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�* � TOWN OF YARMOUTH BOARD OF HEALTH
� � APPLICATION FOR LICENSE/�lY , � , �:'��; '� � "�€;�� �
�� * Please complete form and attach all necess t do ' t �� ber .�pT
Fai lure to do so wi l l resu lt in t he return o f your app lication pa .
ESTABLISHMENT NAME: L�w; � T • ��� ��� ��
LOCATION ADDRESS: �' ` � � .,t'R IW TEL.#: S'o $ ' �� / �`/33
MAILING ADDRESS: ��
OWNER NAME: o d z �-.� � l v.^ �.�e�
CORPORATION NAME(IF APPLICABLE): RT�.. r�p t� .�c�, 1-r�L
MANAGER'S NAME: I.�„ .� L� �{ /'�•w. TEL.#: S �-�
MAII.ING ADDRESS: Cc..►�+n.0
POOL CERTIFICATIONS: �� �'—'
The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated
Paol 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 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
provide new copies and maintain a�le 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 establishmen�
�. f� � �t�<�� L, bti�,�, .�,. 2.
__ PERSON IN�IAR�E:_---__ ___ ---- - _ _____
_ _--- - _ _ _
Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation.
l. �?o�r��- L , ht���r 2.
HEIMLICH CERTIFICATIONS: � j�
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 REQUIItED FEE PERMIT#
_B&B $55 _CABIN $55 _MOTEL $55
_INN $55 _CAMP $55 _SWIMMING POOL $80ea
�LODGE $55 �o� w5o _TRAII.ER PARK $105 _WHIRLPOOL $80ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# '
I 0-100SEATS $85 a'l� _CONTINENTAL $35 _NON-PROFTT $30
_>100 SEATS $160 �COMMON VIC. $60 �Q�S _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. $225 _VENDING-FOOD $25 '
� � � I
_<25,000 sq.ft. $80 _FROZEN DESSERT $40 _TOBACCO $95 �
NAME CHANGE: $15 AMOUNT DUE = � Z�O.0O '
��
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** �
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ADMIIVISTRATION
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
AFFIDAVIT MUST BE COMPLETED AND SIGNED, �R
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 G
_.,_ _ _. --i4�f3�-�€:��C�'I'.E�P�:�13�i����"TABLIS�'IEl�S
T1tANSIENT 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 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. !
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�
POOLS
POOL OPE1vING:All swimming,wading and whirlpools which have been closed for the season must be inspected F
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 f
thereafter.
_ _ i
_ �
POOL CLOSING:Every outdoor in ground swimming pool must be drained or covered within seven(7)days of �
closing.
FOOD SERVICE '
i
SEASONAL FOOD SERVICE OPENING: j
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. 4
;
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. E
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:
Catsi�caf�s�i:�.-�;-t;ut����ating�vi��aite�f��it��-�sssen' , �:ast hav�Pricr appr�val fro�.t3��$oard�f I�e�ith.
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
THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 15, 2011.
ALL RENOVATIONS TO ANY FOOD ESTABLIS��VVIENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT,ETC.),MUST BE REPORTED TO AND PROVED BY THE BOARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY SITE PLAN.
DATE: �U� l I �� SIGNATURE: �
PRINT NAME&TITLE: �o�3� r�-�- L r�a-w.�- O�-�
Rev.10/25/I1 `
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The Commonwealth of Massachusetts �
Department of IndWstrial Accidents
N�riN�M,�s
600 Washington Street, 7`"'Floor
Boston,Mos� 02111 "
Worl�ers'Compeesallos Imw�ante AtRdav�t: • _. '
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wock site Iceation(full address)• ;
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I am a sole proprietor and have no one working in any capacity.
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the following workers'compensation polices: i
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/ .�co` CERTIFICATE OF LIABILITY INSURANCE °"'�`�"'°°""""'
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THIS CERTIFlCATE IS ISSUED AS A MATfER OF INFORMATI�1 ONLY AND CONFERS NO RIGHTS UPON THE CERTIFlCATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATiVELY OR NEGATIYELY AMEND, FXTEND 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: If the certificate holder is an ADD1710NAL iNSURED,the paicy(ies)must be endorsed. if SUBROGATION IS WAIYED,subject to
the temis and conditions of the policy,certain policies may require an endorsement A statement ai this cerdficatie does not corrter rigMs to the
certificate holder in lieu af such endoraement(s).
PRODUCER �: DAV].CI Cr8Mf02'fl
�ldredge & Lvdnpkin Insurance Agency, Inc. �� (508)945-0393 F� t5os)9as-aoae
697 Main Street a .david@elinsurance.coa -
INSU S AfFORDING COVERAGE � NAIC A
Chatham MA 02633 iNsur�en;Ll 's of London
INSt&2ED II�URER B•
RTL Properties, Inc. ���;
DBA The Inn at Le�vi s BB�I INSURER D:
57 Maine Ave. ��E:
West Yarmouth l�i U2673 i� �F,
COVERAGES CERTIFlCATE NUMBER.'roxn of Yaraonth BOH REVISION NUMBER.
THIS IS TO CERTiFY THAT THE POLICIES OF 1NSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOl1MTHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CQNTRACT OR OTHER DOCUMENT 1MTH RESPECT TO VWi1CH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFOROED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POUCIES.LIMITS SHOYVN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR TYPE OF INSURANCE POLICY NUMBER POLICY EFF POLlCY EXP LIiUTS
��^����TM enCH occURREwcE E 1,OOO,OOO
X COMMERCIAL GENERAL LIABIl1TY PREMI S Ea o�me� S 5O�OOO
A CLAIMS-MADE �OCCUR Z10350 /30/2011 /30/2012 MED EXP(My aie parsan) S 5�000
�RSONn�&a�v IruURY S 1,OOO,OOO
GENERAL AGGREGATE S 2�OOO�OOO
GEN'L AGGREGATE UMR APPLIES PER: PRODUCTS-COMPfOP AGYi E 2�OOO�OOO
X aoucv �a LOC S
p�E���y IN SINGLE L1MfT
Ea ' n
ANY AUTO _ _ �DILY INJURY(Per peison} S
— _� --- -
ALL OWNED SCHEDULED � � � BODILY INJURY(Per accideM) S
AUT0.S AUT0.S
NON-0WNED �PE�R�MAGE _
HIRED AUTOS AUTOS
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UN�F��e LU1B p�UR EACH OCCURRENCE i
a���B CLPJMS-MADE AGGREGATE S
DED RETENTION S
WORKERS COI�ENSATION VNC STATU- OTH-
ANO EMPLOYERS'LIABILITY Y/N: �� �
ANY PROPRIETORlPARTNER/IXECUFIV/E❑ N 1 A E.L.EACH ACCIDENT i
OFFlCERAVAEMBER EXCLUDED?
(Ma�M�taY h NH) E.L DISEASE-EA EMPLOYE S
If Yes�des�x�e urWar . .
DESCPoPTION OF OPERATIONS below E.l.DISEASE-POLICY UMIT S
DESCWPTION OP OPERATIONS!LOCA710NS/VENICLES(ASach ACORD 101,Adtlkio�pl R�marks Sehe�iq H more�is nequirad)
Bed & Breakf88t Inn
CERTIFICATE HOLDER CANCELLATION
(508)398-0836 sHout.0 at�n oF niE Aeove oEscc�n Pouc�s�caNCEu.E�eEr-or�
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELNERED IN
ACCORDANCE WITH THE PQIICY PROVISIONS.
Town of Yarmouth
Att: Board of Health
1146 Rte. 28 A��E°�r�s��rArnE
South Yarmouth, l�i 02664
David CraMford/BI.DDCl ��"'� ��'�j='
ACORD 25(2010t05) m 1988-Z010 ACORD CORPORATION. AN rights reserved.
INS025 r�n1�n.5i m 71+n A!`AR11 n�nw�net Innn aro ronieMroei mae4ee nf A(`_ARII