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� TOWN OF YARMOUTS BOARD OF HEALTH� „, "'
APPLICATIQN F4R LTCENSE/PE � �� A�;� � � :, �
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* Please complete form and attach all necessary do en ��er S o� ��-'` ° �
ailure t� �� so will r�sult m the return�f y apnc�ation pac et.
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NAME OF ESTA$LISHMENT:_��iir,�o,�imct,� �.h.�,e� ��ie�-�- �` "T'DO� TEL. #
LOCATION ADDRESS: `� �su.�. �2 �!J � �—t'�R p�
i MAILING AI)DRESS: ` � C.�'�c�`
OWNER NAME: L� ' D FE or �
CORPORA,TION NAME (IF APPL CABLE):C�e����'�t�c��ize.e ,�L1tB�d,,�,�ye.�
MANAGER'S NAME: `
TEL. #
; MAIi.ING ADDRESS: � a�of��
POOL CERTIFICATIONS: �t�
The pool supervisor must be certified as a Pool Qperator,as reqnired by State law. Please list the designated
Pool Operator(s) and attach a copy of the certification to this form.
1. _ 2.
� Pool operators must list a minimwm of two employees currently certified in basic water safety,standa,rd First Aid and
� Community Cardiapulmanary Resuscitation(CPR}. Please list these employees b�low 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.
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FOOD PROTECTION lvIANAGERS - CERTIFICATIONS: r���
All food service establishments are required to have at least one full-time employee who is certified as a Food
Protecrion Manager, as defined in the State Sazutary Code for Foad Service Establishnnents, 105 CMR 590.000.
Please attach copies of certification ta this application. The Health Department will not use past years'records.
You must provide new copies and maintain a file at your establishment.
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i PERSON IN CHARGE: � ____ �________
_ -- - – ------- – --- – --- ----__- --
; Eac�foo�es�ablislunent�nust have at f ast one�erson Tn Charge (PIC) on site during hours of operation.
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HEIMLICH CERTIFICATIONS: '� ��
All foad service establishments with 25 seats or more must have at least one employee traincd in the Heimlich
� Maneuver on the premises at all rimes. Please list your employees trained in anti-choking procedures below and
attach copies of employee certifications to this form. The Health Dep artment will aot use past years'records.
You must provide new copies and maintain a t"ile at your place of business.
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RESTAUR.ANT SEA'I"ING: TOTAL# �
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OFFICE USE ONLY
LODGING:
LIC�NSE REQUIRED FEE PERMI�'# LICENSE REQUTRED FE� PERMIT# LICENSE REQUIRED FEE PERMIT#
_,B&B $55 i,CA$IN $55 _„MOTEL $55
INN $55 CAMP $55 _,_SWTMM1rTG POOL �80ea.
il � �
_LODGE $55 _,_,_TItA1LERPAItK $105 WHIItI,POOL $80ea.
FOOD SERVIC�:
LICENSE REQUIRED FEE P�RMIT# LIC�NSE REQUIRED F�E PERMIT# LICENSE REQUIR�D FL� PERMIT#
�,0-100 SEATS $85 _..CONTINENTAL �35 �NON-PROFI�' $30
>100 SBATS $160 �COMMON VTC. $60 �WHOLESAL� $80
RET.aIL SERVICE: �.RESID.KITCHEN $SO
LICENSE REQUIl2ED FEE PERMIT# LICENSE REQUIRED FEE P�RMIT# LICENSE REQUIRED FEE PERMTT#
<50 sq.R. �50 >25,000 sq.f�. $225 ` �VENDITTG-FOOD �25
�QS,000 sq.8. S80 � _,_,FRp�N DESSERT $4U TOBACCO $55
N���G�: $is AMOUNT DUE = S 30, Op
""*""PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM"*"**
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ADMINISTRATION ' �
Under Chapter 152, Section 25C;Subsection 6,the Tawn 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 ATTACH�D STATE WORKER'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLET'ED AND SIGNED, OR
/ �
CERT. OF INSURANCE ATTACHED �
OR
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WORKER'S COMP. AFFIDAVTT 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 ESTABLISHII�ENTS
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TRANSIENT OCCUPANCY: For purpases of the limitations of Motel or Hotel use,Transient ocaxpancy shall be
limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel use.
Transient accupants must have and be able to demonstrate that they maimain:a principal place afresidenc�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)raonth period. Use of a guest unit as a residence or
dwelling unit sha11 nat be considered transient. Occupancy that is subject to the collection of Room Occupancy
Excise, as defined in M.G.L. c. 54G or 830 CMR 64G, as arnended, shail generally be considered Transient.
