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Home My WebLink AboutApplication and WC, , � �J�`�PQ--�j`�—e�� TOWN OF YARMOUTIi BOARD OF HEALTH r�4� �'�• �"� APPLICATION FOR LICENSEIPERMIT-2017 S. i`�t1tNY1��'`'t�2� •Plesse complete form and attach all nece�sar�+documents by��`��. c�-�� Failure to do so will result in the return of your appliratton pac cet. ESTABLISHMENT NAME: LS �. � i LOCATtON ADDRESs:,,��s� DC-D �►�4��u Sr2£�r TEL.#: S� — �Rv-y�3� MAILdN(3 ADDRESS: �� • '� E-MAIL ADDRESS: OWNER NAiv�: U � �_t.c�P _ --�M Q_ _ 5 C.. CORPORATION NAME(IF APPLTCABLE): �— MANAGER'S NAME: TEL.#: MAILWG ADDRESS: m o � � D —na IT1 I POOL CER'T�ICATIONS: � �� (7 ; The pooi aupervisor must be certiffed as a Pool Operntor,as reqaired by State I�w. Please list the designated 2 � �i7 Poot Operator(s)at�d attach a copy of the certification w this form. rp N � i. 2. � � t71 v Pool operators must list a tninimum of two employces curnntly certified in standard First Aid and Communi Cardiopulmonary Resuscitarion(CPR),having one certified employee on premises at all times. Please list th �/ employees below and st#ach copies of thcir c.erq�cations tc>thls foem.The As�tth Depxrtment w�tl not use past �\ yeara'recards. Yon m�st provide ne�r copk�and m�iataiu s Cile at yoar place of basiaas. � 1. 2. 3. 4. ; I FOOD PROTECTION MANAGERS-CERTIFICATIONS: ' All food service establishments are required to have at least one full-time employee who is certified as s Food,,.---- ' Protection M�nagcs,as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. ' Please attach copies of certification to this�pplic�tion. The Health Department wfII not use past yeaia'rceords. : ! You must provide new copies and maintain a file at yoar estabtishmen� ' � l. 2. � �::s=. PERSON IN CHARGE: Each food estabiishment must have st ksst ait Person In Charge(PIC)on site during hours of operation. ` __ 1. 2. ALLER(3EN CERTIFICATIONS: Q All food service estab2ishments are required w have st least one fui!-tisne employee who has Allergen cert�cation, � �s defined in the State Sanitary Code for Food Strvice F.stablishments,105 CMR 590.009{C�}(3xa). Please attach � copies of certification to this mpplication. 'The H�tth Dep�rtment will not uas paat years'reeords. Yoa�nat N provide new copies and maintain a file at your establia�mest � 1. 2. HEIMLICH CBRTIFICATIONS: � All food service establishments with 25 seats or more must have at least one employee trained in the 1Keimlich � Msneuver oa th�premises at a!!limcs. �tease list your emmployees tisined in anti-chok�ag�xooedtue.s betow and attach oopies of emp�loyee ceitifications to this form. T6e Hesit6 Department will not use past years'records. You must provFde new copies and mnintain x file at yoar place of bnsineas. 1• 2. 3. 4, RESTAURANT SEATIN(3: TOTAL# OFFICE iJSE ONLY L(?DGIIVG: LICENSE REQUIRED FEE PERMiT ff LICENSE REQUIRED FEE PERMIT k LtCENSE REQUIRED FEE PERMIT# �8 SSS CABIN S35 MOTEL 5110 —1NN SS CAMP SSS _3WIMMlNG POOL S1l0ea. �.OD(iE �SS TRAH,ERPARK 5103 _WHIRLPOOL SilOea F'OOD SERV[CE: LFCENSE REp'(('g�(�p FEE PERMIT tF LICENSE REQIJIRED EEE PERMIT 8 L[CENSERREOpp UIRED FEE PERMI�� O�IOOSE�ATS SY00 _C��IMONrViC Sf60 NOOLES [E S 0 RETAIL SERV(CE: —1tFSID•KTfCHEN f80 LICENSE REQUQtED FEE PERM[T# LICENSE REQUIRED FEE PERMIT# L[CENSE REQUIRED FEE PERMiT d <SOsq R. SSO >2S� R S2&S VENDING-FOO' �QS,OOOsq.ft. Si30 _FRbZEN�ESSERT S40 =TOBAG'CO SltO — NAME CHANGE: S I S AMOUNT DUE $�, OO •rr*rpLEASE TURN OVER AND COMPLETE OTHER SIDE OF FOItM**�"• _ , ADMINISTRATION Under Chapter 152,Section 25C,Subs�tion 6,the Town of Yarmouth is now rtquired to hold issuance or rcaewal 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 COMPEN5ATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR CBRT.OT INSURANCE ATTACHED " OR WORKER'S COMP.AFFIDAVTI'SIGNED AND ATTACI�D Town of Yarmouth taxes and liens must be paid priar to renewal or issuance of your permits. PLEASE CHECK APPROPRIAT'ELY IF PAID: YES� NO MOTELS AND OTHER LODGING ESTABLISIiMENTS TRA.NSIENT OCCUPANCY: For purposes of the limitarions 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. Ta�ansient occ�panis snust have smd bt ablc to'demoustrat� that they maintain a priacipal place af re�ckxtce elsewhete.Transiertt oc�c��ncy shatl gemrally refer to continucrus occupancy of not mor�tFian thirty(30)days,az� an aggregate of not mote than ninety(90)days within any six(6)month period. Use of a guest unit as a residencx or dwelling unit shall not be considered tcansient. 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 Tr�nsient. POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Deparnneni rior to opening. Contact the Health Department to achedale the inspection thr�(3) ciays prior to opeaing.P EASE NOTE:P�ple�re NOT allowecl to sit in the pool area until the pooi has been inspected and opentd. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate couni by a State certified l�b,�nd submitted to the Health Department thr�(3)days prior to opening,�and quarterly thereafter. POOL CLOSING:Every outdoor in ground swimming pooi must be drained or covered within seven(7)days of closing. FOOD SERVICE SEASONAL FOOD SERVICE OPENING: Atl food service establishments must be inspected by the Health Department prior to opening. Please cont�t the Health Department to schedule the inspection�(3)days prior to opemng. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the requued Temporary Food Service Application fonn 72 hours prior to the catered event. These forms can be obtamed at the Health Department,or from the Town's website at www.yarmouth.ma.us under Health Department, Dovmloadabte Forms. FROZEN DESSF�tTS: Froun desscrts must be tested by a Statc certified lab}xi'ior to opening and montlily thcreafter,with sample results submitted to the Health Department. Failure to do so wtll result in the suspension or revocation of yo�r 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 Board of Health. j OUTDOOR COOKING: i 4utdoor cooking,preparation,or display of any food product by a retait or food service establislunent is prnhiblrted. t NOTICE:Permits run annually from lanuary 1 to December 31. IT IS YOUR RESPONSIBILITY TO RE'NRN , 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 ` ; EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR � TO COIvIIvIENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. : DATE: SIGNATURE: � �a1a,Q�`n.�,��n�Yl6l/(__. __ ; PRINT NAME&TITLE: �I o�52. S�s3Q'�,(\ }}a,1�N�►bi/1 ' �.iaivi6 Z�Fd� I?.11�.$t � The Commonwealth of Massachusetts Department of Industrial Accldents �� OJ,�ice of Invest�gations 1 Cangress Stree�Suite 100 �_ Boston,MA 02114-2017 (�� www»ias�gov/dia /�, Workers' Compensation Insurance Affdavit: General Businesses A licant Informatian Please Print Le 'bl Business/Organization Name:�`�. ��V��`�t j[_s�� v;2� Address: c�0 S �L,-0 YY��}-� Il� S`�. City/State/Zip: �-��N M� Phone#: �B-`3�t �-�'�-� Are yoo an employer?Check the appropriate boa: Busin�ss Type(required): 1.❑ I am a rmployer with employees(fi�l and/ 5. ❑Retail or part-time).* 6. ❑Restaurantl'Bar/Eating Establishment 2.❑ I am a sote proprietor or partnership and have no �, �O ce andlor Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No wortcers' comp.insurance required] g• on-profit 3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment their right of exemption per c. 152,§1(4�and we have 10.�Manufacturing no employees.[No workers'comp.insurance reyuireciJ* t 1.Q Health Care 4. We are a non-profit arganization,staPfed by volunteers, with�eraployees. [Aio workers' comp.insurance req.j 12.[�Other `�Y sPPlic�t ti�at chedcs box#1 must a3so fill out the eaxion below�win�g their wor{cecs'oomPensatian PolicY infotmatia►. ••If the corpoiste offioers have exeanpted thernselves,but the oarporation Las otha e�loyas,a vvorkais'�rt�pensa�ion policy is t+equired md auch an org�ation should c3►ed�box#I. I am an emp[oyer that�s provtdin workers'compensa�tion lnaurance jor my employet� Below!s the polfcy fnfornratio�r. Insurancc Company Name: ��1�1� TI�IS UIIQ�..Ut(� �"n> > Insurer's Address: City/State/Zip: Policy�or Self-ins.Lic.# Expiration Date: Attach a copy of the workers'compensation poHcy declaration page(showing the policy nnmber and ezpietittion date). Pailure 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 SI,500.00 andl�ar�-year imprisostmec�t,�s well as civil penaities in tt�form of a STOP WORI�ORDER and a fine of up to 5250.00 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 kereby cernfy,under the pains and penalties of perlury that t�ie�refarneatlon provided abovr i's true and corred � v�� „��..:...--� �c,_,.,,��.--,�--�. � Date• (c7(2$ � I I� ��i..o�#• �$�3°�� —�E a-�-�, Ofj`Jefal use anly. Do not wr�te�n th�s area,to be completed by eity or town ofJ�e� City or Town: Permit/License# Issaing Aathority(circle onej: 1.Board of H�lth 2.Buitding Department 3.City/Town Clerk 4.Licensing Bos�rd 5.Selectmen's Office 6.Other Contact Person• Phoae#• i W1YW.111ffiS.$OV�AIS � � , y AC�J/w.�� DATE(MMIDDIYYYI� CERTIFICATE OF LIABILITY IN�URANCE ��ober 13, Zo 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 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 the certificate holder in lieu of such endorsement(s). A RODUCER �une: Trace Parent The Church Insurance�qency Corp HONE F� 19 East 34"'Street ac,No,e�: 800 293-3525 ac,r�o: S00 557-1395 New York,NY 10016 -Ma� DRESS: RODUCER USTOMER ID#: INSURER S AFFORDING COVERAGE NAIC M NSURED NSUReR A: Libe Insurance Cor Diocese of Massachusetts NSURER B: 75 S 138 Tremont St Nsu�c: Boston,MA02111-1318 NSURER 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 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. TYPE OF INSURANCE INSR WVD POLICY NUMBER MMIDLIpCY EFF MPMOpIpCY EXP LIMITS GENE��TY CH OCCURRENCE � AMAGETO RENTED �OMMERCIAL GENERAL REMISES Eaoccurrence CLAIMS-MADE OCCUR ED EXP M one erson ERSONAL 8 ADV INJURY ENERALAGGREGATE EN'L AGGREGATE LIMIT APPLIES PER: RODUCTS-COMP/OP AGG LICY PRO-CT LOC ABILITY MBINED SINGLE LIMIT Ea accident) Y AUTO DILY INJURY(Per person) L OWNED AUTOS ODILY INJURY(Per accident) CHEDULED AUTOS ROPERTY DAMAGE IRED AUTOS ON-OWNED AUTOS MBRELLA LIAB OCCUR CH OCCURRENCE XCESS LIAB C��MqpE GGREGATE EDUCTIBLE ETENTION $ RKERS COMPENSATION WC STATU- OTH- /� D EMPLOYERS'LIABILITY Y/N Y X WC7625900009016113 9/30/2016 9/30/2017 TORY LIMITS E ' NOPRIETOR/PARTNER/EXE .L.EACHACCIDENT 'I OOOOOO BT��E rrirFa�n�Gn�Rca Fvri i�nGn� .L.DISEASE-EA EMPLOYEE �,OOO,OOO Mandatory in NH) f vue rlcerrihn i inrinr � ESCRIPTION OF OPERATIONS below .L.DISEASE-POLICY LIMIT $�,OOO,OOO ESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,'rf more space is required) CERTIFICATE HOLDER CANCELLATION St Davids Episcopal Church SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 205 Old Main St THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN South Yarmouth,MA 02664-4529 ACCORDANCE WITH THE POLICY PROVISIONS. ��