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Home My WebLink AboutApplication and WC � � i Z � � TOWN OF YARMOUTH BOARD OF HEALTH � � : �; � ' (��VJJ[�D -, � � APPLICATION FOR LICENSE/PERMIT=2��.� A - �� -�� c�v � 12 o i� * Please complete form and attach all necessary documet�ts`6y�e�'em�er S 2011. Failure to do so will result in the return of your application pac et. HEALTH DEPT. ESTABLISHMENT NAME: TAX ID• ��- ' LOCATION ADDRESS: ' � TEL.#:.S -7 -G l�f� ' MAII.ING ADDRESS: ,` OWNER NAME: �-i/�e7` cr�, �i CORPORATION NAME(IF APP CABLdE): �m� MANAGER'S NAME: ,�� ca,��! .�Q- u 7�i TEL.#: ,S'D�- 77/-�/8=s ' MAII.ING ADDRESS: - � 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. 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 pro�ide new co�ies and x�aintain_a f�e_at your placQ of busin�ss. 1. 2. 3. 4. 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. i 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�le at your establishment. i 1. 2. , PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. 1. 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 i 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. I i RESTAURANT SEA,TINCJ;._�QTAL# -� - - _ _ _ ; � OFFICE USE ONLY f LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# I _B&B $55 _CABIN $55 _MOTEL $55 I _INN $55 _CAMP $55 _SWIMMING POOL $80ea. ! _LODGE $55 _TRAII.ER PARK $105 _WHIRLPOOL $80ea. � FOOD SERVICE: ; I LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _0-100 SEATS $85 _CGNTINENTAL $35 _NON-PROFIT $30 _>100 SEATS $160 _COMMON VIC. $60 _WHOLESALE $80 RETAII,SERVICE: —RESID.KITCHEN $80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUII2ED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# ' _<50 sq.ft. $50 _>25,000 sq.ft. $225 _VENDIIVG-FOOD $25 � 1<25,000 sq.ft. $80 � _FROZEN DESSERT $40 1 TOBACCO $95 -�,�� I NAME CHANGE: $15 � AMOUNT DUE _ �__1–I'rJ •00 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** I �� , � i 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 AT'�ACHED /J ; OR �� , WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED � 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 MOTELS AND OTHER�.ODGING 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 place of residence ' elsewhere.Transient occuna�cy shall generally refer to�cont;nuous occup�ncy of not more than thirty(3Q)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 I� 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 De�artment 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 �i 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. �I 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: 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 produc�by a retail or food service establishment is prohibited. NOTICE:Permits run annually from January 1 to December 3 l. IT IS YOUR RESPONSIBII.ITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15, 2011. ALL RENOVATIONS TO ANY FOOD ESTABLISHIVIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIl'MENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SIT P . i ' DATE: / SIGNATURE: i�ic ar �aur ' r � PRINT t�TAME&TITLE: Rev.10/25/11 � ___ ; ' The Commonwealth ofMassachusetts , � _ - Department of Industrial Accidents " Office of Investigations ' ' 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Anplicant Information Please Print Legiblv • Business/Organiza.tion Nazne: � �. � Address: ioo �n�.�sv� . • City/Sta.te/Zip:��, ea oi�oa Phone#: aoo-zis-s�aa Are yna an employer?Check the apprupriate box: Susiness Type(reqnired): 1.(� I am a employer with6�ooa f employees(fuli and/ 5• ❑Retail . or pazt time)•* 6. Q Restauran2BarlEating Establishmeat 2.❑ I azn a sole proprietar or par�ersvip and have no �. �p�ce and/or Sales(incl.real estate,suta,ac.) employees worldng for me in any capacity. g. D Nan-p�Ofit [No workers'comp.insuz�ace requiredj • . 3.[Q� We aze a corporation and its offxc�have ex�rcised 9. ❑Fatcxtai�cat � � their right of exemptaon per c. I52, §1(4),and we have 14.�Manufactuzing ' no employees.[Na worgeas'comp. ins�aance requiredJ* � 4.❑ We are a non-pmfn organszation,staffed by volnnteess, I I.[]Hea�th Care � , with no employers.jNo worke�s'comp.insurance req.] 12.�OtLer c�s s't�Ia�/� s`Ta�$S , "Aay appticaat fhat c'6ecks box#F inast al�fifl out the sectiaa below sLowmg 8�eir workers'compensation poticy iufozlrtmtiaa � ' *"`If(6e coipotam officess bave exempted 6eemaeJves,btn the corporation Las o9eer em�ployoes,s workers'c.ompensatioa po&cy is aqnimd sad snch an mgani�atiou ahoc7d ohack3wx l�1. . I am an employer that is�roviding�workers'comper:sation insurance for rxy employe�s. Betow is ihe policy u formation. Insurance Companry Name: � �c1�N � c�ol�z Insuz�es's Address: � �, 33 a�t s'�r, soi� 2400 � � ' City/Sfate/Tip: B[k,`i+oN. �1A 02110 ' � PoIicy#or Self-ins.Laic.#a�u�,.ra�� Exgiration Date: 4/oi/�2 ' Attach a capy of the workers'camgensation policy dedarafion page(showing the poticy nnmber and ezpirntioa date). Failur�to secwe coverage as required under Sectian 25A of MGL c, 252 can Iead to the impositioat of crimmal penalties af a � frne up to$2,SOOAO anc#!or ane-year im�aisonment,as well as civ��penalties rn the form of a STOP WORK ORDER and a�ne of np to�250.00 a day agaFnst the violator. Be advised that a co�y af 8�is statement�ay be forwarded w the Office of In�gations of the DIA for insnrance covera veri5ccabion. I do hereby eertify,urader e alt s of perjuiy that the information provided arbove is� a�d correex Si ature: Date_ l // � c ard Fournier P�one#: 800-225-97D2 %1491 , O,�iicr`ol use onEy. Do not wrue in is area,ro be completed by city or town offieiaL ' City or Towa: Pera�it/L.icense# � Issning Anthosi#y{rircIe one): 1.Board of Health 2.Bnilding Department 3.CiiylTowa Cterk 4.Licensing Board 5.Seleetmen's Uffice � 6.Other Contacf Person: Phone#: www.ir�ass.gov/dia : A�0� DATE(MM/DD/YYYY) �— CERTIFICATE OF LIABILITY INSURANCE o4,�,20„ 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 INSUREO,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to � the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate dces not confer rights to the w certificate holder in lieu of such endorsement(s). � m PRODUCER CONTACT a AO� Risk Services Northeast, IFlC. NAME: Provi dence RI Offi ce (NCNNo.ExtJ: �866) 283-7122 a.No.: (847) 953-5390 9 100 westminster 5treet, lOth Floor e.a�aa� vrovidence RI 02903-2393 USa aoor�ss: _ INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A Indemnity rnsurance Co of North ,4merica 43575 GUMBERLAND FARMS, INC. INSURERB: ACE AOIEflCd11 rnsurance COttipolly 22667 100 �rossing Boulevard Framingham 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 �µq �p POLICY NUMBER M�ppryyyy M�pn.� LIMITS GENERAL L4461LITY EACH OCCURRENCE COMMERCIAL GENERAL LIABILITY PREMISES Ea oeturrence ��.. CLAIMS-MADE ❑OCCUR MED EXP(Any one person) � PERSONAL 8 ADV INJURY o N � GENER4LAGGREGATE 0 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG � POLICY PRa LOC p � AUTOMOBILE LUIBILITY COMBINED SINGLE LIMIT 'n Ea accident ANY AUTO BODILY INJURY(Per person) Z ALL OWNED SCHEDULED BODILY INJURY(Per accident) m AUTOS AUTOS a+ HIREDAUTOS NONAWNED PROPERTYDAMAGE V AUTOS Per aecident ,F � m UMBRELLA LIAB OCCUR EACH OCCURRENCE V EXCESSlJA6 CLAIMS-MADE AGGREGATE DED RETENTION A WORKERSCOMPENSATIONAND WLRC43118547 04/O1/2011 04 O1 2012 X WC STATU- OTH- EMPLOYERS'LIABILITY � TORY LIMITS ER ANY PROPRIETOR I PARTNER/EXECUTIVE Y I N Work Comp-- --Aos B OFFICER/MEMBEREXCLUDED? a N/A SCFC4311$S$4 04/Ol/201104/Ol/2012 E.L.EACHACCIDENT $Z,OOO,OOO (MandatoryinNFQ Work �omp-- -MA E.L.DISEASE-EAEMPLOYEE S1,OOO,OOO If yes,describe under DESCRIPTION OF OPERATIONS bebw E.L.DISEASE-POIICY LIMIT $1,OOO,OOO� . � DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Sehedule,H more spaee is required) � ��. rhe insurance afforded by the policy described herein is subject to all terms, exclusions and conditions of such policy. � i � � � �� CERTiFICATE HOLDER CANCELLATION � 1f SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DEWERED M ACCORDANCE WITH THE POLICY PROVISIONS. �� TOWfI Of varmouth AUTHORIZED REPRESENTATNE ' rown Clerk 1146 Route 28 South Yarmouth MA 02664 USA � `';�� f/'�� e/'/ 07988-2010 ACORD CORPORATION.Ail rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD