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Home My WebLink AboutApplication and WC , � � RECEtVED • � ► TOWN OF YARMOUTH BOARD OF-HEALTH �""``a' � � APPLICATION FOR LICENSE/PERMIT-20 ��7j �� ' 2��6 �'"` * Please complete form and attach all necessary documer�s h�cembe�r`" S DEPT. Failure to do so will result in the return of your application packet. TM ESTABLISHMENT NAME �ia�mnu-�-t,Paa-t U i 1�4�4P �t-aa�e TAX ID � - •� v LOCATIONADDRESS:��„�n po� 6R �yaa-mcsc.�+hPo�fi.(`�1�--o26`1S TEL.#:SoR-3�2-24oa MAILINGADDRESS: j_ Pa-t�-ic.K� UJ4t.� , �a2�-eS-t-d�l-�f (Yl#�-o26+�4 E-MAILADDRESS: �/i�}�ct��'721�16��-�'e•��oo_ CorYL OWNER NAME: L)i g j�a.L �h u C�C t cL CORPORATION NAME (IF APPLICABLE): �►e� t-(4.�rrnai.t-�-� Co�a-P MANAGER'S NAME: iJ�'g�ict,L Sh u Ik!� TEL.#: So�-S 2�t-334y MAILING ADDRESS: � Rz�-�-�"cKs W�� -f zsa-es-I-cLczd�e � �'TlA -��6tl4 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 standard First Aid and Community Cardiopulmonary Resuscitation (CPR), having one certified employee on premises at all times. Please list the employees below and attach copies of their 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. 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. 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. 2. ALLERGEN CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who has Allergen certification, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.009(G)(3)(a). 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. 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. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# , OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&B $55 CABIN $55 MOTEL $110 INN $55 CAMP $55 SWIMMING POOL$110ea. _LODGE $55 _TRAILER PARK $105 WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE P�E,��IT,�#, LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# ( 0-100 SEATS $125 �� —CONTINENTAL $35 NON-PROFIT $30 _>100 SEATS $200 _COMMON VIC. $60 WHOLESALE $80 —RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 � �<25,000 sq.ft. $150 � =FROZEN DESSERT $40 �TOBACCO $110 � NAME CHANGE: $15 AMOUNT DUE _ $ ��$�j_pQ *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** 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 1NSURANCE 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 V NO MOTELS AND OTHER LODGING ESTABLISHMENTS 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 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, 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 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 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.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 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 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 RETtJRN THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 15, 2015. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: �- ► S-- 2oi6 SIGNATURE: `�� -�-..-- � PRINT NAME & TITLE: ��I��i � �J�i ll I-C�Q � �2feSic��c�' Rev. 10/O1/15 , � ;��nt°Fo��rt , ` � The Commonwcalth ofMassachusetts A..��; Department of Industrial Accidents " Office of Investigations ` ' I Congress Street, Suite l00 Boston, MA 02114-2017 www.mass.gov/dia ' Workers' Compensation Insurance Affidavit: General Businesses ' Applicant Information Please Print Legiblv ; i ' Business/Organization Name: h►Q� �a�� ,,,�� Q��,P� �+1� e. S-�c�a-e_ i Address: .��jp, �atx.`�-� 64� i City/State/Zip: ��c.��-, rn�} _0 2 6�5 Phone #: 5 o�'c_52�-33�14 Are you an employer? Check the appropriate box: Business Type(required): i 1.� I axn a employer with�_employees(full and/ 5. � Retail or part-time).* 6. ❑ RestaurantBar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no �, � Office and/or Sa1es(incl.real estate,auto, etc.) employees working for me in any capacity. o workers' com .insurance re uired g• ❑ Non-profit � P q � 3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per a 152, §1(4), and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]* 11.❑ Health Care 4.❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.❑ Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#1. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: Insurer's Address: City/State/Zip: Policy#or Self-ins. Lic. # Expiration Date: Attach a copy of the workers' compensation policy declaration page(showing the policy number and ezpiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify,under the pains and penalties ofperjury that the information provided above is true and correct. Signature• Date q 1 � (6 Phone#: �a� -S 2�--, �lZy Official use only. Do not write in this area,to be completed by city or town officiaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2. Building Departmenf 3. City/Town Clerk 4.Licensing Board 5. Selectmen's Office 6.Other Contact Person• Phone#• www.mass.gov/dia � ACO� DATE�MM/DDNYYY) ��. CERTIFICATE OF LIABILITY INSURANCE 10/25/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATNELY 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 have ADDITIONAL INSURED provisions or 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 does not confer rights to the certificate holder in lieu of such endorsement{s). PRODUCER N�EACT Deborah Hathaway G.H.Dunn Insurance Agency, Il1C. PHONE 508 322-3242 F� 64 Fairhaven Road � � � {ac,No�:{�8�322-3243 PO Box497 aooR�ess: deborah@ghdunn.com Mattapoisett,MA 02739 INSURER S AFFORDING COVER.4GE Nac u wsuReR a: MA Retailers U00000 � INSURED NewYarmouth Corp dba Yarmouthport Village Store INSURER B: 1 Patricl6 Way Forestdale,MA 02644 INSURER C: � � INSURER D: � INSURER E: � INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: TI-9S IS TO CER7IFY Tli4T THE PaLIC1ES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED f�IAMED ABOVE FOR TF� POUCY PEPoOD INDICATED. NOTWI7HSTAf�ING ANY REQIAREN�NT, 7ERM OR CONDIl10N OF ANY CONTRACT OR OTHER DOCUMEM"WITH RESPECT TO WI-9CH THIS CERl1FICATE MAY BE ISSUED OR MAY P�2TAIN, TNE INSURANCE AFFORDED BY l}� POLICIES DESCPoBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS ANO CONDIl10NS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUBR LTR TYPEOF INSURANCE POLICY NUMBER MMIDDlYYYY MMIDD�YY LIMITS COMMERCIAL GENERAL LIABILITV EACH OCCIA�REI`JCE 3 CLAIMS-MADE �OCCUR DAMAGE TO REPIfED PREMISES Ea occurrence � MED E;Q�(Any one person) S . PERSONAL&ADV II`1.11RY $ GEh1L AGGREGATE LIN9T APPLIES PER: GEh�IERAL AGGREGATE S PRO- POLICY ��CT ��OC PRODUCTS-COMP/0P AGG $ OTHER: $ AUTOMOBILELIABILITY COMBIf�IEDSIPJGLELIMIT $ Ea accident � AhJY ALJTO BODILY IIWlk2Y(Per person) $ OWNED SCHEDULED BODILY Ih,UURY ) AUTOS O�LY AUTOS (Per accident $ HRED N0�1-OWfJm PROPERTY DAMAGE AUiOS Oh�R.Y � AIfiOS O�dLY Per acciden $ i S ; UMBRELLAIIAB OCCUR . EACHOCCIA�REhICE S � - EXCESS LIAB CLAIMSMADE AGGREGATE $ I 1 DED REfETJrION $ . g � q WORKERSCOMPENSATION ASSIGN201610181326115729 10/31/2016 10/31/2017 PER OTH- AND EMPLOYERS'LIABILITY Y�N STATUTE ER ANYPROPRIEfORlPAR1NER/EXECUiNE E.L.EACHACCIDEfdf $ SOO,OOO � OFFICER/MEMBER EXCLUDED? � N�A jUO,OOO . (MantlatorylnNH) E.L.DISEASE-EAEMPLOYEE $ If yes,describe under j DESCRIPTIONOF OPERATIONS below � � E.L.DISEASE-POLICY LIMIT $ �Q�� DESCRIPTION OF OPERA710N5/LOCATIONS!VEHICLES (ACORD 101,Additlonal Remarks Schedule,may be attached if more space is requlred) Yarmouthport Village Store 330 Route 6A Yarmouthport MA CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE 1MLL BE DELIVERED IN Town of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Rt 28 South Yarmouth,MA OZ664 AUTHORIZED REPRESENTATIVE J/��/��y��+j�� l�l�� L�i�.4a-'G�l,�� i.�L��l1C. O 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03y The ACORD name and logo are registered marks of ACORD