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` * TOWN OF YARMOUTH BOARD OF HEALTH ����s���OPS
� . ��003
� � APPLICATION FOR LICENS , T -28-12��^
� Ov ' � ��11 d t a h 11 neces r���o - m��b�e� e
Please complete form an a t c a i� . y �'���.'a d��°
Failure to do so will result in the ret of �ip�'tir�a�'ion pa et. ���� � � ���
ESTABLISHMENT NAME:� ' �Jiee �``1�� H TH
LOCATION ADDRESS: �s�. vu.�e- ,?S t,t��e.� �'1�"1 v2�?3 TEL.#: -
MAILING ADDRESS: ��b %/�.i�'�,t G�-, �ca�r�'I Q �Z�3� C,�.ttrrr: �- �;YY'4�r��� '�
OWNER NAME: �f��ta�irl-c�.a- clr�-z- �ie�,�e,�-, �-�-•
CORPORATION NAME(IF APPLICABLE): .,¢Q.ryze,
MANAGER'S NAME:�-�2� GCI.�'�?�i,Q-rn,a-- TEL.#: a�"'o.�-�?�"�f3i.,�i !
MAILING ADDRESS: _,o1�.nu �,t- Ci�c�-
POOL CERTIFICATIONS: /t/�/4
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 this form.
,
- C
L 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. ,
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FOOD PROTECTION MANAGERS - CERTIFICATIONS:
All food service establishments are required to have at least one full-time employee who is certif'ied 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.
PERSON IN CHARGE:
-- -- ------- ----___ -----__--- -__ ---�--- ---,-_ ----_--- =_- - - - - - _ ___---
Each fooci establishment must have at least one Person In Charge(P1C)on site c�uring hours of operation. '
1. 2. �
4
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 file at your place of business. ,
1. 2. '
3. 4.
RESTAURANT SEATING: TOTAL# 4 �
i
� OFFICE USE ONLY � �
LODGING:
LICENSE REQUIl2ED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_B&B $55 _CABIN $55 _MOTEL $55 '
_ a:r5 _ _ _ _
i
_ _;�il� . __ _ _-=c:EuYfP �55 _SWIMMING POOL $80ea. '
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_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
RETAII.SERVICE: —RESID.KITCHEN $80
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PEI2MIT#
_<50 sq.ft. $50 _>25,000 sq.ft. $2'25 _VENDING-FOOD $25
LQ5,000 sq.ft. $80 �� _FROZEN DESSERT $40 _TOBACCO $95
NAME CHANGE: $15 AMOUNT DUE _ $ ��.�� st�I�
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*****
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ADMINISTRATION
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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, OTT�
�
CERT. OF INSURANCE ATTr�CHED
OR '
WORKER'S COMI'. AFFIDAVIT SIGNED AND ATTACHED ✓� i
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Town of Yarmouth ta�ces and liens must be paid prior to renewal or issuance af your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
��S � NO
MlJTELS Ah� C!�'����..,�'����1G �ST�3�.I�7rT�ii �'r',NT� '
�
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. �
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.
POOLS
POOL OPEl�1ING: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 srt m the pool area until the pool has been inspected 'i
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.
POOI.CLOSING:Every outdoor in ground swimming pool must be drained or covered within seven(7)days of
closing.
FOOD SERVICE
SEASONAL FOQD SERVICE OPEl�1ING: i
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. !
j
CATERING POLICY: .
Anyone.who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the
required Temporaiy Ft�od 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:
, _ —�t�«� � ". :, w ' : �.���:f��i�,�e�s s��:���,:�a�t��v�Y�c�r�g�-�f��-��a�cci afHealth. _
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 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 S E PLAN. �I
DATE:��(�(f�� SIGNATURE: � � � G�,/� I,
PRINT NAME&TITLE: ��T�f �fr�c�E� DtQ���- �F Rt� ��C� I
Rev.10/25/ll
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�'� The Commonwealth of Massachusetts
Department of Indr�strial AcciJents
N�I Niw�tM�i
600 Washiegton Street, 7`"'Floor
Boston,Mass. 02111
Worl�ers'Compeesatios Irooraece AfRdavih
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name: �fc l�d'���5 �iQt'� �Of� 'w'�0�� ,
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c�itY �c�� l�f�'I,�UTf� state: �� zin• b�b�J3 Ph�# a�'6�= ?7$�Sl�� �
work s;te tocation(full addnss):
❑ I am a homeowner performing all woric myseif.
