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Home My WebLink AboutApplication and WC W��r T�s-r � ... ��,Pi 4,.�GVrB � � TOWN OF YARMOUTH BOARD OF HEALTH � � APPLICATION FOR LICENS�/�E I�- 0,�7 �: �.�� :, � ,,,� - �`°� * Please complete form and attach all nece�s�i�'�nl,i(e°rrif�fs� ��c mber 16 2016. Y , ' Failure to do so will result in the r�t�'rn ofyo�r�1,�� ack�q�TH �EPT ESTABLISHMENT NAME: :�►4 s (,t�c� "�"�..�#- TAX ID: a`� "�� c;.�� ' LOCATION ADDRESS: �d � lC y C: �' °u` � L.#: ; MAILING ADDRESS: ��t k� �r '�a-- i E-MAIL ADDRESS: � ' OWNER NAME: � • - 1",�cti� ! CORPORATION NAM (IF APPLICABLE): ' MANAGER'S NAME: ��,�, �,� TEL.#: �g- 3 6 a-�3 5 � MAILING ADDRESS: . (�� l,t�n4�C,cc,,�� , U,�►,A„,,� Q�d'/�j�- Gd-� � S" 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. ,,� - ' _�-�,r� E---��-�-, �-- �,.- _�,�,�-� �=` ,�r, _ 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. � r r 1. J�t'� S2��r,r.t, S 2. `�"�rl�i.�{'(.�.�t c��Yu r)�,d � _ 3._z{� �� ; �'o,�..� � 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. 1. 2. . PERSON 1N CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. �. , _ .�. _ 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. 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 copies and maintain a file at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# _ _�FF� , F nN �_—_ __ -- - ----- �—�)(�1N(:�: __ _ LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $110 _INN $55 CAMP $55 =SWIMMING POOL$I l0ea.-��(?�� _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 _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,OOOsq.ft. $150 _FROZENDESSERT $40 TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE _ $ IIO.00 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** (o� �o�+SP-lS-l2-`i 2-02 i 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 V OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid priar 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 priar 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 priar 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.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 EMENT. RENOVATIONS MAY REQUT A SITE P N. DATE: SIGNATURE: PRINT NAME & TITLE: (� L U l � Rev. 10/12/16 ' - • � The Commonwealrh of Massachusetts Department of Industrial Accidents Office of Investigations ` y 1 Congress Street, Suite I00 .8oston, MA 02114-2017 � � www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legiblv � �' Business/Organization Name: � J Address: � GU � l�A °a �' City/Sta.te/Zip: Y Phone #: �5'0�3jo� `�t�� Are you an employer? Check the appropriate box: Business Type(required): � I am a employer with employees(full and/ 5. ❑ Retail or part-time).* 6. ❑ RestaurantlBar/Eating Establishment �r�ZCili•• ••••' LV 1N1 11• 11 ��+-��1-- '. _. _ _ - � _ - "'�-�rIvga�� ar�r"'s r�-�n�'�a 7. Office and/or Sales(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. ❑ 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.] 12�ther *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. **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 employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: G�r �!'7 � - �.c �a� Insurer s Address: � L 9 18 � City/State/Zip: � 1� v Policy#or Self-ins.Lic.# L.I�C;.S"�c3�� -�a�� a� Expiration Date: " ��` Attach a copy of the workers' compensation policy declaration page(showing the policy number and egpiration date . Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a �ine up�o b ,I�6�5�anc�tor one=ye�r im�risanri�e�t�a5 w�ti a�crvil�E�i�ies-iz tl�e fonn�f a�T@P�t?Rii��1��R an�a fin� 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 of perjury that the information provided above is true and correct. SiQnature• Date: _ Phone#: Official use only. Do not write in this area,to be cornpleted 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 ,i Contact Person: Phone#: www.mass.gov/dia ��1 KINGWAY-04 CNORMANT ACOROa CERTIFICATE OF LIABILITY INSURANCE °`'TEc""""'°°"'�'r'' � 11/16/2016 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 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 cert�cate does not confer rights to the ceRificate holder in lieu of such endorsement(s). aRouuceR License#1780862 coNrncr NAME: HUB International New England P,vHO N E :(978)657-5100 �N,;(978)988-0038 299 Ballardvale Street Wilmington,MA 01887 A DARESS: INSURE S AFFORDING COVERAGE NAIC A iNsuReR n:Philadelphia lndemnity Insurance Compan 18058 INSURED iNsur�R s:Federal Insurance Company 20281 Kings Way Condominium Trust INSURER C: 64 Kings Circuit ATTN Communky Mngr iNsuaeR u: 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 TypE OF INSURANCE LI Y EFF P LI Y EX LIMITS LTR POLICY NUMBER MM/DDIriYY MM/DDIYYYY A X COMMERCIAL GENERAL LIABILITY �� EACH OCCURRENCE $ �,OOO,OO CWMS-MADE a occuR X HPK1455643 02N8/2016 02118/2017 pREMISES Eaoccurrence S 100,000 MED EXP(My one person) $ 5,�� PERSONAL&ADV INJURY $ 'I,OOO,OO GEN'L AGGREGATE LIMIT APPLIES PER GENERAI AGGREGATE $ 2,000,00 POLICY❑�E o- �LOC PRODUCTS-COMP/OP AGG $ Z,OOO,OO OTHER: $ � AUTOMOBILE LIABILITY � � � COMBINED SINGLE LIMIT $ � � � Ea accident ANY AUTO BODILY INJURY(Per p�son) $ ALLOWNED SCHEDULED BODILYINJURY(Peraccident) $ AUTOS AUTOS NON-0WNED PROPERTY DAMAGE � HIRED AUTOS AUTOS Per acadent $ $ UMBRELLA LIAB X p�CUR EACH OCCURRENCE Z ZS,OOO,OO : B � EXCESSLIAB CLAIMS-MADE 993977273009 02N8/2016 02/18/2017 qGGREGATE $ 25��0 � DED ��X� RE7EP/iION$ � 0 � . � $� � � � . . WORKERS COMPENSATION PE OT ANDEMPLOYERS'LIABILITY Y�N STATUTE ER ANY PROPRIETORlPARTNEWEXECUTIVE E.L EACH ACGDENT $ OPFICERIMEMBER EXCLUDED? � N�A (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ Ifyes describe under DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT S A ommercial Property PHPK1455643 02118/2016 02118/2017 Blanket Bldgs 71,018,4 B rime(;10,000 ded) 2357090 02/18/2016 02/18/2077 Employee Dishonesty 4,000,00 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schadule,mey be attached if mora apaca is requfred) 456 residentlal condo units located on vrs streets,Yarmouthport MA.The Dartmouth Group Is tncluded as aninsured on the Employee Dishonesty AKA Crime coverage. The foliowing are included on this program:SpecfalForm;Replacement Cost;Agreed Amount;Equipment Breakdown;Colnsurance waived; Ordinance/Law A full Iimit,6&C$2M combined; Earthquake a45M with 2%deductible;Wind 8�Hail deductible 1°�(minimum$25K)per bidg.Per the condo docs,the master policy covers the entire building-original specifications oniy-excluding unit improvements(this would be considered all in,original specs,excluding unit improvements).Policy deductibles are a25,000 plus 525,000 per unit for water&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 �!�'�� O 1988-2014 ACORD CORPORATION. Ail rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD A�oRo� CERTIFICATE OF LIABILITY INSURANCE DA��,��0,��) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVEtY OR NEGATIVELY AME1dD, 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 WANED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certi£cate does not confer rights to the certificate holder in Ileu of such endorsement s. PRODUCER NAME: Cheryl Woodside HUB INTERNATIONAL NEW ENGLAND LLC PH�E • (781 792-3238 a N,: E�A�� che I woodside hubinternational.com ADDRESS: �Y• 600 LONGWATER DRIVE INSURERS AFFORDINGCOVERAGE NAIC# NORWELL MA 02061 iNsuaeRa: TRAVELERS INDEMNITY CO OF AMERICA 25666 INSURED INSURER B: KINGS WAY CONDOMINIUM TRUST INSURERC: KINGS WAY CONDOMINIUM TRUST INSURERD: C O PROPERTY MANAGEMENT AT 64 KINGS CIRCUIT INSURER E: YARMOUTH PORT MA 02675 INSURER F: COVERAGES CERTIFICATE NUMBER: 104633 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. �LTR TYPE OF INSURANCE ADDL UBR pOLICY NUMBER MMIDD EFF MPOLICY EXP � LIMITS COMMERCWLGENERALLIABILITY EACHOCCURRENCE $ AMA ET CLAIMS-MADE �OCCUR PREMISES Ea occurrence S MED EXP(An one person) $ N/A PERSONAL 8 ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY❑�E�7 �LOC PRODUCTS-COMP/OP AGG $ OTHER: a AUTOMOBILE LIABILITY Ea accident N LI I $ 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 acadent $ UMBRELLA LiA6 p�CUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION $ WORKERS COMPENSATION X STATUTE ER AND EMPLOYERS'LIABILITY ANWROPRIETOR/PARTNER/EXECUTIVE Y�N E.L.EACH ACCIDENT $ SOO,OOO /� OFFICER/MEMBEREXCLUDED7 PUA PUA N�A 6HU60175N6981.6 �Z26�2��6 Dy26�20�7 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ SOO,OOO If yes,desaibe under DESCRIPTION OF OPERATIONS below E.L.OISEASE-POLICY LIMIT $ SOO,OOO N/A DESCRIPTION OF OPERATIONS/LOCATION3/VEHICLES(ACORD 101,Addklonal Remarks ScF�edule,may be attached'rf more apace is roquired) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 O6 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 certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The 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/investigations/. 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 PROVISIONS. Health Department 1146 Route 28 AUTHORIZEDREPRESENTATIVE `1,�.Q C a� South Yarmouth MA 02664 Daniel M.Cr 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