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TOWN OF YARMOUTH BOARD OF HEAI.TH
APPLICATION FOR LICENSE/PERMIT-2017
*Please complete form a�xl attach all necessary documents by���
Failure to da so will resWt in tt�ret�m of yoor applicarion pec
ESTABLISHMENf NAME: v • -- �
LOCATION ADDRESS. Ol T TEL.#• J — —2 S� �
MAILING ADDRESS: .9 '�
E-MAII,AL?DRESS: C� l
OWNER NAME:
CORPORATION NAME(IF APPLICABLE): �" ,�-kr
MANAGER'S NAME: ,�'�fzo\ �1 ��` TEL.#:
MAILING ADDRESS: g c.v� P�� t��a�-�-
POOL CERTIFICATIONS:
TLe poa!saperviwr�aat be certified as a Poat Operator,aa rcqaircd by State Mw. Please list the�signatad
Pool Operator(s)and attach a copy of the ceitificstion w this form.
1. 2.
Pool operaiors must list a minimum of two employees currendy certified in standard First Aid and Community m O �0
Cardiopulmanary Re.�scitation(CPR),having o�cerdfied emp�oyee onp�m�ses at all times. Please list the D ,n RI
ea►ployees below and altac.h oopies of their caefic�ions to tLis�oim.1'Le Health�arfnert wi��t�past r (')
yara'records. Yoa most pr+evide new�copies and maietsin a 5k at your placc of b�. = 0 m
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1. 2. � rv �
3. 4. � � �
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FOOD 1'ILOTECI'ION MANAGERS-CERTIFICATIONS:
All food service establishments are roquir�to have at least�e full-time�nployce who is cxrtifiai as a Food :
Protection Maoager,as dcfined in the State Sanitary Code for Food Sen+ice Establishments,105 CMR 590.000.
Please attach copies of ceitification to this application.T�e Hahh Depnrto�eat will�at nse psst}�ears're�rds.
Yoa maat previde ecw�copies asd mamtau�a Sk st yew ahbN�ahment ^A.N:y�r3�
I.S4Q�� J VJ �S�M 2. J Q -�- 11'aM � l��; � �
PERSON 1N CHARGE: `"� Y
E�h food establishment must have at least one Peison In Charge(PIC)on site during ho�us of operation.
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ALLERGEN CERTIFICATTONS:
All food service establishment�are roquired to have at least o�full-time�ployee who has Allergen certification, ' "", .��
as defined in the State Sanitary Code for Food 3ervice Fstablishments,105 CMR 590.009(Gx3xa). Please attach "+�`��
copies of cearti5cation w this application. The Heakh DeparMeat w�ill■ot use past yau�a'r�rds. Yom m�st "�x
provide new copies nud s�ai.taia a fik at yow estsb�istimen�
�. �cro\ � i,.� 2. S Q-N-��e� k `^'3 c�-�---
HEII�.ICH CERTIFTCATIONS:
All food�vice establishments vrith 25 seats or more must have at least one emplaye.e trained in the Heimlich
Maneuver on the premises at all tanes. Please list your emt�ployces trained in anti-cholang procodures below and
attach copies of eanployee c�tifications to dris form. T'he HaiUh Departmett�riD�ot�e paat yesrs'reeards.
Yoo most provWe ucw cop�es and mamtain a Sk at yoar place of basinesa.
1. 2.
3. 4.
RESTAURANT SEATWG: TOTAL#
i.oncnvc:
OFFICE USE ONLY
LICENSE REQUQtED FEE PERMff A LICENSE REQtIlRED FE� P&RMIT N LICENSE REQUIRED FEE PERtiIIT�
BdtB S55 CABIN SSS Mp7'EL, f110
�� �S CAMP S55 =SWD�RTIGPOOLSIIOea
�� =`I'RAII.ERPARK 5103 _WHtRI..POOL S110ea.
