The URL can be used to link to this page

Home My WebLink AboutApplication and WC • �� ,�-tA N� Fi4��-P1S �22�g I �; - �� ► TOWN OF YARMOUTH BOAKD OF HEALTH G3(��OM�DD � � APPLICATION FOR LICENSE/PERMIT -2012 __, .��,��,, ,.�. ?fF �. �1 °� � �0 i 1 � Please complete form and attach all necessary d�Ct�r��n�� ..r�e b� �"0 1. Failure to do so will result in the return of�our ag�l��i�� ALTH DEPT. ESTABLISHMENT NAME: ��, ms � ID: LOCATION ADDRESS: / o/ , v� S• cz.r TEL.#: S'o�=��CJ�-,�/37 MAII.ING ADDRESS: G� o .�n � � 7 ; OWNER NAME: � � CORPORATION NAME(IF PLICABLE): ! MANAGER'S NAME: ��,s-%�>— Gr�.� TEL.#: SO�'- �?O-� 3� MAII.ING ADDRESS: . � i � � 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 this form. 1. 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid f 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 ; grovide new co�ies and n�aintaiu a�le at your place of busipess. i _ _ __ ___ _ __ I 1. 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. II � PERSON IN CHARGE: ; Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. ' l. 2. ' 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. I 1. 2. ' 3. 4. RESTAiJRANT�LF.A'FIN�'�> TQ'�Aai.�# __ -_---- _>e__ ��--- ----t�_ ---, OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMTT# _B&B $55 _CABW $55 _MOTEL $55 _INN $55 _CAMP $55 _SWIMMING POOL $80ea. ' _LODGE $55 _TR.AIL.FR PARK $105 _WHIRLPOOL $80ea FOOD SERVICE: LICENSE REQUIRED FEE PERMTT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _ _._ _ – -- _ ' _0-100 SEA'TS $85 _CONTINENTAL $35 _NON-PROFIT $30 I _>100 SEATS $160 _COMMON VIC. $60 _WHOLESALE $80 RETAIL SERVICE: —RESID.KITCHEN $80 i LICENSE REQUIRED FEE PERMTT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# i _<50 sq.ft. $50 _>25,000 sq.ft. $225 _VENDING-FOOD $25 � ( Q5,000 sq.ft. $80 �a�� _FR07.EN DESSERT $40 � TOBACCO $95 /vZ�� _ I NAME CHANGE: $ts AMOtJNT DUE _ $ t'I5.OU ; � *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** , ; � ^� R ADMINISTRATION '� � Under Chapter 152,Section 25C,Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal il of any license or permit to operate a business if a person or company does not have a Certificate of Worker's I Compensation Insurance. THE ATTACHED STATE VVORKER'S COMPENSATION INSURANCE I� AFFIDAVIT MUST BE COMPLETED AND SIGNEID, OR i c/ 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: i YES NO ' MOTELS AND OTI�I��LODGIN�ESTABLISfIlVIENTS 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 pl�ce of residence elsewhere.Transient occupancy shall genera�ly refer tu contintF��as occt�pancy of not more th�n t�hir�y(30)days,anci ! 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 OPEIVING: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 cic�sing. - 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 i required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be ; obtauied at the Health Department,or from the Town's website at www;yarmouth.ma.us under Health Department, i 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 i Dessert Permit until the above terms have been met. ; , i OUTSIDE CAFES: � Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. , OUTDOOR COOKING: I 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, 2011. , Ai"i" RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPOR'TED TO AND APPROVED BY T OARD OF HEALTH PRIOR j TO COMMENC ME . RENOVATIONS MAY REQUIRE A SIT PLA . � '� DATE: / SIGNATURE: PRINT NAME&TITLE: r�i har ournier Rev.]0/25/11 ' . � � . . w � The Commonwealth of Massachusetts � ' K Department of Industrial Accidents Office of Investigations ; � ' 1 Cohgress Street, Suite 100 ' Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Auulicant Information Please Print Le�iblv ; , � ' • Business/Organization Name: � �• � ' - � Address: ioo �aoss�.�a�sv� � � . , � � i City/State/Zip:��, ffi oi�a2 Phone#: $ao-7is-s� Are yoa art emgloyer?Check the appropriate box: Bnsiness Type(reqaired): 1. z(-] I am a e�atployer with6,000 + employees{fnll and/ �• �� or part tinne).* :6. � Re�-tauran#/Bar/Eating Fstablishm�t � - _ : _ ., . .._ 2.❑ I am a saIe praprietar or partaeaship and have no 7. ❑Office and/or SaSes(mcl.real estate,suto,etc.) eonployees worI�ng far me irn any capacity. � �TTo workers'comp.insnrance reqnired] 8. ❑Nau-paofit , . . 3.[]�We are a cozporation and i�ts afx"icez�liave exercised 9. ❑��t , their right of exemption per c. 152, §1(4},and we have 10.(�Mantcfac�iuing � ' na employees.[Na warke�s'comp. ins�mance required]* I I.�Hea��C�re � 4-❑ We aze a nonrgrofrt organszatian,staffed by voluuteers, � , with no employees.[Na workets'comp.insurauce req.] �2.[�Other cas st1►t�[at/oa�v�e s� , , "Aay appticmf fhst c3ecks box#2 mast a7so fiIl out 4e sectiaa be'fow showia��eir workers'oo�npeasation poHcy infoiiebtivn. • **If tbe coipmate officers bave txempted 4iemaelv�es,bw tLe corporation has o8�er employaes,e workers'compeasation polioy is reqa'trod snd snch sa org�izatioa shoa]d check box t/1. . f am an employer that is�rovidaiig�rvorkers'comper�,satien ins�rance jor a�y employees. Betow is the policy informalion. ; 7nsurance Company Name: � � � � Insurer'S Address: ACE 1lSA, 33 E3eCH S'�c, SOIZE 2�0 � • ' Ciry/Staxe/Zip: Eob� !Q► 0z110 � PoIicy#or Self-ins.I.ic_#scRfiax,�A�ua Fxpiratian Date: 4l01/�2 . Attach a copy of the workers' campensation policy dedarafion pa.ge(showing the poiicy nnmber and espi�ration date). Failure to secure coverage as requn�ed nnder Section 25A of MGL c, i 52 can Iead to the impositiatt of crimina3 penalties af a • fine�p to$1,504A0 anci/or ane-year impQisonment,as welI as civt�penatties in the form af a STOP WORK ORDER and a fine of np to�250.00 a day agai�nst the violator. Be�vised fhat a co�y of this statement may be forwarded to the Office of Inwestiigations of the DIA for insnrauce covera ve�cation. I do hereby cerlify,under e alt s of perjury thvt the in,farmation provided arbove is irue and correct si ature: ichard Fournier D��: / /� l . �c an PhOile#: 800-225-9702 %1491 O,�`'icral use onfy. Do not wrue ia rs area,ro be completed Iry city or town of,ficiat City or Towa: PermiUL.ieense# � Issning Aufhority(circIe one): 1.Board otHealth 2.Bnilding Department 3.CityiTown Cferk 4.I.,icensing Board S.Selectmen's t}fftce � 6.Other � Cantacf Persort: Phone#: wcvw.mass.govldia � � . � .� < . : A�� DATE�/O6/20�, . �- CERTIFICATE OF LIABILITY INSURANCE 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. If 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). � PRODUCER CONTACT �p �� NAME: Aon Risk Services Northeast, IIIC. HONE �g66) 283-7122 F� (847) 953-5390 m Provi dence RI offi ce �ac.nw.eXe►: ac.ruo.: .o 100 westminster street, lOth Floor E-�� _ Providence Ri 02903-2393 u5A noor�ss INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURERA: IIICIEIillllty IIISUPd17G2 CO Of North America 43575 �. CUMBERLAND FARMS, INC. INSURER B: ACE American insurance �ompany 22667 100 Crossing aoulevard Pramingham MA 01702 USA INSURERC: INSURER D: � INSURER E: � INSURER F: COVERAGES CERTIFICATE NUMBER:570042101206 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. Limits shown are as requested LTR TYPE OF INSURANCE �Ng yyyp POLICY NUMBER M�yyp M pryyyy LIMITS � GENERAL LIABILITY EACH OCCURRENCE .. COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrenee CLAIMS-MADE ❑OCCUR MED EXP(Any one person) PERSONAL 8 ADV INJURY p � GENERALAGGREGATE N 0 GEN'L AGGREGATE LIMR APPLIES PER: PRO�UCTS-COMP/OP AGG o POLICY PR0. LOC � AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT � Ea accident ANY AUTO BODILY INJURY(Per penon) Z ALL OWNED SCHEDULED BODILY INJURY(Peraecident) m . AUTOS AUTOS � ' NON-OWNED PROPERTY DAMAGE , HIRED AUTOS AUTOS Per accident � � � m UMBRELLA LIAB OCCUR EACH OCCURRENCE V ��. EXCE33 LIAB CLAIMS-MADE AGGREGATE '�, DED RETENTION '��. A WORKERSCOMPENSATIONAND WLRC43118547 04/Ol/201104 Ol 2012 X TpRYUMITS ERH � EMPLOYERS'LIABIUTY Y/N work Comp-- --AOS � ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT EZ�OOO�OOO '� B OFFICER/MEMBEREXCLUDED4 �N/A SCFC43118584 O4�OL�ZO11 O4�OL�ZO12 (MandatoryinNli) work Comp-- -i�a, E.L.DISEASE-EAEMPLOYEE 51,��,0�� It yes,describe under DESCRIPTION OF OPERATIONS bebw E.L.DISEASE-POLICY LIMIT El,OOO,OOO_ � � DESCWPTION OF OPERATION31 LOCATIONS/VEHICLES(Attach ACORD�01,Additional RemaAcs Schedule,if more apaca is required) ��. The insurance afforded by the policy described herein is subject to all terms, exclusions and conditions of such policy. � �■ � � � CERTIFICATE HOLDER CANCELLATION °� SHOULD ANY OP THE ABOVE DESCRIBED POLICIES BE CANCELLED BEPORE THE EXPIRATION DATE TFEREOF, NOTICE VNLL BE DEWERED N ACCORDANCE WITH THE - � POLICY PROVISIONS. TOWI1 of Yarmouth AUTFbR¢ED REPRESEMATNE �. rown Clerk 1146 Route 28 I `��Y _�� South Yarmouth MA 02664 u5A CY/ IC/s B e.Y�osa i�.wrG 01988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD