑Individual ❑Partnership �Corporation �Joint Veriture �Association �Other Other workplace.s not shown above�_ _ , _� 2. The policy period�s frork%0514f'E�2�'[2 �°-ta E�/�11f2f)'b3 '" 12:01 a.m.standard time at the insured's maifing address. 3. A. Workers Compensation Insurance:ParE One of the pol'�cy appifes to the Workers Compensation Law of the states I'�sted here; MA ' B. Employers Liabl�y insurance:Part Two of the policy appfies to wo�lc in each state listed in item 3A The limits af our liabitity under Part Two are: Bodily Injury by Accident$ 100.000 each acadent BodTy Injury by Disease $ 500.000 oolicy i'imit Bodily Injury by Disease $ 100.000 each empioyee C. Other States Insurance:Coverage Repiaced By Endorsement WC 20 03 06A ' D. This policy indudes these endorsemerrts and schedules:SEE SCHEDULE 4. The premium for this policy will be determined by our Manuals of Ru�s,Ctassfica�ons,Rates and Rating pians. All infoRnation required below is subject to verification and change by audit. .- Ciassfications Premium Basis Rates Cade Estimated P�r 5100 Estimated No. Tot�Arun� Of �a� Re�mmerafim Remunera8on Premnan INTRA 119515 - SEE SION OF INFORMATI PAGE � Minimum premium$ 274.00 Total Estimated Annual Premium $ 492.00 As indicated irrterim adjustrner�ts of premium shail be made: Deposii Premium $ 505.00 � AnnuaUy ❑ Semi Annually ❑ Quarterly ❑ Morrthly MA AssessmeM Chg. $220.OQ x 5.9000% $13.00 ��sz This policy,including all endorsements,is hereby countersigned by 05/01/2012 Author¢ed sign�ure Date GOV GOV KIND PLACING CLAIM NAME SAFETY James E Suilivan Ins Agency STA7E CLASS AUDIT OFFICE OFFICE CHECK GROUP 885 Main Street ', MA 9Q15 2 701 Tewksbury,MA 01876 ', WC 00 00 01 A(7-11) Indudes copyr9ghted materi�a B,e Natio�l co�a,cit on canpensason�nsurarxe. used with ita pertnissian. 6/ 19/2013 9 : 11 : 19 AM 8740 � Ol /02 I TO F�X#: 91�087603472 EXTENSIO'�; FROM: DEBBIE COX, 8740 PAGES; 2 (INCLI.IDI�G THIS CO�jER PAGE) SUBMITTED, 6119r'2Q 13 9:11;19 A1�1 If t�l1S faCSltlll�Z 1S IlOt COIlIpI2t�l�r��a�abl�Ot 1S 1I11SSlIlg pa��S,pl��S�lt]fOTIII t�l�p�rS011 WIlO r�qU2S1ed��lZ 1I1�0I�Ilat1011. That persor�wlll have to re�request the infonnation from this ser�Tice, 6/ 19/2013 9 : 11 : 56 AM 8740 m 02/�2 ,ac�� CERTIFICATE OF LIABILITY INSURANCE DATE(MMlDDM'YY) �r os�,si2o�a THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DUES NOT AFFIRMATIVELY OR NEGATIVELY 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: It the certificate holder is an ADDITIONAL INSURED,the policy(ies) rnust be endorsed. li SUBROGATION IS WAIVED,subject to the terms and co�ditions of the poGcy,certain policies may require an endorsement. A statement on this certiFicate does not conter rights to the certificate holder in lieu of such endorsement(s). PRODUCER !)4]Z� -OO� NAME CT � James E Sullivan Insurance Pl�N.�; {978)861-9600 �ac.No.: 885 PAain Street E�Aa Tewksbury,MA 01676 A DRESS: INSURER SIAFFORDING COVERAGE NAIC# R . A.�.M.Mutual Insurance Company 33T58 INSURED INSUHER B: Bass River Waterfront Townhouses INSURER C: 111 North Main Street INSURER D: South Yarmouth,MA D2664 SU ER E' CaVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LJSTED BELOW HAVE BEEN ISSUED TO TNE INSURED NAMED ABOVE FCR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT VNTH RESPECT TO IMiICH THIS CERTIFICATE MAY 6E ISSUED OR MAY PERTAIN, THE INSIiRANCE AFFORDED BY THE POLIGES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIO�S OF SUCH POLICIES.UWIITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIVIS. INTR TYPE OF INSURANCE INSR SYYVD POLICY NUMBER MM1Dp� MM,up�jyyri LIM'��.TS �� GENERAL LIABIUTV EhCH OCCJRRENCE S COf�IMERCIAL GEhERAL LIAEI'�_ITY A�AGE TO REN EC $ PREMISES Ea occurrence CLAIMS-NADE ❑OCCUR MED EXP(Any une pe�son� 5 PERSONAL 8 A�V IMJURY $ GFfJFRAI..AGGRFGATE $ EN'L AGGREGATE LItd1T APPUES FER: PRODUCTS ��CMPlOP AGG S OLICY ECT OC AUTOMOBILE 1IA81LITY COMBRJE�SI�GL l M111 5 _a accident ANY ALTO BODILY INJUR�(Per person) S ALL OlAT1ED '� 9CHEOU_ED BOOILY INJUR"(Per at�eident) S AUTOS �'' A�TOS HIREGAJTOS '' �N-0N?JED � Y 4MAGE S � AL'TOS .2�accidentl , 5 UMBRELLA LIAB OCr�q EhCH OCCJRRENCE $ ��: ExCESS LIAB CLAIMS MADE AGGREGATE S � DED RETENTION � 5 P�ND E�LOYERS'LSABILITY x TORY L Pd TS ��ER �. hNY PROPRIETp RIFARTNER! XECUT'�.VE Yf N E�_.EACH ACCIDENT $ 1OO�OUO.DO f� OFFICERlMEA1BEREXCLUDE�? N❑ N!n AWC-400-7D29102-2a13Q 61912013 6/112014 �. (Mandatory in NH) E._.DISEASE EA EMFLOY6E L 100,��0.00 D�S�RIPTIO�OF OPE4AT10NS belrnv E.:.�ISEhSE-POLICY Uul' S SOO,OU0.00 DESCRIPTION OF OPERATIONSI LOCATIOVSlVEHICLES�Attach ACORD 101,Additional Remarks Schedule,if r�ore space is required) � CERTIFICATE HOLDER CANCELLATION Town oi Yarmo�th Attention:Phillip Renaud,Health Department SHOULD ANY OF THE ABOVE DESCRIBED POLICIES 8E CANCELLED BEFORE 1146 Rt 28 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN S Yarmouth,MA 02664 ACCORDANCE WITH THE POLICY PROVISIONS. . AUTHORIZED REPRESENTAT�VE ��ti��z 01988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marlcs of ACORD 3651