❑ I am a sole proprietor and have no ocie worlcing in any capacity.
�am an employer�oviding w�kers'compensation f�my employees woticing on Wis job.
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: �'���� CE'RTlFICATE �'F LIASILlTY INSURANCE page i of 1 02�28�Zo �
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
BEIOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZEO
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 ofthe policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
. � PRODUCER . CONTACT
Willia of New York, Inc. PHONE 877_945-7378 F� 888-467-2378
26 Century Hlvd. -MAIL
• P. o. sox 305191 certificatesQwillis.com �
Nashville, TN 37230-5191
� INSURER(S}4FFORDING COVERAGE NAIC#
INSURERA:Arch Ineurance Company 11150-002
INSURED
Bed Hath & Seyond, Inc. INSURERB: St. Paul Fire and Mariae Inaurance Compan 24767-001
. 650 Liberty Avenue . � INSURERC: �
IInion, NJ 07083
INSURER D:
_..:,-- _» INSUhBRE:
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COVERAGES CERTIFICATE NUMBER:15547385 REVISION NUMB�R:�
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 CONOITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR TypEOFINSURANCE DD• SUB pOIICYNUMBER POLICYEFF POLICYEXP ��Mn,g �
p, ceNew►�unsiurr 11GPP4934604 3/1/2011 3/1/2012 �pCHOCCURRENCE S 1 000 000
$ COMMERCIALGENERALLIABILIN PREMISES Ee��r°nce 8 1 OOO UOO
CLA�MS-MADE�OCCUR ' MEDEXP(M orreperson $
- ' PERSONALBADVINJURY. S 1 OOO OOO
GENERALAGGREGATE S 1 00 000
GEN'LAGGREGATELIMITAPPUESPER: PRODUCTS-COMP/OPAGG $ 2 000 000
$ POLICY PRa LOC $
p� AUTOMOBILELIABILITY blPa 11CAB4934504 �1�2011 3�1�2012 (Eeax�ideD�INGLEIIMiT $ 1,000�000
A X ANYAUTO AOS 11CA84934404 3�1�2011 3�1�2�12 BODILYINJURY(Perperson) $ �
ALLOWNED SCHEDULED BOO�IYINJURYPeraccideni $
AUTOS AUTOS � ( ) �
HIREDAUTOS NON-OWNED
AUTOS (Peraccidenl) S
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$ X UMBRELLALIAB X OCCUR QR09002301� /1/2011 3�1�2012 �CHOCCURRENCE S lO OOO OOO
EXCESS LIAB CLAIMS-MADE - . AGGREGATE S 10 OOO OOO '
�ED RE7ENTION$ g
p WORKERSCOMPENSATION AOS 11WCI4934104 3/1/2011 3/1/2012 X
AND EMPLOYERS'LIA8ILITY
A ANYPROPRtETOR/PARTNER/EXECUTIVE� N�A WI & OR 11WCI4934204 �1�2011 3�1�2012 E.L.EACHACCIDENT E 1,000,000
OFFICER/MEMBER EXCIUDED?
A� tMandatoryinNH) �PA & OH 11oPC84934304 -. 3/1/2011 3/1/2012 E.L.DISEASE-EAEMPLOYEE S . 1�00�0�000 .
ff yes,descnbe under - , : .
� DESCRIPTIONOFOPERATIONS�below � �� E.L.DISEASE-POLICYLIMIT S� 1�000,000� � �
DESCRIPTIONAF OPERATIONS/LOCATIONS!VEHICLES lAttaeh Aoord 101,AddlWnal Remarks Schedule,if more spaee is raquired) �
Evidence of Inaurance
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 POUCY PROVISIONS.
The Commonwealth of Maseachuaetta
� Depdrtment Of IIIduBtrial ACCid6nt8 AUTHOR¢EDREPRESENTATIVE . .� � � . � �
Office of Inveetigationa
600 Waehington Street
Boeton, MA 02111
Co11:3280867 Tp1:1227172 Cert:15547385 OO 7988-2 10ACOROCORPORATION.Allrightsreserved.
ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD