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TOWN OF YARMOUTH BOARD OF HEALTR
' APPLICATION FOR LICENSEJPERMIT-2017
� *Please complete form and attach all necessary documenis by Decenrb�r l6 2016.
' Failure to do so will result in the return of your applicahon pac t.
' ESTABLISHMENT NAME. �
' LOCATTON ADDRESS: i � �a(/��!'EL.#:�$�,�nc�_q���j
� MAILINGADDRESS: _ `#; S�d(` 'C?c'• N[���rtvtit\�; '1�V ?,�-�
E-MAII,ADDRESS: ^
OWNER NAME: ,`LC
I CORPORATION NAME(�APPLICABLE):
' MANAGER'S NAIvIE;S l�Ll_}.� r W�a�0��C 'FEL.#:
� MAILINGADDRESS: i+-i ��hrP,�,,�_yC�rfnni����-,��(1�} (���D�-�
POOL CERTIFICATIONS:
The pool snpervisor mnst be certified as a Pool Operator,as required by State Isw. Please list the designated
Pool Operator(s)and attach a copy of the certification to this form.
1. '�l�� 2.
Pool operators must list a minimum of two employees currentty 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.TLe Healt6 Department will not uae paet
years'records. You mnst provide new wpies and maintxin a file at yoar plaae of bnsiness.
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FOOD PROTECTION MANAGERS-CERTIFICATIONS: D < ��'
� All food service establishments are required to have at least one full-time employee who is certified as a Food � �v ��
' Protection Manager,as defined in the State Sanitary Code fbr Food Service Establishments, 105 CMR 590.000. s N p"�
� Please attach copies of certification to ttus application. The Health Departmeat will not ase past years'ra ords. � N �'
� You must provide new copies and maintain a file at your establis6men� -�'�� o g'L�:��
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1.��C.►�f��� �i��j�f �,� 2.��t��0.A�'l U rx(0(,.t_�'t A v�i rx n .
PERSON IN CHARGE:
Each food estabiistunent must have at least one Person In Charge(PIC)on site during hours of operation.
1.1)�c+���e:.r� �n�V���lo S��oS� ' ��n 2.C�P��7'l �-{C�fbu�-z�j'1,+c�n�a°�P� S�i.e,�.1.1
J
ALLERGEN CERTIFICATIONS:
All food service estabiishments 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 �>`��
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, co ies of certification to this lication. The Health De artment will not nse ast ears records. You must .
P aPP P P Y
�
provide new copies and maintain a file at your establisLment. �,,,.
1. �(1 2.
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HEIMLICH CER'TIFICATIONS:
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 enployees trained in anti-choking procedures below and
attach copies of employee certifications to this form. The Heaith Department will not ase past years'records. �•��
Yon must provide new copies and mnintain a file at your place of basiness. �� � �
1. 2.
3. 4.
RESTAURANT SEATIl�IG: TOTAL#__,`�l0 �j
0
i.oncn�c:
OFFICE USE ONLY �
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMCT# LICENSE REQUIRm FEE PERMIT# �
B&B SSS CABIN S55 MOTEL 5110 !'
—INN SSS CAMP S55 =SWIMMING POOL S110ea �
_.ODGE SSS _ RAILER PARK 5105 _WHIRLPOOL S110ea �
FOOD SERVICE: W
LICENSE REOUIRED FEE PERMIT# LICENSE REqUIRED FEE PERMIT q LICENSE REQUIRED FEE PERMIT#
0-100 SEA'i'S 5125 CONflNETI'CAL $35 NON-PROY2IT S30 �
=>100 SEATS 5200 �� �COMMON V1C. S60 ,�Z �WHOLESALE S� �1
RETAIL SERVICE: —RESID.KI7'CHEN S80 ,
L[CENSE REQUIRED FEE PERMTf# LICENSE REQUTRED FEE PERMiT# LICENSE REQUIRED FEE PERMIT# a
<SOsq ft. SSO >25,000 ft. 5285 VENDING-FOOD S23
=Q5,000 sq.R. 5130 _FROZEN�ESSERT S40 =�I'OBACCO 5110 V��
NAME CAANGE: S1S AMOUNT DUE _ $�,,�C}.t�
•trrtpLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM'***`
�
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ADIMIINISTRATION
Under Chapter 152,Section 25C,Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal
i 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. TAE ATTACI�D 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 tarces and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES� NO
MOTELS AND OTHER LODGING ESTABLISIiMENTS
TitANSIENT 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 demonstr�te that they maintain a principal place of residence
elsewhere.Transient occu�ncy shall generally refer to continuous�cupancy of not more than thirty(30)days,and
'' ___ ____ __ _ _ __ a�ag�egatee€ ' f9A}�e3`swithi�an3�si��)aienth ' . ' ' __ _
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 Deparbment prior to opening. Contact the Health Department to schedule the inspection three(3)
daya prior to opening.PLEASE NOTE:People are NOT allowed to sit in the pool area until the pool h�ss 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 outdoar in ground swimming pool must be drained or covered within seven(7)days of
closis►g.
FOOD SERVICE
SEASONAL FOOD SERVICE OPENING:
All food service establishments must be insp�ted by the Health Department prior to openlug. Please cornact the
Health Department to schedule the inspection three(3)days prior to opening.
CATERING POLICY:
Anyone who caters within the Town of Yarmouth must norify the Yarmouth Health Departrnent by filing the
required Temporazy 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.varmouth.ma.us under Health Deparlment,
Downloadable Forms.
FROZEN DESSERTS:
Frozen desserts must be tested by a State certified lab priar to opening and monthly thereaRer,with sample resuits
submitted to the Health Department. Failure to do so wilt result in the suspension or rev�ation of your Frozen
Dessert Permit until the above terms have been met.
OUTSIDE CAF�S:
Outside cafcs(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Boarci of Health.
OUTDOOR COOIQNG:
Outdoar cooking,preparation,or display of any food product by a retail or food service establishment is prohibited.
NOTICE:Pernuts run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN
TI-IE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 16,2016.
ALL RENOVATIONS TO AN� FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAIlVTIIVG, NEW :
EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY'Tf�BOARD OF HEALTH PRIOR �
TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
DATE:�,I�-I 11 f� SIGNATURE:���.SL.�-'y�II/� � R�F�I?.t���t `
PRINT NAME&TITLE:YY�O{a `�X«c\�Fiet r� �a�, l�S��- �c� /��C��,,��-a�r.t'
�—� �
Rev.10/l2/16 �+
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� The Conunonwealth ofMassachusetts
Depardnext of Industrial Accidents
O,f�'tce of Investigations
' ' 1 Cong►ress Stree�Suite I00
�
; Boston,MA 02114-2017.
www mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Aoulicant Information Please Print Leeiblv
Businessl0rganization Name: qq QeS�o,���o� � 'R�o � �4
Address: 14 P�e_rn,� AJ'Qan�►P
City/Sta.te/Zip: �acm��.#�r, , /Ylq (��p�-3 Phone#: 5C� - �l�a- qqad
Are yon an empIoyer?Check the appropriate boa: Bnsiness Type(required):
1.� I am a employer with�employees(full and/ 5. ❑Retail
; or part-time).* 6. � RestaurantrBar/Eatic►g Establishment
_ _- —-- ---
_ _ - __
2.❑ I am a sola proprietor or partnership and have no 7, � p���a/or Sales(incl.real estaie,auto,etc.)
employees working for me in any capacity.
[No workers' comp.insurance required] g• ❑Non-profit
3.❑ We aze a corporation and its officers have exercised 9. ❑Entertainment
their right of exemption per c. 152,§1(4),and we have 10.0 Manufacturing
' no employees.[No workers'comp.insurance required]*
4.❑ We are a non-profit organization,staffed by voluntcers, 11.[]Hea1th Care
� with no employees. [No workers' comp.insurance req.] 12.[]Other
I •Any applicant that che�cs box#t must also fill out the saction below showing tbeir vw�rkus'compensation policy infoimaLion.
I •'If the oorporate officeis have exempted themselves,but the corporation has other employces,a wockers'�mpensation poficy is requi�ed and such an
organization shouid chedc box#1.
� I am an employer tJeat is provlding workers'compensation insurance for my employee� Below is the pnlicy tnjormatton.
iInsurance Company Name: �r-,�FP�A ►�If1. orin.,� �,Q��cx�T�"'
Insurer's Address: I�8?�"� Sr�n��Q,� (Zd.
city/state/zip: S+.1�l.0 S � dVlb� l03 IU tD
Policy#or Self-ins.Lic.# �C UO��Zf� Expiration Date: � l nt I�t,��
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under S�tion 25A of MGL a 152 can lead ta the imposition of criminal penalties of a
fine up to$1,500.00 andlor one-year imprisonment,as weff as civil penalties in the form of a STOP WORK ORD�R and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this stateanent may be forwarded to the Office of
Investigatians of the DIA for insurance coverage veriScation.
I do kereby certify,uRder the s and penalties of perjury that the�ieformation provlded above is due and correa�
Si pate• 11 1� C7110
Ph ne#• �J- (0-�
Offlcial use oK[y. Do not write in thu area,to be completed by c3ty ar town o�j''iciaL
City or Town: Permif/License#
Issuing Authority(circle one):
1.Board of Health 2.Bnilding Department 3.City/Town Clerk 4.Licensing Board 5.Setectmen's Office
6.Other
Contact Person: Phone#:
www.mass.gov/dia
SAFETY NATIONAL CASUALTY CORP Workers'Compensation and Employers'Liability
1832 SCHUETZ ROAD Insurance Polic
ST. LOUIS, MO 63146
(888)995-5300 Polic Period
Polic Number From To
LDC4055543 08/O1/2016 O8/01/2017
12:01 A.M.Standard Time at the address of
the Insured as stated herein
' Transaction
New Business
1. Named Insured and Address A ent
11845
ABRH, LLC WILLIS OF TENNESSEE, INC.
3038 SIDCO DRIVE P 0 BOX 305025
NASHVILLE, TN 37204 NASHVILLE, TN 37230-5025
Telephone: (615) 872-3000
_ Customer#__ Carrier# FEIN# Risk ID#_ ___ Entity of Insured
16349 371689186 917057680 LLC
Additional Locations if applicable: See attached Location Schedule
2. The Policy Period is from o s/01/2 016 to 0 8/O 1/2 017 12:01 a.m.Standard Time at the Insured's mailing
address.
3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the
states listed here:
AL AZ AR CO CT FL GA IL IN IA KY LA ME MA MI MN MS MO NE NH NM NY NC OK OR RI SC TN
UT VT VA WV
B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits of
our liability under Part Two are:
Bodily Injury by Accident S 1,o 0 0,o 0 o each accident
Bodily Injury by Disease S 1,000,o0o policy limit
Bodily Injury by Disease S 1,000,o0o each employee
C. Other States Insurance: Part Three of the policy applies to states, if any, listed here:
All states except ND, OH, PR, VI, WA, WI, WY and states designated in Item 3.A.
D. This policy includes these endorsements and schedules: See attached Schedule of Forms and Endorsements.
4. The premium for this policy will be determined by our Manuals of Rules,Classifications, Rates,and Rating Plans. Atl
information required below is subject to verification and change by audit.
SEE EXTENSION OF INFORMATION PAGE
Minimum Premtum Total Estimated Annual Premium
NYCCPAP Adjustment
Expense Constant
Assessments and Tax�s Premium Dlscount
Deposit Premium
_ This is a Three Year Fixed Rate Policy
Premium Adjustment Period: � Annual _ Semiannual _ Quarterly _ Monthly
Countersigned this Day of ,
Authorized Representative
Issued Date: 08/30/2016
ISSUIng OffIC2: Safety National Casualty Corporation
WC 00 00 01 A 02 96(WC 99 04 03 in California)