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Home My WebLink AboutApplication and WC z s�,� . � o � � � , . �P � ,�,� TOWN OF YARMOUTH BOAI� O�'HEALTH �' � � C#� 003 , � � �� `L� APPLICATION FOR LICEN . �T-20�3{� w i1 �, ��+ a�� , ,�:. i 1,. D�C 0 6 2012 ... �� 4� * �-. �;��`�� , Please complete form and attach all nec cuments by ce 2012. Failure to do so will result in the return of your applicati • ESTABLISHMENT NAME: C�RI S i/�f�S �"'T/r'�"� �`6� .�Z�3 TAX ID: ___ L.00ATION ADDRESS: ��Q Ot.� �� G��ST 1�Rk'/'Lmt.�7"�-�M� a�l�L..#:�b�-7'75-��1 MAILING�DDRESS: tv�L,t$��T`y �4✓�l,l/VfUdl�� 11?.S �d8� ��v.� R�Sk r�G��r7� OWNFR NAME: �"'� —�— CORPORATION NAME (IF APPLICABLE): ��/'«7'y�t/�,i�'F�E�6fOf�_,,,�h� �� _ MANAGER'S NAME: �c,�S1�/t� {�tll�LE 1�– �� /�Gk'- TEL.#:qo�-��-o�" _ MAILING ADDRESS:� o ��;��i�rl��T,� �l�J r�a �� POOL CERTIFICATIONS: �'� ` The pool supervisor znust be certified as a Pool Clperator,as requ't.red by State law. Please list the desi�nated � _^,�..��'�� y-t-�tt�r-��g�-of�, .___�� _.� .. �.:. .•. . � 1 i..i� J -iIi3, v �� x TII-�i�..t:- .CJ[-4�7��.�v'Y�Y.-'--__ . � -�---------__ _.-,.,_._.__ _ 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 file at your place of business. l. 2. 3. 4. - 5�'�L o�U�.�l l�'�'��''�1��L-�A �'�� 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. 1. 2• - �'�>��`��.'�:_ , �_—_ -- _--_- , Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. ; 1. 2• HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or mare 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 will not use past years' records. ; You must provide new copies and maintain a file at your place of business. � f G 1. _ 2. F � 3. 4. � k RESTAURANT SEATING: TOTAL# � � OFFICE USE ONLY � LODGING: i LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# I B&B $55 CABIN $55 _MOTEL $55 � INN $55 . _CAMP $55 _SWI1VI1vIING POOL $30ea. f — i 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 _ f >100 SEATS $160 _COMMON VIC. $60 _WHOLESALE $80 _ ! I RETAIL SERVICE: —=RESID.KITCHEN $80 . .... � LICENSE REQUI1tED FEE PERMIT# LICENSE REQIJIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $50 >25,000 sq.ft.. $225 _VENDING-FOOD $25 _ _ � I <25,000 sg.ft. $80 ��3" "� � —FROZ�N DESSERT $40 =TOBACCO ` $95 --�� — ___ �� NAME CHANGE: $15 AMOUNT DUE _ $�O��0 ; i ***x*PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** i f� . � � ` ADMINISTRATION � i ' 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, OR CERT. OF INSURANCE ATTACHED . . . OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED I Town of Yarmouth taYes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES � NO 1 , ' 1VIOTE�,�AND OTHL�R LODGING EST�BLISHMENTS ' ' � � 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. f Transient occupants must have and be able to demonstrate that they maintain a principal place of residence � elsewhere.Transient occupancy sha11 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 I, 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 j . ' j 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 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 , j by a State certified lab, and submitted to the Health Department three (3) days prior to opening, and quarterly j ' thereafter. _ _ _ _ . _- - POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. 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 TowY'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 j submitted to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen � �'I Dessert Permit until the above terms have been met. ! OUTSIDE CAFES: I i Outside cafes�i.e. outdoor seatin with waiter/waitress service),must have prior a�proval 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. NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN I 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 REPORT�D TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TQ COIVIMENCEIVIENT. RENOVATIONS MAY REQUIR,E A SITE PLAN. • . i DATE: �i ��Q�l� SIGNATURE: -t�l�. I PRINT NAME& TITLE:��7N 1-��kE�� j,Q�C7z�� p,C �{�Sf� �CM-t' Rev. 10/09/12 _ � � , � .� ` � The Commonwealth of Massachusetts Department of Industrial Accidents - � Office of Investigations 1 Congress Street,Suite 100 � Boston,MA 02114-2017 4 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Anplicant Information Please Print Le�iblv Business/Organization Name: ��/�157'/?22F35 �� „��Z� Address: (P d� ��1� �1�� I � ; City/State/Zip: u�'�O�j d1J� O�f� 3 Phone#: _ Are you an etnployer?Checrtc�tue:aPPropri�fe b�- -- :_ E�siness'Pype{recpuircd): �-- - -- ` 1.