FOOD SBRVIC6�
L(CENSE FEE P L[CENSE REQUIRED FEE PERMIT k LICENSE FEE PERMCf�Y
�aioo�sizs ��j�`8Z coxrn�xrw�, sss �rr.rx� �
>�oo s��s s2oo �co�ox v,c. seo ��
Rcrwu.s�ce: =xFsro.�s�
LiCENSE REQUIItED FEE AERMIT M �B REQUIItED FEE PIItMIT q LICENSE REQUIItED FEE PER1�ffT N
<SO�.g, SSO >25 000 a. 5285 VENDINC'-FOOD 525
=QS,OOOsq.R 5130 =�R(SZEI�i�SS�tT f40 �fOBACCO S1t0
NMZE CHANCE: f15 4MOIINT DUE � S L�C�.��
r:�i�PLEASE}'[lJtN OVER AND COMPI.ETE OTHER 5IDE OF FORMat:��
�oN�-i�-�6i t`'q-OJ
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ADMINI5TRATION
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 opezate a busi�ss if a person or com�ny dces not have a Ceitificaite of Worker's
Compensation Insucance. T�IE ATTACHED STATE WORKER'S COMPENSATION INSURANCE
AFFIDAVI'!'MUS'1'BE COMPLE'TED AND SIGNED,OR
CERT.OF INSURANCE ATTACHED �
OR
WORKF.R'S COMP.AFFIDAVIT SIGNED AND ATTACI-IED
Town of Yarmou�taxes and liens must be paid p jer to renewal or issoance of your petmits. PLEASE CHECK
APPROPRIATELY IF PAID: ✓
YES NO
MOTELS AND OTNER LODGING E5TABLISNIYI�NTS
TRANSIENT OCCUPANCY: For purposes of tlu limitatiom of Motel or Hotel use,Trnnsieat ocxupa�y shall be
limited to tl�temporary and s}�rt term occupancy,ordinarily and customarity a5sociatecl with motel and hotel use.
Transient ocxupants must have and be able to d�►onsuate th�t they maintain a principal place of residence
elsewhcYe.Transient occ�pancy shall genetally ref�to continuovs occupancy of�t more thanthitiy(30}days,and
an aggregate of�t more than ninety(90)days withia any six(�month period. Use ofa guest unit as arc�idence or
dwelling unit shall not be con4idered tian.�ient Occupancy that is subjext to t�wllection of Room Occ►�mrn.y
Excise,as defined in M.G.L.c.64G or 830 CMR 64G,as amended,shall genernlly be considered Tran�ent.
POOLS
POOL OPEIVING:All svvimm _o,in�wading a�xi whidpools which have been closed foz tbe season mugt be it�spected
the Health or to o�. Contact the Healthµ�ent to sc6edde the iaspectioa ttire�(3)
d�aya prior to o��.]voTE:People are NOT allo to sit in the pool area vntil tbe pool has been
����•
POOL WATER TESTII�G: The water must be tested for pseudomonas,total coliform and standmi p]ate co�mt
by a State oertified Iab,and submitted to tbe Heatth Departmern thtee(3)days grior to opening,and quarterly '
the�ea$er.
POOL CLOSII�G:Every outdoor in ground swimming pooi must be dtainexl or covered within seven(�days of
closing.
FOOD SERVICE :
SEASONAL FOOD SERVICE OPENII�TG:
All food seivice establishments must be ins�eeted by the Health Department prior te opeai�g. Plea�e contact tl�
Health Departm�t to xhedute the inspect�on thrce(3)days Pnor to oPeninB•
CATERING POLICY:
Anyone who caters within the Town of Ya�nouth mvst notify the Yarmouth Health Departrnent by filing the
reqwred T Food Serviceqpp lication f�m 72�urs prior to the c�event. Thrse fams can be
obtained at thec�th Depa�ment,or�'rom the Town's website at www.varmouth.maus.underHeahhDe�nt,
Downloadable Forms.
FROZEN DESSERTS:
Fmzen d�ts must be tested by a State ce�tified lab prior to opening and monthly thereafter,with s�ple resutts
submitted to the Heatth Departrnent Failure to do so wiil result in tbe suspension or c+evocation of ycxu Fmzien
Dessert Permit wrtil the above tern�s have been met.
OUTSIDE CAF�S:
Outside cafe.c(i.e.,outdoor seating with waiter/waitress s�vice),must have�iorappmval&om the Bo�+d ofHealth.
j Ot7TDOOR COOKING:
y Outdoor cooking,preparation,or disptay ofany food Tuoduct by a mtai(or food service establishmexit is pr�bital.
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NOTICE:Permits nm annually from January 1 to Decembes 31.1T IS YOUR RESPONSIBILiTY TO RETURN
, TEIE COMPLETED RENEWAL APPLICATION(S)AND REQUIItED FEE(S)BY DECEMBER 16,2016.
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' ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAIlV'I'II�1G, NEW �
i EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEAL'TH PRIOR
' TO CONII�TiCEMENT. RENOVATIONS MAY REQUIItE A STfE LAN.
DATE: L SIGNATURE: �` W '
PRI1V'P NAME&TITI,E:�_�� (I-� r �
Rev.1a12lI6 ,
� Tlie Comnwxwta/th of Massachusetls
Dtpm�iere�rt of Iridus�rial Accidtnts
O,�ce of Invesdgations
' 1 Congress Stree�Srute I00
Boston,MA�211�h2017.
www ma��gov/dia
Workers' Compensation Insnrance Affidavit: General Bnsinesses
ADu6cant Information Please Print_Le�iblv
Business/Organization Name: -, �-W �-�.��s�� / � �p� �"��-' '� �res���S ���-
--.—
Address: �� J�e� �ra-�� ��
City/State/Zip: sa-}�C., 0�°�°P�,one#:� � S� � -7 b0 ZS l8
Are yon an empbyer?Check the apprapriste boz: Bosiness Type(reqnired):
1.� I am a employ�with �" employ�s(full and/ 5. ❑Retail
or part-time).* 6. ❑RestaurantlBar/Eating Establishment
2.❑ I am a sole propriexor or partneaship and have no 7. ❑Of�ice and/or Sales(inaL real estate,auto,etc.)
entployees working for me in any capacity.
[Na workers'comp.ins�uance required] 8. ❑Non-profit
3.❑ We sre a carporation and its oi�'icers have exercised 9. ❑Entertainme�
their right af exemption per c. 152,§1(4�and we have 10.�M�ufacturing
no employees.[No workets'comp.insurance required]'�
4.❑ We are a non-profit organization,staffed by vohmteers, 11.�Heatth Care
with no employ�s.[No workers'comp.insurance recl-1 12.(�Other �7@� `�- �l`����
•Any applic�mat c�Irs box�Yt�sc ai�o fin a�the saxmn belovn showing thea wa�ioe+s'oo�aa po�r mfacm�an•
••If the corpa�of�cers have exempted th�lves,but the ooipaa�ioo has ot�x emP�Y�.a�'�P��Y is raqoired and snch�
or�ian xhould checic booc#L
I ain are enipGiyer tkat is prnvidiRg wnrkus'S�r�3��urancae jor my eniployee� Below is dY�poUcy lirjonr�tios.
Insurance Company Name: V�I e5 Co � C� �j ,
��S Aaa�sg: "6o 0 5 U per��c P�v��, �-h � Z� �r ��
c�ri�s�P: C\�-\G. �- 01� �i� t+ `�
Policy#or Self-ins.Lic.# �n(W � '� �� � 9 �o�i Expiration Date• _3�Z3 ,�2.� �7
Attnch�oopy of the workera'compeaa�taa policy dedsration psge(skowiog the poliry nmmber asd ezpirallo�date� '
Failure to secitt+e coverage as required under Sedion 25A of MGL a 152 can lead to the imposition of criminal penalties of a '
fine up w 51,500.00 and/or on�-year im�isonment,as well as civil penalties in the form of a STOP WORK ORDER�d a fine
of up to SZSO.OQ a day ag�ainst the violator. Be advised that a copy of this stat�►ern may be forwarded to the Ot�ice of
Investigations of the DIA for insurance coverage verification.
r�►���+, tke paiirs awd penal�is ofpa,�icry t�ot dUe lAcfom�on pravided abovr Is trae a�ed corrax
Z
I�one#: 5'0$ —7 b O—28 (�
O�Jicial use only. De�wr3te in tkis m+ea,to be c�in�let�ad by rity or towR o,,Q�cial
Citp or Tow�a• Pere�it/I,iceage#
�ni�Aathority(circk ote): ,
1.Board of H� Z.BaiWiag Dep�artment 3.CYIy/Towa Clerlc 4.Licesaing Board 5.Seleetmen'a Olfice
6.Ot�er '
I
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Cantact Person• � Phone#: i
rvw.w.ma�.g�ov/dia �
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3t�1�1B WCPbIic�Conirm�a�aiPedcet
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FOr OtfrCe USe:
� �&S14i�lS�7AC0
/QiCY1Tt"USt NOt't�'1 /4C1'1�1'ICc� wesco Insarance Company
An AmTrusfi Financial Company
800 Superior Avenue East, 21�t Fioor, Cleveland, OH 44114
Tefephone: 877-528-7878; Fax: 8Q0-487-9fi54
Worker`s Compensation Confirma�on
Producer Ir�formatian
Agency Name: Ciuett Commercial insurance A9��Y 53638
Agency, Inc. Number:
I
Applican#Informa�on
Applicant Name: JCW Enterprises
�Doing Business As Name: The Captain Fairis House Bed � Breakfast Inn
Mailing Address: 308 Old Main Stree#
City/StateiPostai Code: South Yarmouth, MA 02664
FEIN/SSN: ;
State: MA
Policy InfoRnation '
Effective Date: 3/23/201 fi Expiration 3/23/2017 '
Date:
fssuing Company: Wesco insurance Company State: MA
Policy Number: V1NVC3196964
Pa merrt Pian: Years In �
Y Business:
Supplemental Underwrii�ng Application
Description of Operations:
bed & breatcfast
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