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Home My WebLink AboutApplication and WC . . c�M . �u 6 ; �� ► TOWN OF YARMOUTH BOARD O�'�[�AL�H �� Qb[�� APPLICATION FOR LICENSE/PE�� 201'3 '' �� ` . � �� d�'.2 * Please complete form and attach all necessary documents y e er 1 . Failure to do so will result in the return of your applicatio pa�LTM DEPT. ESTABLISHMENT NAME: r� I v`L TAX ID• ��-� � LOCATION ADDRESS: I TEL.#: � - � 13� MAILING ADDRE S: � � � — OWNER NAME: CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME:�A,C`.e�4 �,i C1".�i -e(, + TEL.#: R.-(,; �-�13�`7 MAILING ADDRESS: POOL CERTIFICATIONS: The pool suFervisor must be certified as a Pooi Operator,as required by State law. Please list the designated -�oa1 t�per�tor�s�a.f��t�ac:�i �c�p�of i:h�; c��iff�,�r-t�r�tis��r��.--- __ _ ---- --_ - _-. 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. � 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. Z• _ _-- --��N�-�s«-SR��: __- - - _ - -- --- ___ , ___ __- - _ ` - ----__ _ _ _ -- --� Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. � 1. 2• HEIMLICH CERTI�ICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich i Maneuver on the premises at all times. Please list your employees trained in anti-chokmg procedures below and '� attach copies of employee certifications to this form. The Health Department will not use past years' reeords. You must provide new copies and maintain a file at your place of business. L 2• 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY i LODGING: ' LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 _CABIN $55 MOTEL $55 �` — _ f .1NN _ $55 _CAMP $�5 _SWIM1VIfNG?OOL $80ea. _ � LODGE $55 TRAILER PARK $105 _WHIRLPOOL $80ea. FOOD SERVICE: I _ LICENSE RE�UIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _- � __ -- ---- �__. ._ _ � _ – `_.__ ..�_ __ 0-100 SEATS $85 _CONTINENTAL $35 _NON-PROFIT $30 I — I >100 SEATS $160 _COMMON VIC. $60 _WHOLESALE $80 � RETAIL SERVICE: —RESID.K[TCHEN $80 � I LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE RFQUIRED FEE PERMIT# , _<50 sq.ft. $50 >25,OQ0 sq.ft. $225 _VENDING-FOOD $25 'f +_<25,000 sq.ft. $80 � " � —FROZEN DESSERT $40 �TOBACCO $95 �(3��Z � NAME CHANGE: $is AMOUNT DUE _ $ 175.00 4 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** ' ' I , r ADMINISTRATION ' i � Under Chapter 152,Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal � i of any license or permit to operate a business if a person or company does not have a Certificate of Worker's iCompensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE � AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR I I CERT. OF INSURANCE ATTACHED `� � OR ' WORKER'S COMP. AFFIDA�IIT SIGNED AND ATTACHED � i I Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK � APPROPRIATELY IF PAID: YES NO � MOTEL�ANI) OTHER LODGING ESTABLISHM�NTS �' TRANSIENT QCCUPAlVC�', For pur�oses af th��imitatiotz:s of Motel or Hotel use,Transien�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,sha.11 generally�e consideredTransient. 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 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. 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 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: j Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval 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 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 REPORTED TO AND APPROVED BY THE BOARD HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE P AN DATE: / / SIGNATURE: ic ourn � PRINT NAME& TITLE: � Rev. 10/09/12 � # � The Commonwealth of Massachusetts Department oflndustrial Accidents O�ce oflnvesdgations 600 Washington Street ' . - Boston,MA 02I11 www.massgov/diac , Workers' Compensation Insurance Affdavit: General Businesses Aaulicant Informadon � Please Print Le�blv Bu8111C8s✓ClrganiZat�ion NBmC: CU1�SxLAND FARMS INC. . Address: 100 Crossi Boulevard City/SffitdZip: Framiaahem, PiA Ot702 Phone#: 508-270-1400 An y�ou itn��oyer?C6eck t6�apprup�iste bor, g 1.� T am a �TY�G'e9�: ! �nployex wiW 6,500 emPbY'�(fult+md/ S. �'Ret� _ _ _ ._. , °rparG'hme).'�. _ - �6. Q3Le�tau�ant/Bar/Ea� -,h_ , 2.Q I am a sole Propr�tor or pattnerehip and bsve no �II8�t°b�°�t emp�yees worldag for me in any cy�acity. �• ❑�and/or Sates(incl.nal e�te,autio,etc.) INo wotloa�s'comp.ins�raacoraquired] 8• ❑Nan-Pi+nBt 3.❑ We ane a cotporation and ite offioas bave exercised g, ❑En�er�nmeat tluir night of exemption per c. 1 S2,�1(4)�aad we l�ave l 0.