�I am a employer with employees(full and/ 5. [t�'�etail 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 a 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 f �Any applicant that checks box#1 must also fill out the section below showing their warkers'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 providing workers'compensation fnsurance for my employees. Below is the policy information. Insurance Company Name: ,�/�-/}-�� /v��- � � Insurer's Address: l� 6"�/�� City/State/Zip: 4'v�LU �O�l�, N y l OC�I_� . . . � . . _ _ 1's�3�y#-�-"-'��i a��„e.� _��-�� -�� _ _- Expirat�e��ate:��-- ---- --- 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 a 152 can lead to the imposition of criminal penalties of 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�nay be forwarded to the Office of ' Investigations of the DIA for insurance coverage verification. I do hereby certify,un r the ains and penalties of perjury that the information provided above is true and correct. Si ature: � _ Date: / �� Phone#: % T��`�S�'08f5'� ; � � Official use only. Do not write in this area,to be completed by cdty or town officiaL ; � � City or Town: rA�M19t�4� Permit/License# � Iss ' o (c� cle one): ' .Board of Health .Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office 6. '. Contact Person: Phone#: c3b8;�tB-��:3/ X�Z-�l , www.mass.gov/dia r ♦ '� ' A�� CERTIFICATE OF LIABILITY INSURANCE paqe � of � o2i28�2o 2 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS LPON THE CERTIFICATE HO�DER.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 BETWEEN 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 WANED,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 hoider in lieu of such endorsement(s). PRODUCER � � CONTACT � VPillia of New York, Inc. PHONE FAX - c/o 26 Century slvd. � 877-945-7378 • 888-467-2378 - r. o. aox 305191 E-�A�� certificates@willis.com Nashville, TN 37230-5191 INSURER(S)AFFORDING COVERAGE NAIC# INSURERA: Safety National Casualty Corporation 15105-001 INSURED . �.. Christmas Tree Shops, Inc. INSURERB: St. Paul Fire and Marine Insurance Compan 24767-001 64 Leona Drive � � INSURERC: Middleboro, MA 02346 � . INSURER D: , � . �. . •�. � INSURER E: � � � � � � �� . � � . . � .. ..:. ..... . .�.� � ., . .. � �� INSURER F. � COVERAGES CERTIFICATE NUMBER:17461616 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING 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. INSR TypEOFINSURANCE DD' SUB pOLICYNUMBER POUCYEFF POLICYEXP � �IMRS � p� GENERALLIABILITY GL4045801 �1�2012 3/1/2013 EACHOCCURRENCE $ 1 OOO OOO � $ COMMERCIALGENERALLIABILITY � . PREMISES Eaoocure°nce $ 1 OOO OOO CLAIMS-MADEa OCCUR MED EXP(Any one person) $ � . � � �. � PERSONAL&ADVINJURY � $ �1 OOO OOO GENERALAGGREGATE $ ` Z 000 000 GEN'LAGGREGATEUMITAPPLIESPER: PRODUCTS-COMPlOPAGG ' $ 2 000 000 g POLICY. PRO- �� . . . .. . . . . ... - . .. . .. . .. . $ .. � . j.� AUTOMOBILELIABILITY � AOS CAS4O4SHOO �1�2012 3/1/2013 � COMBINEDSINGLELIMIT 1,000,000 . . (Ea accident) $� . X ANYAUTO 80DIlYINJURY(Perperson) $ � ALLOWNED SCHEDULED . BODILYINJURY(Peraccident) $ H RT DAUTOS NON OWNED Peraccitlentj $ AUTOS � $ $ X UMBRELLALIAB X OCCUR ZUP-12S81692 3�1�2012 3/1/2013 EACHOCCURRENCE $ 10 000 000 EXCESS LIAB CLAIMS-MADE AGGREGATE S 10 000 000 DED RETENTION$ � � � ' WORKERSCOMPENSATIQN,...-. . .... � '�-AOS LD34O4SHO2 - �Z�ZO12 3/1/2013 � X �� A AND EMPLOYER§'LIABILITY �� A ANYPROPRIETOR/PARTNER/EXECUTIVEY� N�A WI P54045803 3/1/2012 3/1/2013 E.L.EA,CHACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? - � � � A iMandawryinNH) WA & OH SP4045749' 3/1/2012 3/1/2013� E.L.DISEASE-EAEMPLOYEE $ 1,000,000 fyes,tlescnbeunder � - DESCRIPTIONOFOPERATIONSbebw E.L.DISEASE-POLICYLIMIT �-$ 1�000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(AtWch Acord 101,Additonal Remarks Schedule,if more space Is required) Evidence of Insurance CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. The Commonwealth of Massachusetts Department Of Industrial ACCid@IIt8 AUTHORREDREPRESENTATNE Office of Investigations 600 Washington Street Boston, MA 02111 Co11:3647758 Tp1:1406815 Cert:i 1616 01988-2010ACORD CORPORATION.Ail rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD