The URL can be used to link to this page

Home My WebLink AboutApplication and WC �s. � - , � , � � ��.+&�I C D � TOWN OF YARMOUTH BOARD OF HEALTH - � �� APPLICATION FOR LICEN"� , E � I�=,2 1�~�-�, � � ' � � l�� ., � ... � * Please complete form and attach all nece�� ts by ec ��, Failure to do so will result in the��turn�f�aiar��pplica on . I ESTABLISHMENT NAME: � � T • - ` LOCATION ADDRESS: TEL.#: ' � � MAILING ADDRESS: � E-MAIL ADDRESS: � •� � OWNERNAME: � ^ ,f �, CORPORATION N E (IF A PLICABLE): ' MANAGER'S NAME: ' TEL.#: �. f n � MAILING ADDRESS: � ��T�y�, , " . _ __ ___ � 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 tlus form. � 1. � � � 2. � � � I Pool operators must list a minimum of two employees currently certified in basic water safety, 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. l. 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 ieast one Person In Charge (PIC) on site during hours of operation. 3._ 2• _� � i ALLERGEN CERTIFICATIONS: ' All 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. 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 a11 times. Please list your employees trained in anti-choking procedures below and attach ! copies of employee certifications to this form. The Health Department wil�not use past years'records. You must ' provide new copies and maintain a�le 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 SWIMMING POOL $80ea. LODGE $55 TRAILER PARK $105 _WHIRLPOOL $80ea. ' FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $85 _CONTINENTAL $35 NON-PROFIT $30 >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 s .ft. $50 >25,000 sq.ft. $225 VENDING-FOOD $25 �<25,000 sq.ft. $80 �� FROZEN DESSERT $40 �TOBACCO $95 ;'�!. NAME CHANGE: $is AMOUNT DUE _ $ 1'1��OC� � *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** � _ � a. �.\.�..i � ADMINISTRATION N , 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 WORK�R'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR 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 MOTELS AND OTHER LODGING ESTABLISHMENTS ��I --—---� � ,�.��. —.__ - --- ---- TRANSIENT OCCUPANCY: For purposes of the limitations of 1VIote1 or Hotel use, ransient 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 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 � 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 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 thereafter. � POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven (7) days of ` closing. . I _ _ _ ___ _ _ - -- _ --- ---- 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.varmouth.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 COOHING: 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 13, 2013. 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 COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ` DATE: ��`�_SIGNATURE: ; ; PRINT NAME&TITLE: „ „ y Rev. 10/08/13 E � � \__.� _ " E � � The Commonwealth ofMassachusetts r � ' Department of Industrial Accidents I Office of Investigations 1 Congress Street, Suite I00 Boston, MA 02114-2017 � www.mass.gov/dia � Workers' Compensation Insurance Affidavit: General Businesses � Aunlicant Information Please Print LeQiblv Business/Organization Name: Address: f � �� City/State/Zip: � n �' Phone#:� -�'�{�-`� .:�(Q (,� Are you an employer?Check the appropriate boz: Business Type(required): 1.� I am a employer with_�employees (full andl 5. ,�Retail j .. or part-time).* 6. ❑ RestaurantlSar/Ea�ir�a Establish:mer.t 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] 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]* 11.0 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#L _ . I am an employer that is providing workers'compensation insurance for my employees Below is the policy information. Insurance Company Name: ��(�(�p j'�.�►,� ��j,�,,t�� L�t �C�i , Insurer's Address: City/State/Zip: ; Policy#ar Self-ins.Lic. #�� Expiration Date: �D��f�_ Attach a copy of the workers' compensation policy declaration page(showing the pohcy number and ezpiration date). i Failure ta secure coverag��:rEc}uired under.S�ctiaia25Aof MGL_c...152 can lead to the impositiarn�f criminal pena.lties Qf a ' 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 certify,under the pains and penalties of perjury that the information provided above is true and correct. ..------ Si ature: Date: ' Phone#: -�� ' - Official use only. Do not write in this area,to be completed by city or town official City or Town: �q�1M,0t�}� Permit/License# circle one): Board of Health .Building Department 3. City/Town Clerk 4.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: 5a8 348-a-�-3/ X/2�/� www.mass.gov/dia � f � � ' _�� CAPECOD-09 KSKA ACOR�� CERTIFICATE OF LIABILITY INSURANCE DATE�MMIDD/YYYY) � 11/22/2013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES � BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETINEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE 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 does not confer rights to the { certificate holder in Ileu of such endorsemen s. 1, PRODUCER � � � A T . � NAME: i Automatic Data Processing Insurance Agency,Inc PHONE FAX 1 ADP Boulevard ac No Ext: A/C No: E-MAIL ROS@land,NJ 07068 ADDRESS: INSURER�S)AFFORDING COVERAGE NAIC# �NsuReRn:NorGuard Insurance Com an 31470 INSURED Cape Cod Farms Ii� LLC INSURERB: 252 Main St Rt 28 iNsuReR c: West Yarmouth,MA OZB73- INSURER D: INSURER E: INSURER F: ! COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: ! THIS iS TO CERTIFY THAT THE FOLICIES OF INSURANCE LISTED BELOW HAVE BEEN fSSUED TO THE 1NSURED NANiED ABOVE FOr�TNE PvLiCY PERfOD INDICATED. NOTIMTHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE 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 BEEN REDUCED BY PAID CLAIMS. INSrnR 7ypE OF INSURANCE ADDL SUBR pOLICY NUMBER MM/�DDY� MM%DD� LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITV PREMISES Ea occurrence 5 CLAIMS-MADE �OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERALAGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY PR� LOC $ � AUTOMOBILE LIABILITY COMBINED SINGLE"LIMIT Ea accident $ ANY AUTO . - BODILY INJURY(Per person) $ . ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident $ UMBRELLALIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE S DED RETENTION$ $ WORKERS COMPENSATION X WC STATU- OTH- AND EMPLOYERS'LIABILITY T Y T ER li /� ANYPROPRIEfOR/PARTNER/EXECUTIVE Y�N CAWC469635 6/10/2013 6/10/2014 E.L.EACHACCIDENT $ ��0��0 ' OFFICER/MEMBER EXCLUDED7 � � N�A �� (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ �00,00 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ SOO,OO DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Altach ACORD 101,AddHional Remarks Schedule,if more space is required) "PROOF OF COVERAGE" CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEfORE INSURED COPY THE EXPIRATION DATE THEREOP, NOTICE WILL BE DELNERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE _.... ::��-_-�"w - ., = - -----�' j-. ..-_ — �'_>•r' - — -= __ ._.. `----� -�'- " � ..�--�—--- y.��".-____. O 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD