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` � ► TOWN OF YARMOUTH BOARD OF HEALTH C�C����
_ � � APPLICATION FOR LICENSE/PERMIT -2013 .
o,,,, � �` DEC 0 4 2012
' * Please complete form and attach all necess doc ' ��,� mber 1 S 2012. I
Failure to do so will result in the retu��f y application ac L H DEPT.
ESTABLISHMENT NAME: � o�?I� T X ID: �
LOCATION ADDRESS: �.� C� EL.#: �Se -- -
MAILING ADDRES : `
OWNER NAME:
CORPORATION NAME (IF APPLIC BLE): '
MANAGER'S NAME:� ' ` ,a �I i TEL.#: sp6-'''1`�(�-(�18 3 .
MAILING ADDRESS: '
POOL CERTIFICATIONS: '
TI�e pool supervisor must be certified as a Pool Operator,as required by State law. Please list the desi�nated i
-�r�a;-��r�{��e'.��ac���;��t1�:,�e:��}wat:�ti�n to_r��i� fQ�-s:�. -___ — ,
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Pool operators must list a minimuxn of two employees currently certified in basic water satety, stanctard�'irst Hid
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.
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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.
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.- __P£-���43P�;;�+���L SE:-- ___ -- _
Eacn food establishment must have at least one Person In Charge (PIC) on site during hours of operation. '�
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HEIMLICH CERTIFICATIONS: i
All food service establishments with 25 seats or more must have at least one employee trained in the Heimiich i
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.
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RESTAURANT SEATING: TOTAL# �
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OFFICE USE ONLY �
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �
B&B $55 _CABIN $55 _MOTEL $55
INN $55 _CAMP $55 _S WIV1MI33G Yt�GL $AOea: '
LODGE $55 TRAILER PARK $105 _WHIRLPOOL $80ea.
FOOD SERVICE:
LICEI�TSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
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0-100 SEATS _ $85 _ � _----�C��1�N��—�35 _ . -- --NON-PROFIT $30 j
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>100 SEATS $160 _COMMON VIC. $60 _WHOLESALE $80
RETAIL SERVICE: —RESID.KITCHEN $80
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# !
_<50 sq.ft. $50 >25,000 sq.ft. $225 VENDING-FOOD $25 f
�<25,000 sq.ft. $80 '��3—�,3(� —FROZEN DESSERT $40 LTOBACCO $95 �/3-02� I
,
NAmE cHarrcE: $is AMOUNT DUE _ $ I?S�0 O '
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*****
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ADMINISTRATION ` '
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 ✓ !
Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK !
APPROPRIATELY IF PAID:
YES NO
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MOTELS AND OTHER LODGING ESTABLIS�IMENTS �
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TRANSIENT OCCUPANCY: For purposes of the limi�atioiis of Motel or Hotel use,Tranaient�ecup�rcy sha.11 be E
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 sha11 generally refer to continuous occupancy of not more than thirly(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 iiot be considered transient. Occupancy that is subject to the collection of Room Occupancy
Excise, as defined in N1.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient.
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 �
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.
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POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of
closing.
FOOD SERVICE
SEASONAL FQOD �ERVIaCE 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.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 I
submitted to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen j
Dessert Permit until the above terms have been met.
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OUTSIDE CAFES: �
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior ap�roval from the Board of Health.
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OUTDOOR COOHING: f
Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited.
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NOTICE:Permits run annually from Janu�ry 1 t�December 31. IT IS YOU�2I�ESI'ONSIBILITY TO RE1,LIRN
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 O HEALTH PRIOR
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TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN:- !
DATE: // - � SIGNATURE:
PRINT NAME& TITLE: R��hard Fou nier �
Rev. 10/09/12 ���!
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� The Conamonwealth ofMassachusetts
Department oflndustrial Accidents
O�ce oflnvestigations
600 Washington Street
Boston,MA O�lll
www.mas�gov/dia
Workers' Compensstion Insurance Affidavits General Businesses
A licant Information
Please Pr�nt Le 'bl
Business✓Orgaaization Name: CUI�BRLAND FAxMB iNC.
Address: 100 Crossi Boulevard
City/St�tdZip: Frsmiaaham, MA 02702 I
Phone#: 508-270-1400
An y�ou nn emp�oyerT CLecic t�approprlste 6or.
l.� I am a B°da�n TYP�(n9�ir'etlj:
emPbyer wiW 6,500 employ�ees(fu11�d/ S. (g�]itebit
�'P���•• °. , � ,:.. _ . �6,�Raeiauneat/Bfr1Ea - - �
2.❑ I am a sole prop�t�r orpumer�h�aad have ao tin8 F.stabliahment
�P�S��8 for me in any capacity. 7• ❑Office and/or Sales(iacl.r�eal e�tate wtv etcJ
[N°w'°rlcers'comp•'°surdux�luin;dl 8• ❑Non-proSt ' '
3.❑ We u+e a corporati�and its officere have exercieed 9. ❑Entertainment
their right of exemption per c. 152,�1(4),and we have 10.[]Maaufaclu�ng
no employees. (No workere'comp,instuanc�requ��«
4.❑ W�ar+e a non-Pmfit ar8auizat�oa,staffed by volunt�s� 11.Q Health Care
with no employ�es.(No workers'comP•inaurance neq.J 12.�OtLer
•Aoy applicmt t6et eheclr�box NI muat�Ito 511 out the�ecxion be�ow
••Iftbe eoiponu offieees have acempted t6emsdva,bot d�e �g�r~o�lcen'�Pd�'�n.
a�ni�on:bouW oLeck box NL �n��°�°f°�0°s'�"''0���OOmPm�on po�y�
n9�a�d�ucb an
I wri aa e�,rployer tliat�a provldirr,d►wiv��Trers'co�rrp�en����ce for wrY i�ployua. Below ia the
Insumnce Company Name: ACE American Insurance Com an ���e�'f"
Insurer'eAddr+ess: c/o Gallagher Bassett Services, 100 Grandview Rd.. Suipe 406
City/Stat�/'Zip: Braintree. MA 02184
Policy#or Self-ias.Lic.# SCFC43118584
AthcL a copy of tlk woWar�'eo '�Pintion D�be:_ 4/1/2013
°1P°°���n P�Y declaratloa Ps�e(rl���e Po�Y n�mlkr and e�p�ration date� I
F8�'0 t°��CO�B°+�rO4�under Section 25A of M(3L c.l52 can lad to the impoeitioa�`��� ;
fi�up bo S 1.500.00 and/or one-year�isommeat,as well ae civil penaities ia t1u form of a S P�1�es of a I
of up to 5250.00 a day against d�e violatot. Be adviee�d�at a �WORK ORDER aad a Sme
copy of tbis�atiememt may bo fon�n�des!tv ffi� �
In ' tions of t�DIA for ineurance covera veri5cati�. . . �o� _
I do keneby e , dtr dGe snd e ;
� . '`��'���°�'�Onp���la b�e rnd con+ec� �
.
• A ril 10 2012 '
508-270— 95
O,�'FcPil rra�e o�rly. Do irot wrlte Jn�tnq b bt co�by�1'�'�t o� '
City or To�n: • PermitR,k�e* '
� (clrck one)s ,
rd of eai �.Building Department 3.Clty/Town Clerk 4.I.We
6.Ot1�er �ng Board S•Sda��'���e
Contact Pe.r�on: Phoae#: ��—3�5�—oz,,z�1 �C'/Zef/
www.m�ss.gov/dia
� ACO� DATE(MM/DD/`rYYY)
�-- CERTIFICATE OF LIABILITY INSURANCE o3n9,2o,2
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFER$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 does not confer rights to the ;,.
certificate holder in lieu of such endorsement(s). �
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PRODUCER �EACT � �
AOn R15k SEPv1Ce5 NOrthedst, InC. (866) 283-7122 F� (847) 953-5390 d`
Provi dence Ri offi ce �ac.nro.e,q: ,vc,N,,; �
100 westminster street, lOth Floor E-MNL �
Providence RI 02903-2393 usA ADDRESS: _
INSURER(S)AFFORDING COVERAGE NAIC#
INSURED INSURERA Indemnity Insurance �o of North America 435�5 '�
CUMBERLAND FARMS, INC. INSURERB: ACE. Affl2flGdn Insurance �ompany 22667 -
100 Crossing eoulevard
Framingham MA 01702 USA irosuREttc: ',
� INSURER D: �.
INSURER E:
i
� INSURER F:
COVERAGES CERTIFICATE NUMBER:570045681621 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LiSTED BELOW HAV�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 p�SR �p POLICY NUMBER MNVDDIYYYY MMID LIMRS
GENERAL LU1B14TY EACH OCCURRENCE
COMMERCIAL GENERAL LIABILITY � PREMISES Ea occurtanee
� CLAIMS-MADE ❑OCCUR MED EXP(My one peroon)
PERSONAL 8 ADV INJURY N
co
GENER4LAGGREGATE
GEN'L AGGREGATE LIMR APPLIES PER: PRODUCTS-COMP/OP AGG �
POLICY PRa LOC p .
n
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 'n ��
Ea accideM '�
ANY AUTO BODILY INJURY(Per person) Z '
ALL OWNED SCHEDULED BODILV INJURV(Per accident) m
AUTOS AUTOS r.
HIREDAUTOS NONAWNED PROPERTYDAMAGE v
AUTOS Per aceident �
Y
m
UMBRELLA LU4B OCCUR EACH OCCURRENCE V
EXCESS LIAB CLAIMS-MADE AGGREGATE
DED RETENTION �
A WORKERSCOMPENSATIONAND WLRC43119424 04 O1/2012 04 1 2013 X WC STATU- OTH-
EMPLOYERS'LL4BILITY TORY LIMRS ER
ANYPROPRIETOR/PARTNER/EXECUTIVE Y�N work Comp-- --Aos
B OFFICERIMEMBER EXCLUDEDY �N I A S�FC43119461 04/01/2012 04/Ol/2013 E.L.EACH ACCIDENT $1�OOO�OOO
(Mandatory in NFQ Work Comp-- -MA E.L.DISEASE-EA EMPLOYEE fl,�00��00 �
If yes,deacribe under �
DESCRIPTION OF OPERATIONS bebw E.L.DISEASE-POUCY LIMIT $1,OOO,OOO_ '.
�
DESCRIPTION OF OPERATIONS I LOCATIONS I VEFtlCLES(Altach ACORD 101,Additional Remarks Seheduk,if more apaee is requhed) �.�{ �
The insurance afforded by the policy described herein is subject to all terms, exclusions and conditions of such policy. �
�
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CERTIFICATE HOLDER CANCELLATION �
�.
� SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE �
EXPIRATION DATE THEREOF, NOTICE VNLL BE DELIVERED IN ACCORDANCE VNTH THE - .
POLICY PROVISIONS. :
TOWII Of varmouth AUTHORIZEDREPRESENTATIVE '�
rown Clerk
1146 Route 28
South YdPmOUth MA 02664 USA � `��j� sg�� I/'����
�.�tf�F c�j�
01988-2010 ACORD CORPORATION.All rights reserved.
ACORD 25(2010/OS) The ACORD name and logo are registered marks of ACORD