[]Manufsc : 4.�_ We ar+e s aon-. fit��'�p�� 1 L Health Car�e _ P� a'8+��,staffed by vohint�s� ❑ with ao emptoyees.[No workere'comp.i�wance nq.] 12.�OtLer `Aoy�pplicmt f�t cLecks box*l muet�bo 51!out t6e section below�6owma�eir wo�cen'oomiim�don policy iufo�. •�If t6e coiponte officas luve acpnpted Wemedvee,but tLe ooryontion�othar anpbyees,a wo�lcas� apni�u�ouW chack box NL CO�°qdO°Po�Y ie t'a�uined and such�n I�a aa cu�plo,yar that�'a provlding xwrAren'co�Prna�O�ixarr�ce for qry e�oyet� Balow�the Iasurance Company Name: ACE Americaa I n s u r a n ce Com aa �� . - Inaurer'sAddc+�s: clo Gallagher Bassett Servicee, 100 Grandview Rd., Suipe 406 City/State/Zip: Braintree, 1�lA 03184 Policy#or Self-ins.Lic.#_SCFC43118584 Facpiration�e_ 4/1/2013 Atbtc�a oopy of tl�e worloert'compe�uatbn Polky'daclaration psee(�ow�th�P�'�ber and�ratton d�te � Failure be�ecure covarage as requind under Section 25A of MClL a 152 can kad to the' � �up to S 1.500.00 and/a�oae•Y��,�e well as civil �ti°�°f��d�of a � of M SZ50.00 e da P�alfies im tLe frnm of a STOP WORK ORDER md a Sme I �P Y��violator. Be advieed tLst a copy af thia etsteaient ms3+be fonvaeded fo th�Offic�of I Ia 'ons of du DIA for insurance oov�a v�ific�a�, h � ; I�o Ar�rieby c , der dG� ax1 of��rry dlwt die � ,� . �i�'o�ur�ioe pro�i�y��A►�e�ard conret � . , ' • A ril 10 2012 ' 508-270- 9t O�rrae onl,�. Do wot wrtae tn A�ris ar�eq to!k co�pktad by dq'or pm�i o�tCL CYty or Torvn: p��e� , Is� �j; " ' Boua or g�r� s�na„rm,�,� 3.cie��r�c�k a.L� 6. °d°g sosra s.sel�ane.a�`.o�e Contact Peraa: Phone t�:�57��-39'�o�3a 7 X'I2.5// www.mas:.gov�ai. : . . AC�� DATE(MM/DD/YYYY) �- CERTIFICATE OF LIABILITY INSURANCE o3n9,Zo,2 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 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. f SUBROGATION IS WAIVED,subject to m the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate dces not confer rights to the � certificate holder in lieu of such endorsement(s). c PRODUCER CONTACT y NAME: Aon Risk Services Northeast, Inc. ►�N (866) 283-7122 F� (847) 953-5390 m vrovi dence Rz offi ce iac.na.exq: ac.nio.: .a 100 westminster 5treet, lOth Floor e-xuu� o vrovi dence rt2 02903-2393 u5n nnorx�ss; _ INSURER(S►AFFORDING COVERAGE NAIC# INSURED INSURER A Indemnity insurance Co of North nmerica 43575 � � CUMBERLAND FARMS, INC. INSURERB: ACE AITiEI'1Gd11 Insurance �ompany 22667 100 Crossing eoulevard Frami ngham MA 01702 USA INSURER C: INSURER D: INSURER E: INSURER F. � COVERAGES CERTIFICATE NUMBER:570045681621 REVISION NUMBER: � THIS IS TO GERTIFY THAT THE POLfEfES OF INSURANCf LISTED BELDIN HAVE BEEN I$SUED 7b 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. Limits shown are as requested LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER MMIDDIYYYY MMIDD/YYYY LiMITS , GENERAL LIABILITY EACH OCCURRENCE ,� COMMERCL4L GENERAL LIABILITY PREMISES Ea occurtence '� CLAIMSMADE ❑OCCUR � � MED EXP(Any one penon) . PERSONAL&ADV INJURY � N ��. GENERALAGGREGATE � � � GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG � POLICY PRO- LOC . o ��.�.. AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT � � Ea accident ANV AUTO BODILY INJURY(Per person) Z ALL OWNED SCHEDULED BODILY INJURY(Per accident) � y AUTOS AUTOS "' � HIREDAUTOS NON-OWNED PROPERTYDAMAGE V AUTOS � . Per accideM � 1' m UMBRELLA LIAB OCCUR EACH OCCURRENCE V EXCE33 LIAB CLAIMS-MADE AGGREGATE DED RETENTION � A WORKERSCOMPENSATIONAND WLRC43119424 04/O1/2012 04/O1 2013 WC STATU- OTH- EMPLOYERS'LIABILITY y�N Work Comp-- --Aos X TORY LIMITS ER � ANY PROPRIETOR/PARTNER I EXECUTIVE E.L.EACH ACCIDENT �Z�OOO�OOO B OFFICERIMEMBEREXCLUDED? �N/A SCFC43119461 �4��1�2�12 04��1�2013 � (Mandatory in NH) work Comp-- -Mn E.L.DISEASE-EA EMPLOYEE $1,OOO,OOO - . It yes,deuribe under � � DESCRIPTION OF OPERATIONS bebw E.L.DISEASE-POLICY LIMIT� Sl,OOO,OOO—� I � � DESCRIPTION OF OPERATIONS 1 LOCATIONS/VEHICLES(Adach ACORD 101,Additional Remarks Seheduk,H mon apaea is requircd) � � � � � � rhe insurance afforded by the policy described herein is subject to all terms, exclusions and conditions of such policy. � ' � � � � CERTIFICATE HOLDER CANCELLATION � ti- SHOULD ANY OP THE ABOVE DESCRIBED POLICIES 8E CANCELLED BEFORE THE � EXPIRATION DATE THEREOF, NOTICE NALL BE DELIVERED MI ACCORDANCE WITH THE - - POLICY PROVISIONS. ��.. TOWtI Of YdP1110UtF1 AUTHOR¢EDREPRESENTATNE �� rown Clerk 1146 Route 28 South Yarmouth MA 42664 USA (� `'��,,p�� ,r/'�� i� t�011� ZA;KG c// ✓ 01988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD