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Home My WebLink AboutApplication and WC1 �� R`t�N �tu��. I�rws�. • a{,� � � ._ __—.-- ,� � °� � .. �. .. � � �� T WN OF YARMOUTH BOARD OF HEAI„tT�I �� APPLICATION FOR LICENSE/PE T ��-s�,�� _ �,. �b��o�; * Please complete form and attach all necessary c{�c��en�s by I�,�c mb , G 1 �� Failure to do so will result in the re�urn o�`°your application acket. ESTABLISHMENT NAME: ^ �� vd fr'r�t F.�?s TAX I : ' LOCATION ADDRESS: /0(� Z (21- z� TEL.#: S�O 8;S�Y— Gyy ' MAILING ADDRESS: l►L �NT��tF �� ua�v�, ht,� d',�, S3>- ; E-MAIL ADDRESS: 3v�L��v(. hnl� ��) �U<- , Ca..�- OWNER NAME: � , CORPORATION NAME (IF APPLICABLE):L2y,��v �.4.��y I f��s'�•�� ts '��t c � MANAGER'S NAME: P�'T�/Z C A�P ab�� TEL.#: SGfs -33 Co —� MAILING ADDRESS: l((Q w l�T�.c rf��s� R r� �,��-�� ih�d- a�-5� Z 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. ,� � � --- _ _ - - _ _ _ 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. l. 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 �le 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-chokingprocedures 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, RESTAURANT SEATiNG: TOTAL# I ; OFFICE USE ONLY ,.. .. __ _ _--—- -- - - ----- - - - --- LICENSE REQUIRED FEE PERMIT# LICENSE REQUIREU FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $110 _INN $55 CAMP $55 SWIMMING POOL$110ea. _LODGE $55 TRAILER PAItK $105 _WHIRLPOOL $110ea. FOOD SERVICE: !, LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �0-100 SEATS $125 �Q2 CONTINENTAL $35 NON-PROFIT $30 � >100 SEATS $200 1COMMON VIC. $60 �Q/ =WHOLESALE $80 RETAIL SERVICE: —RESID.KITCHEN $80 ' LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# I _<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 _ $ ($�.pO ****�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 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 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 COOHING: 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 16, 2016. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQL?IPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. . DATE: ' '��''�`U SIGNATURE: ".� "'��' PRINT NAME & TITLE: � ��t� �'^""`P�"�v� ' Rev. 10/12/16 , . ' � : � The Commonweatth ofMassachusetts Departtnent of�ndustrial Accidents � Office of Investigations � ' 1 Congress Street, Suite I00 ; T Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses ! Applicant Information Please Print Le�iblv � � Business/Organization Name: f2yq��✓ �it�,.,i�y ,��-�.r � ` Address: �1(� �/i�i i=� t-f��s� '�1 ; ; City/State/Zip: �o��.ti F_ �}- B�.� � Phone #: jG� —7S"g� S�/� 1 Are you an employer? Check the appropriate boz: Business Type{required): � 1.� I am a em lo er with 5. Retail p y _l � U employees(full and/ ❑ ior part-time).* 6. ❑ RestaurantlBar/Eating Establishment I .u i am a�oi�PrcPri�tar-or�artr�ership�dfiave no ---- - . _ _---_ —_ __ ---- , 7. �O�ce and/or Sa1es(incl. real estate,auto, etc.) employees working for me in any capacity. ; [No workers' comp. insurance required] g• ❑ Non-profit 3.❑ We are a corporation and its officers have exercised 9. ,�ntertainment their right of exemption per c. 152, §1(4), and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]* 1 l.❑ Health Care 4.❑ We are a non-profit organization, staffed by volu.nteers, 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 o�cers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an j organization should check box#1. I � I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. � InsuranceCompanyName: C�S76��i/L�D ��Su,��Nc� Cd Insurer's Address: /� �G�'fL �r ✓r.c �'� ' City/State/Zip: �!J ! �k�S � � i6 k�� , �f'7 �g`7 Q,� —110 z d Policy#or Self-ins. Lic. # � y Gt� C(o,SGIo��/d Expiration Date: /L (�/��G!6 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 ', _ t�iil�ii t�?��v.Pi�a.Li"i�idT - c i 1i11"1'ISDri111�11� �i�_i.YJ1�""'�I3a��i�S 11I�i E i-� _r c�m�n. P � �11E Y"a � , Y �VBItI:�JP.DE�4.na a fi:�e _ 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 o perjury that the information provided above is true arfd correct. r Si ature: Date: D �o�' ZG�� Phone#: '�U b r 7 S--r'j - .�y�+ �1 Official use only. Do not write in this area,to be completed by ciry or town officia� City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Oftice 6. Other Contact Person• Phone#• www.mass.gov/dia , , ,. �,�-� RYANF-1 OP ID:WM '`;�� CERTIFICATE OF LIABILITY INSURANCE �os�os��o�s THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPOW THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMAl1VELY 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 the terms and conditio►is of the policy,certain policies may require an endorsemerrt. A statement on this ce�cate does not confer righls to the certificate holder in lieu of such endorseme s). PRODUCER NpMEACT William B.Markhard,CPCU McLaughlin insurance Agency P�E 7g1-665-2775 ��;781-665-0295 828 Lynn Fells Parkway ac No�a: Melrose,MA 02176 A��;wmarkhard claughlinins.com Wiiliam B.Markhard,CPCU INSURER�S)AFFORDING COVERAGE NAIC# msu�R a:Houston Casualty Company INSURED Ryan Family Amusements,Inc. �Nsu�Re:Commerce Insurance Company 34754 Attn: Mike Crowley „�sur�Rc:Guard Insurance Group 116 Waterhouse Road Boume,MA 02532-3867 �Nsu�o:Torus National insurance Comp INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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 WHfCH 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 SHOVIM MAY HAVE BEEN REDUCED BY PAID CLAIMS. �� TYPE OF INSURANCE POLICY NUMBER MM D�F M�Y EXP V�� A X COMMERCIAL CaENERAL W►BIUTY EACH OCCURRENCE S �,�,� CLAIMS-MADE �OCCUR SC1600597A ��2��6 05/01/2017 pREMISES Eaoccurrence $ ��0 MED EXP(Any one person) $ EXCIUC�@ X LIQUORLIAB SC1600597A 05/01/2016 05l01/2017 pERSONAL&ADVINJURY s 1,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 2,��,� POLICY❑PR� �LOC PRODUCTS-COMP/OPAGG S 2r�,� JECT orHeR: Liq.Liab a 1 m/2 AUTOMOBILE LIA&LITY COMBINED SINGLE LIMIT s � �� Ea acddent � � B ANY AUTO 16MMBDPRLQ 04J10t2016 04J10/2017 BODILY INJURY(Per person) 3 � ALL OWNED X SCHEDULED BODILY INJURY(Per'accatleM) 3 AUTOS AUTOS NON-0WNED PPeOa��DAMAGE $ . X HIREDAUTOS X AUTOS , a �( UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5r��r� p EXCESSLIAB CIAIMS�tADE 70531N761ALI 05/01/2016 05/01/2017 qGGREGATE S 5.�� DED X RETENTION$ 70�� t WORKERS CAMPENSATION AND EMPLOYERS'LJABILJTY STATUTE ER Ci ANY PROPRIETOR/PARTNER/EXECUTIVE Y❑ RYVVC659240 12/31/2015 12/31/2016 E.L.EACH ACCIDENT S �� OFFICERMIEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMP�OYE $ ��,� It yes,desaibe untler - DESCRIPTION OF OPERATIONS below E.L.�ISEASE-POLICY LIMIT $ �,OO DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 107,Adtlidonai Remarks Scheduie,may be akached ff more space is required) Yarmouth Summer Celebration Rick Off , June 25th, 2016 at Bass River (3mugqler's) Beach, Shore Drive, Yarmouth I�+.. General and Liquor Liability have been extended to apply to thia event. CERTIFICATE HOLDER CANCELLATION YARM001 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Yarmouth TME EXPIRATION DATE THEREOF, NO110E 1MLL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town Hall , 1146 Route 28 pUTHORRED REPRESENTATNE So.Yartnouth,MA 02664 � � I� �vy I �1988-2074 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD ' Warker's ComQensation and Em�lover's i,ia�ti#i�y Poficv � �� EastGUARD Insuranc��orrrpany-A Sto+ck Cc►m�any 1 ��r�S��r� HC�t�lt�V�+a� � Palicy Numl�erRYWC65924Q �� Insurance Renewai o#RYWC5235�9 ;- �'�i �� Cornpanies NCCi Nv. [33935� ; Policy InfQrrnation Page . 1 ; ; [1,]IVamed Insured and Mailing/hddress AgencY � Ryan Family Amusemet�ts Inc TPA INSURAMCE A�G�NCY TNG. � 11b Waterhause Raad iQ NEW ENGLAf�D BUS C7R � 8ourne,MA fl2532-3867 SUITE 303 Andover, MA Q18�.Q � Agency Code; MATPAAit3 � ! Federai Ernpltryer's IU � Insured is Corporafiion Risk-lD Number 9175�5287 ; t�o�tiOnS o�7'POIiCy -See E�ctension of Infarmation Page -Schedute of Locations �2� Rolicy Peri++c>d From �ecember 31, 2015 to December 31,2Q16, 12.01 AM,standard time at the insured`s rnailing � address. : [3� Coverage , A. Workers'Comp�n�atinn Ir�surante- Part One of thiS poticy applies to the Wt�rkers'Cort�pensation ' t,aw of the fallowing states; Massachusetts,Rhode Island � B. Emplayar's Uabil�ty Insurance-Part Two of this policy appt�es to work in each of the states tisted # in itern[3]A. The limits of aur iia6tiity under Part Tvvo are: � Bodily Injury by Accident-each accident $500,OQ� Bo�#ily Injury by Disease-each emplc�yee $SOO,OQO ` Badity Injury by`D[sease- poliey limit $5i}0,400 � � G. 4ther 5tates Insuranee-Part Three af this poticy applies to a!1 statesr excep�any state#isted in - ifem [3JA.and the states�f North Dakota, �hio, Washington,and Wyoming. D. This palicy inetudes these endorsem�nts and scheduiesc G See��ensEan of InformatiQn Page-Schedufe of Fvrms � �4� Premi�t�t . ; The PrerniUrn Basis and,therefore,the pr�mium wiil be determined by aur Manua!of!tules, ' Glassificatl4ns, Rates, and Rating P1ans. Ail requ�red informatifln is suhject to uer9flcatinn and change by � �utlit. {Cantfnued on'another page} � ; i 2 i i i � � k � . . . � . . . . . � 7atat Estimated Policy Premium _ $ 2Z,62i, j Totai St�rcharges/Assessments $, i,315.00 � Tatal Estimated Cost � �3,936.Q0 � �ittVALUSE 7�t Page- i- Tnformation Page � MGA :RYYUGfi59240 WC 000003A � i3ate :13/U712015 � MAN(3TE' � issc�ing Dffice: P.O,Box�►-E1,�6 S, Rlver Street,Witkes-Banre,PA 18783�{?020 s wwrw.guard.com i � � ,�_',� Worke�'.��omaen��on and Em�iayer`s Lia tlity �olicv- �,� EastGUARD Insurance Catmpany-A Stock ComQat�y �� Berkshire Hath�way P�rltcy Mwmaer RYWC659240 �� Insurance R�newa[ af f�YWC523549 � Companies NCGT No. [33936] , t�olicy Informa#ion Page ; E�cctensian of Infvrrr�ration Page � y Schedute of t,ocations , ; (LZ) 20�Main S#reefi, Buzzards 8ay, MA 0�532(12/31j201S- 12j3iJ2Q16) ' {�3} 441 Main Street,Hyannis, MA 02b(}1 (12f31f2Q15 - 22/32J2016} i (L4} ].Q57 Rte 2$, South Ya�'mouth, MA Q26�4 (12/3112015- 12l31/2016} ' 3 (L5} i15 f�ew state Nwy, ttayn�arn, MA o2767(�.2/31/2o�.s- i.2/31/2�16) �' (L�i) 1170 Main Street, Mitlis, N1A02�54(�2J31/2U15 - 12j31/2416) (L7'j 999�5c�. Udash'rngCon , Nt�rth Attlebor'o, MA 0276t} (22J31/ZtI15- 12/3Z(2026} ({,8} 23'f awn Hati Sq, , Fatmouth, MA U2S40(12j31/Zfl15-i2/31J2f}16)' (Lg} 19 Gircuit Ave, C?ak 81uffs, MA Q2557 (12/3�.j2015-12J3�.f2016) (L10} 258 Thames St, Newpart, RX U2840 E12j31/2fl15- 12J31/2t}16j - (�#.1} 769 Lyannaugh Road , Hyannis, MA 02601 (12j31j2015- 12/31JZOlfi) ; i 4 } 7 t , . �1 i i { {! ! 1 1 t ( i � 1 � 1 , � ! } �u I � ?NTERNAi L1SE XX 4�3ge-2- InfOr7f18#ipt}Page i MGA : RYWC65924f� WG 000003A ' Date :42/07/2U25 MANOI'E ` issuing Office:P.O.Bax A-N,16 S.Ri�rer Street,Wilke�-Barre,FI#187D3-0020 s www.guard.cam