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' TOWN OF YARMOUTIi BOAItD OF HEALTH �
AP'PLICATION FOR LICENSElP'ERMIT-ZOl?
*Please complete form and attach all necessary documents by De e r 6 �.
Failure to do so will result in the return of your applicaUon p'�
ESTABLISHMENT NAME: �u
LOCATION ADDRESS: ' TEL.#: ' — — �/
MAII..ING ADDRESS: ' o .
B-MAIL ADDRESS: N,
OWNERNAME: ' 6 h u$t
CORPORATION NAME(IF PLICAB E):
MANAGER'S NAIvIE: TEL.#• — _ g�i
MAILING ADDRESS: � G/
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 fonn.
1. � /` O 2. �OSt"�o`! ��'�/
Pool operato must list a minimum of two employces currendy certified in standard First Aid and Community
Cardiopulmonary Resascitation(CPR),having one certified employce on s at ail rimes. Please list the
employees below and attschcopics e�€�eir certi8cagoas to thigfirm:�he H��Be�rtmest�aet:�e paat __ _
yexrs'recorda. Yoa mast provide new copks xnd wlntain a tile nt your place of businas.
1. ��Q� �a �Qr I� �h S 2. J o S e�[�► �i�c��.,
I 3. 4.
i = � �
FOOD PROTECTION MANAGERS-CERTIFICATIONS: D C �
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 appiication. The Health Department will not ase past years'rceorda. �' � �
You muat prnvide new copiea and maintain a ffle at your estsblis6ment. � t� �
� � �
1. 2.
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 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(GX3xa). Please attach �
copies of certification to this application. The Health Degartment will not use past years'recorda. You mnst �w�
provide new copie�and maintain a flle at your establis6men� �
k �
1. 2. .�.
HEIMLICH CERTIFICATIONS: �
All food service estabIishments with 25 seats or more must have at least one employee tiained in the Heunlich �,'�"'
Maneuver on the prcmises at all timcs. Piease list your emmployxs ttained in anti-choking procedures below and
attach.copies of employee certifications to tlris form. The Health Department wili not use paat years'ncorda.
You muet provlde new copies and maintain a file at yoar place of busiaees.
1. 2,
3. 4,
RESTAURANT SEATING: TOTAL�t
i.oncnvc:
OFFICE USE ONLY
LICENSE REQUIRED FEE PERMIT# LICENSE REQUII2ED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
88cB SSS CABIN SSS M07'EL 5110
=SWIMMING POOL S110ea���,
�-�� SSS _�'1'RAIt,ERPARK Ss04 WFQRLPOOL SllOea.
FOOD SERVIC&:
LICENSE UIRED FEE pERht�T p LICENSE REQUIRED FEE PERMIT M LICENSE UIRED FEE PERMIT N
a oos� sioo =co°n�u��o�x�v�c sso —w°►;o�� �o
RETAiL SERV[CE: —RESID.K[TCHEN S80
LICBNSE REQUIRED FEE PERMIT# LICENSB REQUIRED FEE PERMt1'# LICENSE REQUIRED FEE PERMIT N
4S0sq ft. S50 >23,000 ft. 5285 VENDING-FOOD S23
_<25,WOsq.R. SISO =FROZEN�ESSERT S40 ='fOBACCO SI10
NAME CHANGE: sis AMOUNT DUE = S 1 t O,00
*"*'PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM•'•**
Lo� Id��+SP-�t5-2375-02.
,
ADMINISTRATION
Under Chapter 152,Se�ction 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 compatty dces not have a Certificate of Worker's
Compensation Insurance. TAE ATTACHED STATE WORI�R'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR
CERT.OF INSURANCE ATTACHED�
OR
WORKER'S COMP.AFFIDAVIT SIGNED AND ATTACHED X
Town of Yarmouth ta�ces and liens must be paid prior to renewa!or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES�i� _ NO
MOTELS AND OTHER LODGING ESTABLISHMENTS
TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotcl use,Tiansient occugancy shail be
limited to the temporary and short term occupancy,ordinarily and customarily associsted with motel and hotel use.
Transient occupants must have and be able to demo�trate#iat t�ry maintain a prineipal place of residence
elsewhere.Transient occupancy shalt generally refer to continuous occupancy of not mone tlutn thiriy(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 resid�i►ce or '
dwelling unit shall not be considered traasient. 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 generaily be considered Transient.
POOLS
POOL OPEIVING:All swimming,wading and whirlpools wlrich have bee�►closed for the season must be inspectecl
by the Health Departmentpnor to openu�g. Contact the Health ep ent to schedale the inspect�on tLree(3)
days prior to opening.PLEA^�E NOTE:People are NOT allowDed to s t in the pool area until tlie pool has been
inspected and openod.
POOL WATER TE3TING: The water must be tested for pseudomonas,total coliform and standard plate count
by a State certified lab,and submitted to the Health Department ttue�e(3)days prior to opening,and quarterly
thereafter.
POOL CLOSING:Every outdoor in ground swimming pool must be drained or cover�i 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 opeivng. ,
CATERING POLICY:
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Heatth Department by filing the
required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be
obta�ned at the Health Department,or from the Town's website st www.yarmouth.ma.�s under Health Deparhnent, :
Downloadable Forms.
FROZEN DESSERTS:
Frozen desserts mast be tested by a State certified lab prior to opeuing and monthly thereaft,er,with s�ple resutts
submitted to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen ,
Dessert Permit until the above termns have been met.
OUTSIDE CAF�S:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior appmval from the Board af Heaith.
� OUTDOOR COOKING:
i OuWoor 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 RENER/AL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 16,2016. �
i
� ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PATrTfING, NEW '
� EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR (
TO COMIvv1EN ME . RENOVA'i'IONS MAY RE UIRE A STfE�AN.
DATE: � �� �U SIGNATURE:
PRIlVT NAME 8c TITLE: c�/" C� k (- ;
Rev.10/IJl16 '
i j
� The Cominonwealth ofMassachuset�s
Department ofLedustrdal Accldents
OJ�ce oflnvestlganons
1 Car�gress Street,Suite 100
Boston,MA 02114-2017
www.mass gov/dia
Workers' Compensation Insurance Af6davit: General Businesses ;
Analicant Information Please Print Leeiblv
Business/Organization Name:��SS �� v�'�` ���P�'L�"6Cc.� 7o�1n G���se s
aaare�: ]3 �7� � r,'��� S'f"
City/State/Zip: � la�`i�'!ou�'Li,l�� OZG`Phfone#: S� t� - 73 7— y���
Are you an employer?CLeck t6e appropriate boz: Bnsiness Type(reqnirai):
1.� I am a employer with � employees(full and/ 5. ❑Retail
�
or part-dme).* 6. ❑RestaurantrBar/Eating Establishment
2.❑ I am a sole proprietor or pardiership and have no �, �pffice ana/or Sales(incl.real estate,suto,etc.)
employees working for me in any capacity.
[No workers'comp.insurance required) 8. ❑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 employee.c.[No workers'comp.insurance required]*
4.❑ We are a non-profit organization,staffed by volunteers, 11.Q Health Care
. � �
with no employees. [No workers'comp.insurance req.] 12.(�Other �rr�o�'r�k� u� �o 0
`AnY epplicant d�chcdcs box#i must also fill out the sedian below showing their workus'c�ompensation policy information.
'•If the corporate officers have exempted themselves,but the corporation has otl�r employees,a wockers'compensation policy is required and such an
organizetion should check box#1.
I am an employer that is providing workers'co�nsatiore inskrance for my en�ployee� Below is the pot�cy�nforr�ttkm.
ee A
Insurance Company Name: 1 t �/ � �f,c T Uc. �__L_f?Cu dQ k C(' � '
Insurer's Addtess: J l !f? i�� /Z r/
City/State/Zip: �uf �%n �o/l � �f g�J� —�'�7d
Policy#or Self-ins.Lic.# �l��� l V b 7 0� �1 0°?'Z Exp'�'on Date: � �� �7
Attnch a copy of the workers'compesastion policy declaration pAge(showing the policy nnmber and zQir�tion date).
Failure to secur�coverage,as required under Section 25A of MGL a 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 13�e form of a STOP WORK ORDER and a fint
of up to$250.OQ 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 cert� ,under the and pena,lties oJperJury that the lnjorniatlon provided above is true a�ed correc�
i
� R D l0 O /
P �• � 7 7 - ��D�
O,/,�3cia1 use only. Do not write�x this area,m be completed by c�ty or town officiaL
City or Town: PermitlLicenae#
Iseaing Anthority(circk one):
1.Board of Healt6 2.Bnilding Department 3.City/Town Clerk 4.Licensing Board 5.Setectmen's Office
6.Other
Contnct Person: Phone#:
www.mass.gov/dia
_ � .
.
WORKE�tS COMPENSATION ANQ EMPL�YERS LIABILITY 1NSURANCE POLICY
INFORMATION PAGE
A.I.M. Mutuat tnsurance Campany
54 Third Avenue, Bur{ington, Wlassachusetts 01803-0970
(8U0}876-2765 NCCI NO 26158
P�LICY NO. AWC-400-7029102-2016A
Pi�tO(�NO. AWC-400-7029102-2015A
� ITEM
i. The insured: �ass River WaterfrontTownhouses
DBA:
. Mailing address: 1376 Bridge Street-#19 FEl�E:*="**
C/o Peggy I'arsons&Joa Frey
South Yarmouth,MA 02664
Legal Entity Type: Other
Other workplaces not shown above: See Location
2. The policy period is from �6/Ot/2016 to 06101/2017 12:Oi a.m.standard time at the insured's mailing address.
3. A. Workers Compensation insurance: Part One of the pollcy appfies to the Workers Compensation Law of the
states listed here: MA
B. Employers'Liabiiity fnsurance: Part Two of the poilcy applies to wark in esch sfate listed in item 3.A.
The limits of liabiliry undes Part Two a�e: Bodily Injuty by Rccident $ 100,000 each a�cident
Bodily Injury by Disease $ 500,000 paficy limit
Bodily In}ury by Disease $ 100,OQ0 each emp(oyee
C. Other States l�surance: Caverage Replaced by Endarsement WC 20 Q3 06 B
D. "Chis Policy incfudes these Endorsements and Scheduies: SEE SCH�RUlE
4. The premium for this policy will be determined by our Manuals of Rules,Classifications,Rates and Rating Plans.
AI1 infotmation required below{s subject to verification and cE�ange by audit.
Classifications ^�� Premium Basis � Rates
Code Estimated Per$100 Estimated
No. TWa!Annuat Ot Annuaf '
Remur�ration Remuneraiion Premium ,
INTRA 0119515
INTER SE CLASS C�DE SGi-tEDU E
Minimum Premium $2S4 Totat�stimated Annual Premium $514
GOV GOV Deposlt Premium $528
STATE CLASS
MA 90i5 State Assessments/Surcharges �
" � $242.00 X 5.7500°k $14 �
�
- l'hls policy,including aA endorsements,is hereby countersigned by �� �� 0�/10/2p16
Aufharized Signature � Date i
Service Offiae: HUB Internatianal New England LLC
54 Third Avenue 299 BallardvaEe Street
Burlington MA 01803 Wilmington, MA 01887
WC t10 00 01 A(7-11)
includes copyrighted material of the Natioriaf Council on Compensation inaurance,
used with Ite permission.
F -. . �
.
A.I.M. Mu#ua1 lnsurance Company
Insured: 70�91 Q2 �'roducer: 01 Q05-OOi-001
Bass River Wat�rfront Townhouses HUB Internatianal New Engl�xnd LLC
1�78 Bridge Street-#19 299 Ballardvale Str�et
C/o Peggy Parsons&Jae Frey Wiimington, MA 018$7
South Yarmouth, MA 02664 "
insuCed FEW: **-""" lssue Date: 05/f0120'!6
Policy Number: AWC-400-7029102-2p16A �ndorsement�ffective Date: 06101/20'16
Policy!'eriod: 06/01/2016-06/41/2017 Endorsement Number:
ENDORSEMEIVT SCHEDULE
The(or►ns tisted below are included in this policy:
Form No. Form Description Applicable Sfates Palicy Effective Date
PRIVACY Privacy Natice .~. ' ~...T 06I01/2016
POOL-Please lmportant Notice#or Paoi Policies 06/01/2016
AIMIMPT AIM-trrrpar�ant PQiicyholder Nofices 06/01/20�6
AIM-3 AIM Waiver of Subrogation Notice 06I01/20i6
AIM-4 MA Bene�iis Claim and Aggregate Deductibie Program OfiIQi/20i6
AIM-5 AIM Commitment of Service 06/0 1 120 1 6
AIM-61 AIM -Servicing Carrier 46/Oi/2016
Senroni Services Oniine Instructians 06/01/2016
WCRIS WCRlt�Circular Letters Notice MA 06lOi/2016
Location Location Sehedule ti6/Oil2016
Class Code Classification Code Schedule 06/01/2016
installment lnstallment Schedule 06l01/20i6
Rating Summary Rating Summary by State Q6/01/20#6
AtM-1 A Dividend Classification Endorsernent 06/01l2016
AtM-2 MA Workers Cornpensation Assigned Risk Pool 06/01/2016
WC�0 00 00 B Palicy Conditions 06/01/2016 '
WC 00 04 04 Penc{ing Rate Change End. MA 06l01/2016
WC 00 0414 Notification of Change in Ownership {)6/01/2016
WC 00 04 22 B Terrorism Risk Endorsement 06101/2016
WG 20 03 Q1 NtA Limits of Liability Endorsement MA 06/01/2016
WC 20 03 02 A MA Assessment Charge MA 06/Oi/2016 ;
WC 20 03 03 D MA Notice to Policy Holder Endorsement MA 06/01/2016
WC 20 03 06 B MA Limited Other States Insurance Endorserr�er�t MA 06/01/2016
WC 20 03 07 MA Assigned Risk Poo!Eligability Endorsert�ent MA 06/01/2016
WC 20 04 05 MA Premium Due Date Endorsement MA 06/01/2016 �
WC 20 04 01 MA Pending Premium Change Endorsement MA 06/01l2016 . ',
WC 20 06�� A MA Cance!lation Endorsement MA 06I0112016
WC 20 06 04 MA Policy Definitian Endorsement 'NIA 06/01/201Fi
EMPNOTlCE MA Rlotfce to �mpioyees MA 06/01/2fl1G �
Insured Endorsement5ch{p4/11}
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