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Home My WebLink AboutApplication and WC� � �� . �.0��i�.�� I �^� TOWN OF YARMOUTH BOARD OF HEALTH I �� APPLICATION FOR LICENSE/PERMIT-2017 i *Please complete form and attach all necessary documents by December 16 20I6. i ; Failure to do so will result in the return of your application pac et. ESTABLISHMENT NAME: l-Gc r rn ov M v � �c�ci- +2_ • � ' ' �' LOCATION ADDRESS: '`�(o <' r" Z- ' �f✓vrir�r,t� TEL.#: �?> � Z�L(f . MAILING ADDRESS: � X �� G� v cv � 2.L�C� ' E-MAIL ADDRESS: � > (_°. Z Z �G i%' �� (� t r�� . OWNER NAME: CORPORATION NAME IF APPLTCABLE): D� �� Lb' G� � O!L P r c� �NIC>c�SF' �Yi C I MANAGER'S NAME: ��✓i-tE' S S�-c_�i vvic�-- TEL.#: S'7>� z��j7�V` i MAILING ADDRESS: S�� /�'�Gn,� t i 9 ; �� POOL CERTIFICATIONS: � � , '� • The pool supervisor must be certified as a Poo!Operator,as required by State law. Please list the designated � :� � Pool Operator(s)and attach a eopy of the certification to this form. - G. �, , �.� �, ,,-,;� �I 1. 2. � • �- � � ' �7 � ; Pool operators must list a minimum of two employees currently certified in standazd First Aid and Community -� a Cazdiopulmonary Resuscitation(CPR),having one certified employee on premises at all times. Please list the --; rn 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. � � i l. 2. 3. 4. i I FOOD PROTECTION MANAGERS-CERTIFICATIONS: . All food service establishments aze 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 Establishxnents, 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 maiatain a file at your estabiishment 1 � i. r� LI 2 /�G=��-t �-[U lt�G �� C z. , � - ��s;;._, 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 aze required to have at least one full-time employee who has Allergen cercification, as defined in the State Sanitary Code for Food Seroice 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 copi nd maintain a Cle at your ptace of business. 1. �1a`(�'Z�_ �_ I�l/t � 2. 3. 4. RESTAURANT SEATTNG: TOTAL# �d OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B�B $55 CABIN S55 MOTEL �I10 �I1`1�' SSS CAMP S55 SWIMMINGPOOL$1IOea. _LODGE a55 _TRAILERPARK $105 WHIRLPOOL SI]Oea FOOD SERVICE: LICENSE REQ LTIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE ��- 0-100 SEA'I'S $125 _CONTINENTAL S35 �NON-PROFIT $30 � >l00 SEATS $200 _COMMON VIC. $60 WHOLESALE $80 RETAIL SERVICE: —RESID.KITCHEN $80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED PEE PERM[T# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. S50 >25,000 sq.ft. $285 VENDING-FOOD $25 _<25,000 sq.ft. $I50 _FROZEN DESSERT$40 =TOBACCO $1 IO NAME CHANGE: S15 AMOUNT DUE _ ��} (�� , **"**PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*"*** �3o t�F-��f-�3S�-a3 � 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 COMPENSA'I'ION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR CERT.OF INSURANCE ATTACHED OR WORKER'S COMP.AFFIDAVIT SIGNED AND ATTACHED L�''�� 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 inspectian three(3) days prior to opening.PLEASE NOTE:People are NOT allowed to sit in the pool azea until the pool has been inspected and opened. ' POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate couni 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 Yaimouth 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 Departrnent,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 CAF�S: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Boazd of Health. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. ; NOTICE:Pemuts run annually from January 1 to December 31. IT IS YOUR RESPONSIBILTTY TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 16,2016. i ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW I , EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR I TO COMMENCE E . RENOVAT'IONS MAY RE RE�IT�AN, y......------ 1 ;,, ,.,'�r `'`"�✓� � DATE: ��(� / � SIGNATURE: • ,/�j� - PR1NT NAME&TITLE: `� !�/ilG�/� �!'//��lf�� `' Rev.10/12/16 s � � � The Commonwealth of Massachusetts Department of Industrial Accidents : � O�ce of Invesfigations � 1 Congress Street,Suite 1 DO i Boston,MA 02114-2017 � www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses A�plicant Information Please Print Legibly Business/Organization Name: �Ct.�w�c�Jl-�• ��e �'"��a l,�-�.�� — ; Address: �� Q !'!/� �i./ �'� �- � i � City/State/Zip: Phone#: ,�Z��" ` ��'�/-- �"Z) �� Are you an employer?Check the appropriate bog: Business Type(required): 1.I.�J' 1 am 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 Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers' comp.insurance required] 8• �Non-profit 3.❑ We are a co oration and its officers have exercised 9. ❑Entertainment rP their right of exemption per c. 152, §1(4),and we have 10.�Manufacturing , * no em lo ees. o workers com . insurance re uired l P Y LI`i P 9 11. Health Care 4.❑ We are a non- rofit or anization,staffed b volunteers, ❑ P Y g with no employees. [No workers' comp.insurance req.] 12.❑ Other *Any applicant that checks box#1 must also fill out the secrion below showing their workers'compensation policy iuformation. '*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 em,ployer that is providing workers'compensation insurance for my entployees. Below is the policy information. Insurance Company Name: N ��L�14 �/`�'l�(x ( �l' Insurer's Address: C' Vf�rk � 7 � �� City/State/Zip: �✓� � �/�/ � " �� Policy#or Self-ins.Lic.# L. �" �'�`�- U� j Z �l��` � Expiration Date: �� .� Attach a copy of the workers' compensation policy declaration page(showing the policy number and ezp ration 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 v 'fication. I do hereby certify,under the ins an en es erjury that the informr�ti.on provided above is#rue and correct. F � � : � r.,. f. "' �.,,..�.�`y,....� Si ature: � Date: � / � Phone#: 7� � �� "��l Official use on[y. Do not write in this area,to be completed by city or town officiaL City or Town: PermitlLicense# Issuing Authority(circle one): 1.Board of Heaith 2.Building Department 3.City/Town Clerk 4.Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone#: www.mass.gov/dia r �-- - - _ .. _ __--- -.____ _..._._.._... _ _..._ _ -- - - ---- - __ __ _. .. _-- _ __ _ __ _ _ _ . __ __ ____ ; DATE(MMIDDfYYYY) A'c�� CERTIFICATE OF LIABILITY INSURANCE �„",i' 11/30/2015 ' THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERT(FICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFPORDED BY THE POLICIES ; BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BE7WEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT_ If the certificate holder is an ADDlTIONAL INSURED,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 does not confer rights to fhe ' certiFicate holder in lieu of such endorsement(s). PRODUCER CO AC ' NAME Lockton Affinity, LLC i Lockton Affinity, LLC aCNNo�ct;866-836-3373 aAc No:913-652-7599 EMAIL I P.O. •Box 879610 ADDRESS: ZCansas City, MO 64187-9610 INSURERSAFFORDINGCOVERAGE NAIC# � INSURER A:xova caauai co 42552 I j INSURED � 1NSURERB: ' Yarmouth Moase Lodge #2270 � � � INSURERC: ' � P.O. Box 186 �NSURERD: � . S. Yarmouth, MA 02664 INSURERE: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: I 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 CANDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS i 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. I I INSR NpE OF INSURANCE A POLICY EFF POLICYEXP UMITS � ( L7R 5 WVD POLICYNUMBER MMIDDiYYY MMIDD/YYYY . i COMMERCIAL GENERAL LIABIUTY EACH OCCURRENCE S ,� CLAIMS-MADE �OCCUR MA N I PREMISES Ea occurrence 5 � � . MED IXP(Any one person) S PFRSONAL&ADV INJURY 5 GEN'LAGGREGATELIMITAPPLIESPER: � GENERALAGGREGATE S POLICY❑PR� '❑LOC PRODUCTS-COMP/OPAGG S JECT OTHER: S I AUTOMOBILELIABILITY COMBINEDSINGLELIMIT 5 I . Ea accident i ANY AUTO BODILY INJURY(Per person) S � . � ALLOWNm SCHEDULED � i AUTO5 AUTOS BODILY INJURY(Per accident) 5 NON-ONMED PROPERTY DAMAGE HIRED AUTOS AUTOS er accident S i S ' UMBRELLA LIAB ppCUR EACH OCCURRENCE S . EXCESS LIAB - CLAIMS-MADE AGGREGATE S , DED RETENTION S S I A WORKERSCOMPENSATION LFR—WK—OOI2469-1 12/15/2015 12/15/2016 g P��E ERH AND EMPLOYERS'LIABILITY y�N ANYPROPRIEfOR/PARTNER/EXECUTIVE ❑N�A E.L.EACHACGDENT 5100,000 OFFlCERIMEMBER EXCLUDED? (Mandatory in NH) EL.DISEASE-EA EMPLOYE 5 100,000 It yes,describe under DESCRIPTIONOFOPERATIONSbelow E.L�ISEASE-POUCYLIMIT 5500 000 . DESCRIPTION OF OPERATIONS!LOCATIONS!VEHlCLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION Proo£ of Coverage SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZm PRESENTATIVE 1988-2014 A ORD ORPORATION. Ail rights reserved. ACORD 25{2014/01) The ACORD name and logo are reg(stered arks of ACORD 17950966 780345 - -_ _ __. ( N�VA NOVA CASUALTY COMPANY Novacasuauvcornaar�r ASTOCK INSURANCE COMPANY 726 EXCHANGE STREET,SUITE 1020 BUFFALO,NY 14210 1-866-633-6945 WORKERS COMPENSATION & EMPLOYERS LIABILITY INSURANCE POLICY REN�WAL INI'ORMATION PAG� POLICY N0. LFR-WS-0012469-2 RENEWAL OF LFR-WK-0012469-1 ITEM 1. � NAMED INSURED AND MAiLiNG ADDRESS AGENCY AND MAILING ADDRESS 10071 � YARMOUTH MOOSE LODGE #2270 LOCKTON AFI'INITY, LLC. PO BOX 186 P.O. BOX 410679 SOUTH YARMOUTH, MA 02664 . KANSAS CITY, MO 64141-0000 I " i � I OTHER WORKPLACES NOT SHOWN ABOVE: SEE EXTENSION OF TNFOAMATION PA6E � INTERSTATE ID : INTRASTATE ID : INSURED IS : NON PROFIT ORGANSZATION FEIN : I BUREAU/RISK ID: 000242725 COMPANY # : NCCI #' : 19191 ITEM 2. POLICY PERIOD is from 12/15/2016 to 12/15/2017 12:01 AM Standard Time at the Insured's mailing address. i ITEM 3. COVERAGE i A. workers Compensation Insurance: Part One of the policy applies to the Workers I Compensation Law of the states listed here: MASSACHUSETTS 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 $ 100,000 each accident I Bodily Injury by Disease $ 100,000 each employee . Bodily Injury by Disease $ 50@,000 policy limit C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: ALL STATES EXtEPT ND, OH, WA, WY AND STATES DESIGNATED IN ITEM 3A OF THE INFORMATION PAGE D. ThiS policy includes these endorsements and schedules: SEE EXTENSION OF INFORMATION PAGE � ITEM 4. PREMIUM ' The premium for this policy will be determined by our manual of Rules, Classifications, Rates and Rating Plans. All information below is subject to verification and change by audit. C L A 5 S I F I C A T I 0 N 5 SEE EXTENSION OF INFORMATION PAGE TOTAL ANNUAL ESTIMATED MINIMUM PREMIUM DEPOSIT PREMIUM PREMIUM $212 Collected in MA 900 $900 � , �4 �s"� DEC 2 3 2016 � , � ,_. ,��.�� WC000001A 06-93 Issue Date: 09-15-16 Issuing Office: Windsor, CT Insured �GA��ED