HomeMy WebLinkAboutApplication and WC ' TOWN OF YARMOUTH BOARD OF HEALT. Q����d��
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� � APPLICATION FOR LICENSE ��I��#';,+2(�.�6 � � JUN U� 2016
� ' * Please complete form and attac h a 1 1 necess .`;doc ' � s�l�a�r i er 1 S 2 0 1 S.
! Failure to do so will result in the return of your application pa et.HEALTH DEPT.
E�TABLISHMENT NAME:� TAX D•
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1VIAILING ADDRESS:
E-MAIL ADDRES S: C.F 11['�" ���_t,�QY1O O•C.CSYY'�
OWNER NAME:
CORPORATION NAME IF APPLICABLE):
NTANAGER'S NAME: � F1PX' TEL.#: $�
MAILING ADDRESS:
PbOL CERTIFICATIONS: .
The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated
Pc�ol Operator(s) and attach a copy of the certification to this form.
L � i'� 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.
F40D 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., � QC�' �V �� �`����1� 2.
�
PERSON IN CHARGE:
Eac food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
_ i
,
1 , 2 __ --
ALLERGEN CERTIFICATIONS:
All food service establishments are required to have at least one full-time employee who has Allergen certification,
asi 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.' ,�,,��1�;���- �-��..V 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 �le at your place of business.
1. 2.
3. 4.
RESTAURANT SEATING: TOTAL#
OFFICE USE ONLY
LODGING:
. LTCENSE I�E�iUIREI7-FEE �#-� Z�I�EIV�E-�QUIRED FEE PERivfIT# LfeENS�REQUIREQ FEE PE�tMI9'#
_B&B $55 CABIN $55 MOTEL $110
INN $55 CAMP $55 SWIMMIAIG POOL$I l0ea.
_LODGE $55 =TRAILER PARK $105 _WHIRLPOOL $110ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE P IT#
0-100 SEATS $125 _CONTINENTAL $35 _�NON-PROFIT $30 ���=��,.0
>100 SEATS $200 _COMMON VIC. $60 WHOLESALE $80
—RESID.KITCHEN $80
RETAIL SERVICE:
LICENS�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 _ $ 30•,Q�
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE UF FORM*****
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� , � 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
Applicant Information Please Print Legiblv
Business/Organization Name:`�aXYp� l�Q.�'11�I S RQO�c�C�C�,��Q,�.�-� �,l.b� �1�1� •
Address: �•�. �(�C, �8
City/State/Zip: ��1 �t ���5 Phone #: �� � r a(p$•Q 0 50
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).* 6. ❑ RestaurantBar/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]
8. 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 providi�g workers'compensation insurance for my employees Below is the policy information.
Insurance Company Name: �,���(�1�GtX 1 n�,( , �],('1!
Insurer's Address: p(� �C�C, �'d Q(�
City/State/Zip: �(�,S�iC.�/1i9 1A/ 1 �j L-j�(,�i^ �(�R�
«---r—
Policy#or Self-ins.Lic. #�1)C�l– 3 �S��0�� �S� �1.'�� Expiration Date:�7��� �af���.
Attach a copy of the workers' compensation policy declaration page(showing the policy number and ezpiration date).
--FailurE to�ecure coverage as required under Sectian 25A ef MG�,c. 152 can lead to the ixnpositiox�of criminal penalties ofa
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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby c rtify,und e ains andpenalties ofperjury that the information provided above is true and correc�
Si ature: Date: t(1 0�. o��l
Phone#:
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3. City/Town Clerk 4.Licensing Board 5. Selectmen's Office
6.Other
Contact Person: Phone#:
www.mass.gov/dia
r
oare(WeeroavYYv)
,ac RO v� CERTIFICATE QF PROPERTY INSURANCE 6/5/15
THS CER7IFICATE IS ISSUED I�S A MATIER OF INFORMATION OI�Y AND CONFEl2S NO RIGHTS UPON THE CERIIFlCATE HOLDER THS
CER7IFICATE DOES NOT AFFIRMATNELY OR NEGATNELY AMEPD, EXTEND OR AL'iER THE CONERAGE AFFOROED 6Y 'tHE POLIqES
BELOW. TF/S CEI7TIFlCATE OF INSURANCE DOES NOT CONSTIlU7E A CON'iRACT BEI'YYEEN THE ISSUNG INSURER(S), AUTHORIZED
REPRESENTATNE OR PRODUCER,AND THE CERTIRCATE HOLDER.
If ti�certificate is being prepaed for a parly who haa an insurable interest in the property,do not use tl�is fi�rm Use/�ORD 27 or I4CORD 28.
aRonucFx
NAIYIE:
John F Martin Insurance Agency . (508) 398-2277 N : (5oe) 398-2239
1023 Route 28 Ao JimMartin321@ ahoo.com
PO Box 350 1924
South Yarmouth, MA 02664 x�su� s n�ori�ir�co ce `L�v��"L���''u''���� Nn # �
���m n�suR�a:Liber Mutual ;
YARMOUTH DENNI$ RED $OX ��►R�t6:
BASEBAIaT� CLUB INC IP6URER C:
P O BOX 7 S INSl1RER D: f'�t���_Ts� r
YARMOUTH PORT, 1� 026'75 It�RIIRERE:
IPl&lRf�t F:
COVERAGES CERTIFICATE NUMBER: REVI.SION NUMBER:
— A[i'�-LII�P7�DE�lY_(llltaeh AOORD W7,/►d�Nmal RamarNs Scled�le,itmore apaoe is�squ�ed)
_ _ ___
lOStation Avenue, South Yarmouth, MA 02664 - "
THIS IS TO CERTIFY THAT THE POLIGES OF INSURANCE LISfED BELOW HAVE BE'EIV ISSUED TO THE flVSUtED NAMED ABOVE FOR THE POLICY PERIOD
INDICAT�. NOTWITHSTANDING ANY REQUREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WfTH RESPECT TO WHICH THIS
CERT�ICATE MAY BE ISSU�OR MAY PB2TAIN,THE INSURANCE AFFORDED BY TFE POLICfES DE�q21BED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONOITiONS OF SUCH POLICES.LIMITS SHOVNV MAY HAVE BEEN REDUCED BY PAID CLAANS. '
MSR TYPEOPINSURANCE POLJCYM111BER POLICYEFFECiNE POtJCYE�IRATION COVEREDPRO�PERTY LMfTB
LTR DATE�1dMlUDIYVYY) OA7E(NMAIDdYYYY)
aRoa�rr sui�awc � .
CAUSES OFI�SS DEDUCTIBLES PERSONALPROPERTY y
&4SIC BUILDING BUSpdESSIPCOME g
BROAD CONT TS IXTRA EXPENSE �
SPECIAL RENTAL VALtE :
EARTHQUAKE �ANl�TBUILDING s
WIND BLANl�TPERSPROP $
FIOOD BLANI�T BLDG&PP $
$
$
INLANDMARNE TYPE OF POLICY E
CAUSES OF LOSS =
NAMED PERILS Pa1CY NUNBER a
$
CRIME
$
_ E.OF POLJCY _
S
BOItER 3MACHIPERY/
EQUIPMENT BREAImO1NN a
S
a
a
SPEQAL COPDITIONS/07HBt COVERAiGEB(ACach ACOt�101,Addklorrl Rertwks Schad�/e,if more apaee is required)
orkers Compansation #WC2-31S-605820-15, effetive 06/07/2016 to expire 06/07/17
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLJCIES BE CA/10E4LED BEFORE
TOF/i1 of Yarmouth ACCORDPANCEwiTM n�E ro�.�c�RowS�lOTI� WILL BE DELJVEREO �1
Board of Health
1146 Route 28 auTM PRESENTATNE
South Yarmouth, MA 02664
0 7995 2009 ACO CORPORATION. All rights reserved.
ACORD 24(2009/09) The ACORD name and logo are regis d marks of ACORD
p��: Fax: E-Mail: