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Home My WebLink AboutApplication and WC� _ , � � � TOWN OF YARMOUTH BOARD OF HEALTH '� `"' � � APPLICATION FOR LICENS�� '� "��' ,, � �� : �`� �:f Q ``°� * Please complete form and attach all necess� a+cuments��?. � er 16 2016. -� Failure to do so will result in the rett�of��ur app�c��otrpa ket.H�A�TH ��T � ESTABLISHMENT NAME: � �u S� TAX ID: �`l� � t�3$ LOCATION ADDRESS: (o ;v► ' '' e l,t,; � ,�, � TEL.#: So�-3�, - S 3 S MAILING ADDRESS: � Y r/ ��i s C;-`u;�-.�vvtor�� P,�� /I?� c��6 7.�" E-MAIL ADDRESS: OWNER NAME: �: - k� � CORPORATION NAME (I APPLICABLE): MANAGER'S NAME: ,� /�ti�� jl TEL.#: �'�� - 3 c .z;- �� -� � MAILINGADDRESS: L� k,;2�,s C';rcu-„`Y— ; �H.� �, �a� � �/�- �'ad 7 5 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. �'� - L � � _�� S _ _ - - _ 2. �4��E-�.:� � s��. ��.� :� _. Pool operators must list a minimum of two employees currently certified in standard First Aid and Community dio ul n PR h vin ne c rtified em lo ee on remises at all times. Please list the Car p mo ary Resuscitation (C ), a g o e p y p 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. �� l�vt- 2. �T� h a,�-L�.c�,� �i rv,.Q�n,, �_� � 3. 4. i ; FOOD PROTECTION MANAGERS - CERTIFICATIONS: j 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. � I l. 2. , PERSON 1N CHARGE: Each food establishment must have at least one Person In Charge (PIC) an 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. l. 2. � HEIMLICH CERTIFICATIONS: i 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 fortn. The Health Department will not use past years' records. You must provide new copies and maintain a �le at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: _ . ._ .. , . � . . , — i..i ii i::.�.L', i�i� i�C.' L;ntvtl: � ll,�i 1 �ll t'h 1� 7f - B&B $55 CABIN $55 MOTEL $110 INN $55 CAMP $55 �SWIMMING POOL$1 l0ea.,�1� d3S _LODGE $55 _TRAILERPARK $105 _WHIRLPOOL $110ea. � FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# 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 _ $ 220�DO **x**PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***�o� pjp�5'P.-(��{2Q 3"��- (91 �6�P"lS^12�t�-d2 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 NO MOTELS AND OTHER LODGING F.STABLISHMENTS 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 dweiling 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. �QOD SERYIeE 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.yarmouth.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 EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMEN EM NT. RENOVATIONS MAY REQUI SITE P, N. DATE: SIGNATURE: � PR1NT NAME & TITLE: �� LL, Rev. 10/12/16 ' � . � The Commonwealth ofMassachusetts � Department of Industrial Accidents Office of Ini�estigations � y 1 Congress Street, Suite I00 Boston, NfA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legiblv Business/Organization Name: . . , Address: City/State/Zip: 1')'J Phone#: � c�10 �' J� Are you an employer? Check the appropriate box: Business Type(required): 1� I am a employer with employees(full andl 5. ❑ Retail or part-time).* 6. ❑ RestaurantBax/Eating Establishment -�_� I a�a s.. .., ' . r ershi a��a�e no — _ - — - - - "��"'lgri��'°Q• c'�� 7, � ��"fice ana/or3aIes�incl.reai esta e, auto, efc.) 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. ❑ Entertainment their right of exemption per c. 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.] 1 Z�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 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: �� I Policy#or Self-ins. Lic.#��"�ls—�� 10��''�(J�(�D Expiration Date "� � Attach a copy of the workers' compensation policy declaration page(showing the policy number an eapiration ate). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ___ fi�up_to 1 00.00 and/or one-year i�risonmentLas 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 rnay be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify,under the pains and penalties of perjury that the information provided above is true and correct. Si ature: Date: Phone#: 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 Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone#• wwwmass.gov/dia �� KINGWAY-04 CNORMANT ACOROR DATE(MM/DD/YYYY) `,� CERTIFICATE OF LIABILITY INSURANCE 17N6/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR 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 certifcate 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 dces not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER License#1780862 NAMEA T HUB International New England PHONE 978 657-5100 F� 299 Ballardvale Street a No EM:� ) �vc No:(978)988-0038 Wilmington,MA 01887 A DR�ESS: INSURER(S AFFORDING COVERAGE NAIC# �NsuReRa:Philadelphia lndemnity Insurance Compan 18058 INSURED iNsuReR e:Federal Insurance Compan 20281 Kings Way Condominium Trust INSURER C: 64 Kings Circuit ATTN Communky Mngr INSURER D: Yarmouth Port,MA 02675 