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POOLS i
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POOL OPENING:A11 swimming,wading and whirlpools which ha.ve been closed for the season must be insp� F
by the Health Department��prior to opening. Contact the Health Departmerrt to schedule the inspection three(3)days �
pnor to opening.PLEASE NUTE:People aze NOT allowed to sit m the pool azea until the pool has bsen inspectetl '
and opened. �
POOL WATER 1'ESTIl�TG: 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 opettin�, and quarterly
thereafter.
PUOL CLOSING: Every outdoar i�n ground swimming pool must be drained or covered within seven(7)d�ys of �
closing.
FQOD SERVICE
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CATERING POLICY: �
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Departmern by filing the required k
Temporary Faod Service Application form 72 hours prior to the catered event. These forms can be obtained at the �
Health Department.
FROZEN DESSERTS:
Frozen desserts must be tested on a monthly basis by a State certifi�d lab. Test results must be sent to the Health ;
Department. Failure to do so will result in the suspemsion or revocation of your Frozen Dessert Permit wrtil the
above terms have been met.
OUTSIDE CAFES:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior appraval from the Board ofHealth.
OUTDOOR COOKING:
Outdoor caokin�;,_pre�aratior�_or disLlay_of any food product by a retail or food service establishment is prohibited.
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NOTICE:Pemuts run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN I,
TI�COMPLETED RENEWAL APPLICATION(S)AND kEQUIRED FEE(S)BY DECEMBER 15, 2009. !
ALL RENOVATIONS TO ANY F40D ESTA.BLISHMENT, MOTEL OR POOI. (i.e., PAINTING, NEW I
EQUIPMENT,ETC.),MUST BE REPORTED T(3 AND APPROVED BY THE BOARD OF HEALTH PItIOR
TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
DATE: �" !a l�:t� SIGNATURE: Ct C�
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PRINT NAME&TITLE: ������-b1RE[�afZ b�' �R��C� M,�
09/25/09 '
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' ' The Commonwealth of Massachusetts
Departmeht of Industria!Accidents
N�Cf If�ff�l/S
600 Washington Stree� 7`h Floor
Boston,Mass. �2111
Workers'Compeasatioa Iosaraaee Affidavih 8ailding/PlambieglEk�ctricat Coatractors
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work site location(fiill addressY
❑ I am a homeowner perfornung all work myself. Project Type: []New Construction QRemodel
❑ I am a sole pcoprietor and have no one working in any capacity. ❑Building Addition
� t am an employer.�oviding workers'compensation f�my employees wodcing on tLis job.
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Q I am a sole praprie#or,geee�d coatractor,or�omeowaer(circle orre)and l�ve lured the co�actors�listed below who have
the following waicers'compeasagon polices:
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eu�s'ia�ptbs�sat aa weY as dH pe�altla�tLe forir ef a 31'Ot WORK ORDSR aad a due e[S1A�N a
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/l0 6enby cerufy der t1Ye <wd �relUea of pe�rrry that tlYe Ixxfona�iow prevdded abeae is�rxe aw�f owr+e��
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Pri�name l�t( N ��C1RAE2 Phone# ����fo�' �8�
offidal ase o'ly da eat�vri�e�t�s area to be :
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A�� CERTIFICATE OF LIABILITY INSURANCE page � of 2 o4iili2 0
PRODUCER 877-945-7378 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
wiliis of xew York, inc. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
26 Century slvd. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
P. 0. Box 305191
xashville, Tx 37230-5191 ' ` -INSURERSAFFORDING COVERAGE NAIC#
'�:. INSURED Christmaa Tree Shops, Inc. INSURERA:Arch�Inaurance Com an � � 11150�-002
64 Leona Drive INSURERB: 3t. Pau1 Fire and Marine Insurance Com an 24767-001
Middleboro, MA 02346
i . . .. .. . � � � � � INSURERC:. . . � . . . .. . . . . . . �
� � . . � � � . � � � INSURER D: � � .. . . .
� � INSURERE:
COVERAGES
THE POUCIES OF INSURANCE LISTED BEIOW HAVE BEEN ISSUED TO THE INSURED NAMED ABQVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING
ANY REQUIREMENT,7ERM OR CONDITIQN QF ANY GONTRACT OR QTHER DQGUMENT WITH RESPECT TO WHiCH THIS CERTIFI�ATE MAY BE ISSUED OR
MAY PERTAIN,THE INSURANCE AFFORQED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TQ ALL THE TERMS,EXCLUSIONSAND CONDITIQNS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR DD' � �POLICYEFFECTIVE POUCYEXPIRATION
LTR N R TVPE OF INSURANCE POLICY NUMBER DAT / AT MM/ D/YYYY LIMITS
� A ceNeRn�unsam � 11GPP4934603 . 3/1/2010 3�1�201.1 EACHOCCURRENCE E 1 Q Q QQ
X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED
PREMISES(Ea occurence) 3 1 0�0 0�0
CLAIMS MADE �OCCUR . . . � . MED EXP(Anyone person) .$ �
� � � � � � PERSONAL&ADVINJURY 5 Z OOO OOO
� GENERALAGGREGATE $ 1 OO OOO
j GEN'LAGGREGATELIMITAPPLIESPER: � PRODUCTS-COMP/OPAGG $ 2 OOO OOO
POUCY jE�7 LOC � -
� A � AUTOMOBILELIABIUTY AOS 11CAB49.34403 �3�/1/2010 3/1/2011 �
COMBINED SINGLE LIMIT
� A X /+NVAuro MA 11CAB4934503 3/1/2010 3/1/2011 (Eaaccident) $ 1,000,000
ALL OWNED AUTOS� � � � �
BODILV INJURY $
SCHEDULEDAUTOS � . (Perperson) . �
HIREDAUTOS � BODILYINJURY
i NON-OWNEDAUTOS . (Peraccident) S � . �
� . . . . . . . . . .. .. . .
� � . � � . � . . . � , � � �. PROPERTY-0AMAGE� �� $�: � .
" �{PeraccidenQ �
� GARAGELIABILITY .� � ��AUTOONLY-EAACCIDENT . E "
ANYAUTO .. . . �. . . . .. . .. . _ . .... . .. .. .EAACC $ � .. . .
� OTHERTHAN
. . . � AUTOONLY: AGG $
$ � . � EXCE33lUMBRELLAl1A61UTV QKQ9OOZO63 . � . . 3�I.�ZOZO .. 3��.�ZO11 .. EACHOCCURRENCE� 5 .ZO OOO OOO .
. )( OCCUR . � CLAIMSMADE . AGGREGATE S �10 �OOO OOO
S
� DEDUCTIBLE � . . . � . � .. . � � a
. RETENTION �$ . . . . � . . �. . � . � S.
WORKERS COMPENSATION WC STAT - OTH-
A AOS 11WCI4934103 3/1/2010 3/1/2011 X roRvuMi�rs : eR
AND EMP�OYERS'LIABILITV YYY��/NNN _ . . � � .— �
�. A ANYPROPRIETOR/PARTNER/EXECUTIVE� yQ= & OR 11WCI4934203 3��.�ZOZO S�I.�ZO11 E.L.EACHACCIDENT� $ 1�OOO �OOO
j� (Man�dato�in NHER EXCLUDEDT - �
rY ) . WA & �H 11WCX4934303 3�1�2��.0 3�1�2�1.1 E.L.DISEASE-EAEMPLOYEE $ j QQQ QQQ
If yes,describe under E.t.DaSEASE-POLICY LIMIT�.$ �
SPECIA PR V IONS belo - �
� � OTHER � . . . ... . . . . .. .
UESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPEC IAL PROVISIONS
Evidence of Insurance
CERTIFICATE HOLDER CANCELLATION
� .�:SHOULD ANY OF THE ABOVE DESCRIBffO POLICIES BE CANCELLED BEFORE THE EXPIRATION
. �DATE�THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN
- , . . NOTICE.TO.THE CERTIFICATE HOLDER NAMED TO THE LEPT,BUT FAILURE TO DO SO SHALL
The Coa�onwealth of Ma89aChusetts IMPOSE NO OBIIGATION OR LIABILPTY OF ANY KIND UPON THE INSURER,ITS AGENTS OR
Department of Industrial Accidents
- OffiCe Of �IIIv68tig8t10A8 � . REPRESENTATIVES. �
600 Waahington Street � AUTHORIZEDREPRESENTATIVE .
Boston, MA 02111
ACORD25(2009/01) Co11:2986304 Tp1:1055996 Cert:14089699 �1988-2008ACORDCORPORATION.Aiirightsreserved.
The ACORD name and logo are registered marks of ACORD
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Page 2 of 2
IMPORTANT
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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 certificate
holder in lieu of such endorsement(s).
DISCLAIMER
This Certi�cate of Insurance 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.
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ACORD25(2U09/01j Co11:2986304 Tp1:1055996 Cext:14089699
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MAR 3 0 Zi)�f�
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� � 64 Leona Dr
� Tree� �s � Maddleboro,Massachusens 02346 • 774-213-6�0 • Fax 774-2I3-b930
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March 25, 2010
To Whom It May Concern:
Christmas Tree Shops is a division of Bed Bath and Beyond. In the future,
please mail all annual Permit and Business License renewals to:
Bed Bath and Beyond
Attn: Risk Management
650 Liberty Ave.
� Union, NJ 07083
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Thank you,
�fa'tt�4i�°!!et
II, _ —-- -------- --____
Harry Rigollet
Project Manager
Christmas Tree Shops
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