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Home My WebLink AboutApplication and WC " " t ��-__ « ►� TOWN OF YARMOUTH BOARD OF HEALT �� _- � - � � � APPLICATION FOR LICENSElPERl��'�"�2�, `y .�� ;� _ � '' . ,��..� 3 F r � ;� � � * Please complete form and attach all necessary docum"ents�.� �cemb € 1 S 2010 Failure to do so will result in the return of yo�r�application pack t�. �;�:�",��Y= �.•�Y��d. ESTABLISHMENT NAME: �E'.Gv� TAX ID��' � LOCATION ADDRESS: -r"�'�- ac✓�e TEL.#: �� }�(- �I,�j MAILING ADDRESS: W ' l U-f ma� � p � 3 �. > OWNER NAME: �� d- o. t�K c� � l��r.rt ' CORPORATION NAME (ff APPLICABLE): � �r -�s � � � MANAGER'S NAME: (3 o I� L� �x ��a-„� TEL.#: G�-�'- S(�-6-/o f� � MAILING ADDRESS: S �,,,,,, t c�s �(��. POOL CERTIFICATIONS: � �' The pool supervisor must be certified as a Pool Operator,as required by State la�v. Please list tlie designated Pool Operator(s) and attach a co�y_of the certification to this form. 1. 2. Pool operators must list a minimum of two employees cun ently certified'ui basic water safety,standard Fu•st Aid azid Community Cardiopulmonaiy Resuscitation(CPR). Please list these ernployees below and attach copies ofemployee certifications to this form. The Health Department will not use past 3�ears' records. You must provide ne�� copies and maintain a file at y�our place of business. l. 2. �i 3. ,� 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: �ll food service establislunents a.re requued to have at least one full-time employee who is certified as a Food Protection Manager, as defined 'ui the State Saiutary Code for Food Seivice Establislunents, 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 �ile at your establishment. 1. I�O�e r� 4 l Dt f/'Vl�e� 2. PERSON IN CHARGE: ,' Each food establislunent must liave at Ieast one I'erson Iil Cllarge (pIC j on siYe duruig hours of operation. 1. /\O 6...�- l..��f� r1N�d...►� 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained ui the Heunlich Maneuver on the premises at all times. Please list your employees trauled in anti-choking procedures below and attach copies of employee certifications to this foi7n. The Health Department will not use past years' records. You must provide new copies and maintain a �le at your place of business. 1. � I �+ 2. 3- 4. RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LODGI\G: LICENSE REQUIRED FEE PERMIT� LICENSE REQUIRED FEE PERivII?# LICENSE REQUIRED FEE PER'�IIT� _B&B S» _CABIN S55 ��OTEL S55 ._iNN S55 _CAMP S5� _ _S��'L'vIl�IING POOL SAOea. ( LODGE S55 ��(,I�� T�R,ERPARK 5105 ��-IIRLpOOL S80ea. FOOD SERVICE: LICENSE REQUIRED FEE PER�VIII'� LICENSE REQUIRED FEE PER��IIT� LICENSE REQUIRED FEE PER.�IIT� I 0-100 SEATS S85 � —CONTINENTAL S3� NON-PROFIT S30 _>100 SEATS S160 �CO'_V�i ION VIC. S60 � �'VHOLESALE S80 RET:�IL SERVICE: —RESID.KITCHEN S80 LICENSE REQUIRED FEE PER�IIT� LICENSE REQUIRED FEE PER�'41IT.~ LICENSE REQUIRED FEE PER'�1IT# _<50 sq.ft. S50 _>25,000 sq.ft. S235 VENDING-FOOD S�5 _Q5,000 sq.ft. S80 _FROZEN DESSERT 540 TOBACCO S>j �A`'IE CHA\GE: s�s AMOUNT DUE _ $ �oo �00 *"��**PLEASE I'I:R\'OVER A\D C0�IPLETE OTHER SIDE OF FOR�T""*�** r �. . . . 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 AFFIDAVIT MUST BE COMPLETED AND SIGNED, QR { 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 � i�►fii��LS Aiv'l3 ��R i.��G�Ii'G L+';�`�A�tI�IS�1i��N`�i� � TRANSIENT OCCUPANCY: For u oses of the limitations of Motel or Hotel use Transient occu an shall be � P rP , P �' 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 ofresidence 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 sha11 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 I I 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 De�artment to schedule the inspection three(3)days pnar to opening.PLEASE NOTE:People are NOT allowed to srt m 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 f FOOD SERVICE " SEASONAL FOOD SERVICE OPENING: All food service establishments must be ins�ected 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 ofHealth. OUTDOOR COOHING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prahibited. ! 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, 2010. ALL RENOVATIONS TO ANY FOOD ESTABLIS��VIEENT, MOTEL OR POOL (i.e., PAINTING, NEW EQLTIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR � TO COMMENCEMENT. RENOVATIONS MAY R UIR SITE PLAN. ' DATE: �D � 1.3 �►� SIGNATURE: � PRINT NAME&TITLE: I?��' �i�� ,,.,,�.�..� (��,r►1n,� f 10!06'10 . j i „ , . . , �\ The Com�nonwealth o M f assachusetLs Deparhneni of I►edustrirt!Accidents � NNfriarrr�J�,rl�s 600 Washingtu►n Street, 7`"'Floor Boston,Mass. 02111 Workers'Compensation Inseraace Afti,davit; 8aiiding/Pinmbieg/Ekctricat Contractors ADDHt�t �t�r�e��y; Plesse PRIlV1'1eQibhr narnc: o bt-i"�" �b-G r Nl s�'1r— addcess: S�" �G�cn.� --- -- — -- �------ — CIN W� �/G�rM 0 V� StBtC� r A----- Zlp l��p�-,D�IO�C# �V � ��' 3�� work site location(full address)• S �^� �^S 0..�`1�_ ❑ a homeowr�er perfornung all work myself. Pro�ect Type: []New Construction�Remodel � I am a sole proprietor and have no one workin Yn an ca ci S Y Pa tY• ❑Building Addition ❑ I arn an employer providing workers'compensatian for my employees working on t6is job. _ / . - f3t�;.(I-�-r�C v�, - __ _ ,_ :__. �- .:_. t��.�_:_ _ ! �omo�.v eam�: —�-� e �aan...- 5 �-- „� ��ri- �� t/�,r�.�� -�. /'t , ��-�t 3 Y 3 o��a o Ins�xe ca ��# -- -- . ,._-,-.,--,-.._,...,_._ ❑ I am a sote proprietor,geaersi costractor,or 6omeo�rner(circ%owe)and have hired tl�e contractors listsd below who have c6e following workers'compensation polices: �COIDOanY O!�!• . . � � . - . idt�il3�• CI haee N: iBaaraaee eo. # ' commsv.�s..• addras- efri: � oio�e!t ' _ _ _ ._ ._ _— -_ _ _ __ _ ios w, _ _ _ # A�hee�i aii�1�Y tiret rtseuoe� Fait�re b sa�re oerera�e n roqsired asdQ SMb�2SA s[MGL 132 cai lad b He �Ya�'teapriwa�ee�a�wd as dH peeaNla In[he ferat ot a 3TOt WORK ORDER��ne ef�11A9 P�•f a rtne ap a S1,3M.a!aaN.r eepy at t4b�tatemeat may be forwarded ts tse ORice o[Igvestl�aWm ot t6e DIA for ceverase ver111eatlss. y�°��me. i neden�d t6at a !do liereby ce n Mre poPws and pentld�r ofPerjr�ry tikat r1Ye iafonrratio�provided aboae Er e►#e awd corn�ct � s��mK �r� T�fL�cJ i Print narne ��r �" r"''�^d'^— Phone#J v� ��—3 �,I ; _ : ... of8eial ox only : do not�►rite�thf�arca to 6e coe�pktM by ciry or�wn oHlciai , `, dry or town: PermttlNeeme# [�Bnydina Department ❑chect if immedia6e re�peme i�rcqoired �LeeeainS Boaril ' (]Scleetmen'a(lf6�Y , rnntact penon: phooe f!; �H�'��rhee�� ' c�a s�zom� Op�Q ACORD CERTIFICATE OF LIABILITY INSURANCE °"'�`M�'°°""""' TM 12/03/2010 � PI�aJCER 508.945.0393 FAX 508.945.4048 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION { Eldredge & Lumpkin Ins. Agency �-Y��V�� 697 Main Street ��'�� ALT�2 7HE COVERAGE AFFORDED BY Ti�POL.ICES BELOW. � Chathaa, MA 02633 � �AFFORDNG COVERp►GE NAIC# i�� RTI. Properties, Inc. iNSURERA Lloyd's of London DBA: DBA The Iim at Lewis Bay MISURERB: 57 Maine Ave. INSURERC: �CSt Y127011t�1, MA 02673 INSURER D: � INSURER E: COVERA�'aF.S THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITH ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUF � MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITION� POLICIES.AGGREGATE LIMITS SHOYVN MAY HAVE BEEN REDUCED BY PAID CLAIMS. � gR TYPE OF INSURANCE POLICY NUMBER ��E �� t�ABTS GENERAL W18it1TY XSZO413S OG�3O�ZOZO OG�.3O�LO11 EACH OCCURRENCE $ 1 (p0 I� X COPoMAERCIAL GENERAL LIABILIIY P MI ES Ea $ rJO CLAIMS MADE �OCCUR I�D EXP(My ane persm) $ rj A PERSONAL 8 ADV INJURY $ j � GENERAL AGGF2EGATE S 2 OOO GEN'L AGGREGATE L�AR APPL�S PER PRODUCTS-CORAP/OP AGG $ 2 OOQ POLICY E� LOC AUTOMOBILE LJABILJTY COMBINED SINGLE LIM(T � ANY AU70 (Ea a�rt) . $ ALL ONMED AUTOS BODILY INJURY �p�P�) S SCHEDULED AUTOS HIRED AUTOS BODILY INJURY Per acciderrt $ NON-0WNED AUTOS � � PROPER7Y DAMAGE $ (Per acadent) GARAGE VAB�ITY AUTO ONLY-EAACCIDENT $ ANY AUTO OTHER THAN EA ACC 3 . AUTO ONLY: A� $ EXCESS�UIM9RELLA LIABILITY EACH OCCURRENCE $ OCCUR �CLAIMS MAQE q(�,�(;p7E $ S DEDUCTIBLE $ RETENiION $ $ WORKERSCOMPENSA'IION WC STATU- OTH- AND EMPLOYERS'UA&LIT1f Y/N TORY LI RSy ER ANYPROPRIETOWPARTNEWEXECU7IVE� E.LEACHACCIDENT $ OFFICERIMEMBER EXCLUDED? — (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,desatbe uda SPECWL PROVISIONS belo+v E.L DISEASE-POLICY LflNff $ 07HER DESCRIP170N OF�ERATIONS/LOCATIONS!VEFMCLES/DCCLUSIO�ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Bed d� Bed Breakfast Im�: The Inn at Lewis Bay, 57 Mai� Ave., �Yest Yar�outh MA 02673 CERIIFICATE HOLDER CANCELLATION sHou�o arn oF n�a�ve oEscr�o rou�Es�car�LLe�eE�e nie exww►na+ DATE iHEREOF,7HE ISSUING INSURER YYILL ENDEAVOR TO MAIL 1� DAYS W WTTEN NOTICE TO THE CERTIFlCATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO�SO SHALL Town of Yar,outh u�vose No aeucanoN or:une�un�aar�ro u�n�iNsur�,�rs ac�Nrs a: Att: Philip 8enaud, Health Inspector �A�, 1146 Route 28 aun�r�rrsEs�rAmr� South Yax�th, MA 02664 Alan g. Lo President ACORD 25(2009/01) O 1988-2009 ACORD CORPORATION. All righis reserved. The ACORD name and logo are registered marks of ACORD � IMPORTANT � If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the certficate hofder in lieu of such endorsement(s). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s),authorized representative or producer,and the certificate holder,nor does it affirmatively or negatively amend,extend or alter the coverage afforded by the policies listed thereon. ; � ACORD 25(2001/08)