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 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. INSR 7ypE OF INSURANCE POLICY NUMBER MM%DD� MM/DD/YYYY LIMITS LTR A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ ��OOO�OO CLAIMS-MADE o oCCUR X PHPK1455643 02/18/2016 02118/2017 pREMISES Ea occurrence S 100,00 MED EXP(My one person) $ 5,�0 PERSONAL 8 ADV INJURY $ ��OOO,OO GEN'LAGGREGATELIMITAPPLIESPER GENERALAGGREGATE $ Y�OOO,OO POLICY� Ra �LOC PRODUCTS-COMP/OP AGG $ 2,000,00 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANYAUTO BODILYINJURY(Perperson) $ ALLOWNED SCHEDULED BODILYINJURY(Peraccident) $ HIR DSAUTOS NON-0WNED PROPERTY DAMAGE $ AUTOS Per accident $ UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ ZS,OOO,OO B EXCESS LIAB CLAIMS-MADE 993977273009 02/18/2016 02/18/2017 AGGREGATE $ 2$,��,�0 DED X RETENTION$ � $ WORKERS COMPENSATION H' AND EMPLOYERS'LIABILITY Y�N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE � N I A E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? � (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.WSEASE-POIJCY LIMIT $ � A ommercial Property PHPK1455643 02N812016 02118/2017 Blanket Bldgs 71,018,46 B .Crime(510,000 ded) 82357090 02/1812016 02118/2017 Employee Dishonesty 4,000,00 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Addiponal Remarks Schadule,may be attached H mo�e apace is requlred) 456 residential condo units located on vrs streets,Yarmouthport MA.The Dartmouth Group is included as aninsured on the Employee Dishonesty AKA Crime coverage. The following are included on this program:SpecialForm;Replacement Cost;Agreed Amount;Equipment Breakdown;Colnsurance waived; Ordinance/Law A full Iimit,6&C 52M combined; Earthquake E45M wlth 2%deductible;Wind&Hail deductible 1%(minimum E25K)per bldg.Per the condo ocs,the master policy covers the enttre buildfng-original speciflcations only-excluding unit improvements(this would be considered all in,original specs,excluding unit improvements).Policy deductibles are 525,000 plus$25,000 per unit for ater&ice damage(per 01-2016 filed resolution,Unit Owners are responsible for the master policy deductibles). CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Yarmouth THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELNERED IN 1146 ROute 28 ACCORDANCE WITH THE POLICY PROVISIONS. South Yarmouth,MA 02664-0000 AUTHORIZED REPRESENTATIVE � � �!�%�I%�� .. /. . O 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD DATE(MMIDD/YYYY) ACORU� CERTIFICATE OF LIABILITY INSURANCE `.,,� ,�i,si2o,s THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subJect to the terms and conditions of the policy,certaln policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). rRoouceR N,,,ME: Cheryl Woodside HUB INTERNATIONAL NEW ENGLAND LLC PHONE �781 79Z-$Z3H ;"�No: E'�� che I.woodside hubinternational.com ADDRESS: 600 LONGWATER DRIVE INSURERS AFFORDINGCOVERAGE NAIC# NORWELL MA 02061 iNsuRean: TRAVELERS INDEMNITY CO OF AMERICA 25666 INSURED � INSURER B: � KINGS WAY CONDOMINIUM TRUST �Nsur�c: KINGS WAY CONDOMINIUM TRUST INSURERD: C O PROPERTY MANAGEMENT AT 64 KINGS CIRCUIT INSURER E: YARMOUTH PORT MA OZG7S INSURER F: COVERAGES CERTIFICATE NUMBER: 104633 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF WSURANCE 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. . INSR TypE OF INSURANCE �DL SUBR pOLICY NUMBER MMWDY EFP MOLI pY EXP LIMRS LTR � COMMERCWLGENERALLIABILITY � EACHOCCURRENCE� � S � � CLAIMS-MADE �OCCUR PREMISES Ea occurrence $ MED EXP(My one person) $ N/A PERSONAL&ADV INJURY 5 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE �. $ POLICY❑jE a �LOC PRODUCTS-COMP/OP AGG S OTHER: a AUTOMOBILELIABILRY COMBINED I LEIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED N�A � BODILY INJURY(Per acadent) $ AUTOS AUTOS NON-0WNED PROPERTY DAMAGE $ . HIRED AUTOS AUTOS Per accident a UMBRELLA LU16 ppCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS-MADE N/A AGGREGATE S . DED RETENTION $ - WORKERS COMPENSATION � STATUTE ER AND EMPLOYERS'LIABII.ITY � ANYPROPRIETOR/PARTNER/EXECUTIYE Y�N E.L.EACHACCIDENT� � $ SOO,OOO A OFFICER/MEMBEREXCLUDED7 N/A run eua 6HU60175N69816 02/26/2016 02/26/2017 (Mandatory in NH) E.L.DISEASE-EA EMPLOYE � SOO,OOO If es,des�xibe under y es xi DESCRIPTION OF OPERATIONS below �� E.L:DISEASE-POLICY LIMIT a 500,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Addklonal Ramarks Sclwdule,may be attached ff more apace is require� Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this cert�cate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). 7he status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/Iwd/workers-compensation/investigationsJ. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Yarmouth ACCORDANCE WITH THE POLICY PROVISION3. Health Department 1146 Route 28 AUTHORI�D REPRESENTATNE South Yarmouth MA 02664 D�e MC� y,CPCU,Vice President—Residual Market—WCRIBMA - O 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD