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� TOWN OF YARMUUTH BOARD OF HEALTH " _ .
A�PIdCATION FOR 7.dCEt�TSF�BRMIT-201?
� 'Please compiete focm and attach all n�y��rts by 1 aAl . ���-` � � ����j
, Failure ba do so will res�ilt in ttre retwn of y�oia appiicabon
X
ESTABLLSfA�VT NAME: �'
� LOCATION ADDRESS: TEI..#: � G! ____, ,---
MATLING A.DDRESS: c�
E-MAII.ADDRESS: `! " �' ,Drn
OWNERNAN�: t11 Pha �3
CORPORATION NAME APPLICABI,E): _ �
MANaGER°s tdAME:��_ � ��,=t� — L°om ,� TEi..�: as' �
MAII.ING ADDRESS: O
POOL CERTtFI�ATiONS:
�'
� �1���r a�ita�ch a certifial as s Poat O�er:tor,as reqnuwi Ly Si�e liw. Plea9e list t�d�signaUod � �-,�;'
UP�a{) c:opy of the ceaiification to this foim �� � �.
1. �c� ��d� 2. `_� �
Pool rs mvst list a minimvm of t�ro � �
op�ata ea�lo�es c�urenfly cestified in standard�irst Aid and Ca�nmunity '�
Cardiogutmonery R:esvscitation(CPR�having ofle oatified�yee on pr�oises at ail times. Ptea�Iist du `'• �
empioyoes be�ow and attach copies of their�tificatioas to this TLe HealtL�wi�mt�e�rast �j � -
years'record,s. Yod mast previde aew cogies a�!a�taio a�e at poar plaoe a b�uas. � '_ .,
i
� 1 2. � __�_u..__ _.
3. 4 ..k"�-
� FOOD PROTECfION MANAC�ERS-CER'I'IFTCATIONS:
All feod scrvia eshablishan�ts are required to have at ksst one full-time employee who is cx�tified as a Food
Pmtection M�aga,a4�eSned in the S�te Sffiii�cy C.o�e for Food Service Es�ablishmeats,105 CMR 590.tri)0. �.
� Please attach oopies of o�tific�tion to tlris agplication. Tbe Hcalth Ucpartmeat�vi8 eot ase paat years'records. ��=- �
i Yem m�st pr�vide new rnpies aad maintaiu a�e�t yo�r�t;b��en�
1. ��'�bt�Ce jZ �tl�LS'S t 2. �v _+�i�C-��>��,YGZt /��c�i�r� �2N1( N
�_:���.
PERSON IN CHARGE: �' '"'�
E�h food estsblishment must have aR least�Pers�on tn Chargc(PIC}on sitc during hwgs of operation. �`�"`'�
i. � c�ic��_ �1�ll 2.��r� ���
ALLERGEN CERTlFICATIONS:
All food se�rvice establishm�ts aie required to i�ve at lea,t one full-tia�employ�who has�4U�agar oeztification, '
as defined in the S't�e S�itary Code far Food Se�vice Estsblishmants,105 CMR 590.004{Gx3xa). Please attsch
copies of certific�tion to tbis�plic�tion. 7'�H�Dqiart�eat�rilt eet�ae pa�st years'ree�rds. Yea�rt
prnvide ae�eapiea aa��t��n a fik rt yopr esdtb6ahmeat
1. � 1GLt�`1�.S �_, �'ir'�P[' 2.
HEIMLICH CER�CATIONS:
All food service es�biishmeats with 25 sei�t.s or�re mnst havs a#teast oae empbyee�in t�e Heimlich .
Maneuver on ttye preamises at all timas. Pkase list y�a����ained in snti-d�oking ptocedtaes bdow a�xl
�tach copies of employee c�eetifications to thu focm. The Dq�art�t w�oot�sc�st pe:rs'r�rda.
Yos a�t provide ae+��aad maiatai�a file at yeer�►lace of b�s.
� L oCe��1 t 1T+�d'�Yt Ct'�(7lul 2.�R'rt�� 't'`"�� '
3. .�dJIQ�...� r�...1 4.
RESTAUR.ANP SEATING: TOTAT.# f d� �• 't'�n''Dqc�,h
Cn.�at�4 n 1'�1�e.1(�
�n�: UFFICE USE ONLY
t[c�vss t�ua�n r� r�tiar r ttctx�x�v��n �e r�wwT� Ltc�xEQu� � r�,nT:
Bara sss cna�r
� 5�.55 � Si5 =�SWD�i�,QNG POOL Sl[Oea�
_IRAl1.Eat PARK 5105 WHIItLPOOL S110ea.
FOOD S�VlG�;
��RFJQU�FD sF� PERhaT# L[C�Sr��IR�ED� PERMiT# LiCE�VSE�IREp� pFRMIT it,O
0.10p SEqI'S
>100 SFATS f200 COMMON i�C. S60 —1MEi0 �/7 /+
RS!'AILSFAVICE: —RES(D.K17�CFiEN S!6
L1G�SsEq�QUIItED � PERMIT IF 1.[�,pEp RpEQt�71RED � PERMtT 1 LI��REQUIRED FEE PERMff#
_�25>OOOsq.lt. St50 =�FRO�i�T S40 �i'OBAC00 F�SI�lOS
1rAME CHAIYGB: S75 A1YI�UIVT�I� � �_�,OQ
atf�tPLBAS$1TlRN OVER A[M�>CQMP[.E7E OTHFdt SID6 OF FORM**twr
�o�4-F-�S-�k�S7-62
T
ADMINIS17tATION
UnderCha�pber 152,Section 25C,Snbsection 6,ti�e Townof Yatmouth is nowroquir�d to hold is�ce orn.ae�ai .
of aap iioease a�r pexmit to opera�e a business if a person�oarmp�ny cloes nat hav+e a C�e of Wo�k�er's
Co�rion �ttance. T� ATTACBED STATE WORKER'S COMPENSATION INSURANCE
AFI+YDAVIT MiJS'1'BE COMPLETED AND SIGNED,OR - '
CERT.OF WSURANCE ATTACHEU �
OR � .
WORKER'S COMP.AFFIDAVIT SIGNED A.1�ATTACHED_��
Town of Yarmo�h ta�c�es and li�s must be paid prior to m,aewal or issaance of ycxu peimits. PLEASE CHECK
AP'PRUPRIATELY IF PAID:
YES� NO �
MOTEIS AND OTHER LODGING EST
TRANSIENT OCCUPANCY: For putposes oft�e limitations ofMo�ei atHotel use,Tt�oax�nc.y shati be
IuniLed to the Ueonporary and�Ort tesm ooca�y,ozdineor�Y and cust�n�►rily associated with motd�and ho�l use.
T�ooc�must�e and be abk to clemon�rate d�at they mamxain a piincip�i place of residenoe
dsew�e.Tr�ieatooc�c,yshall gme�aitym.fr�to continuou�ox�cy of�ot moie d�atlwtY C�)�i'$,�
�aggreg�e ofnotmore than►ni�ety{90)days within any six(�mo�di p�iod Use ofa guest unit a4 aresideaoe o�
dwelling umi shall aot be co�d transiexit. Ooaq�uey that is subject to t2re coltedian of Roonn Occ�ncy
Txcise,as de6nod in M.G.L.c.64G c►r 830 CMR 64G,as$rneaded,shall generaily be�sideied Tr�.
POOI.S
POOL Uk�NING:Ail sw�imming,wading amd whiripools which have bam closed f+�r the�asonmust be i�eCted
by the Hesith De,gactmart too�g Con�et ti�e Health�t to achedale tlt�iusP�oa ffiree C3)
�prior�o�P��SE NO�E:People are NOT allo to sit in the pool area wrtii the pool has bc� i
1
I'OOL WATER TESTING: The water must be tested farpxudo�nas,total colifomi�st�datl ca�t '
by��lab,�d submitted to�Health Dep�meat t�ee C3)days P��'���l�Y �
FOOL CI.USING:Every outdoor in groimd swimming pool must be drained or covered withia xve�('T1 day�s of
CIO�.
FOOD SE1tViCE • '
SEASONAL ROOD SERVICS OPENIPTG: .
AU food se�rvice es�blisht�s mu�be in�Cted hy 1he Healtb Dep�nent pri�r te epmio�. Piea�e cantact tl�e
Heahh D�t to sclxdule the in�pa�on three(3)c�ys P�ior to�ning•
CATERIATG POLiCY: I
Anyo�e wt�caters within tbe Town of Yaimouth must notify tbe Yarmwrth Nealth D�t bp SI'm8 the '
T Food Se�vioe A�h cation fonm 72 l�ours or to the c�tr�ed evc�t 'Iha�e fio�ms c�be
o�bta�'a�ed at the H De�artrmat,or�rorn the Town's v�site www varn�h.ma.us.�mderHealth DepOrm�ent,
Downtoadab[e Forms.
FRO7.EN DESSERTS: '
Fro�en dessects must be tesbad by a State certified lab prior toopen�ng and mo�h(y t�,with sample r�suits
submitted to the Health Depatmncot. Failure to do so will result in the�sion or r�vocation of your Fm�
Des�t P�it wrtil the above texms�ve bee�met -
OUTSIDE CAF$3:
Outside cafes(i.e.,o�oor seating with waiter/waitress�ervice),musthavepriorapp�trval ft+�the Bo�d of FIealth
f OUTDOOR COOKII�iG:
; ��B.P��,ei'di�la3'ofanyfoodp�oductbyardailorfoods�vice�ablishn�eutispro�ed.
i
NOTICE:P���nnualty from lanuary 1 to Decembcx 31.iTIS YOUR RESPONSIBILiTYTORET'[)RTV '
.
1I�COMPLETED RENEWAL APPLIEATION(S)AND REQUIRF�FEE(S)BY DECEMBER lCr�Zt}16. j
' ALL RETiOVATIONS TO ANY FOOD ESTABLISFIMENT, MOTEL OR POOL (ie., PAWITI�iG, NEW �
i EQU[PMENT,EfC.�MUST BE REPORTID TO AND APPROVED BY'I�BOARD OF HEALTH FRIOR
TO CO . RENUVATIONS MAY REQUIRE A S1TE PLAN
DATE: ,�'�!��' �L��l�i SIGNA'TtJRE: r
PRIN'fNAME8cTffLE: �E���.=j ��Y�: II�r. �r-ctl`r�"'��v��...__
Rev.IflR1/16 �'
' ° . � Thc Commnnwealth of Massrrchusetts
Depart�ertt ofl�drr�rral Accide�cts
O,,�ce oflnvestigations
1 Congress S�+e�Srote 100
�oston,MA 02114-20�7.
www.�nnars�gov/dia
Workers' Compensation Insurance A.ffidavir Geners�l Busine.sses
Aunlicaat Information Please Priat I.eeibiv
Business/Organization Name: , c ��J p�' �c�i't' CI u j� .�n
aa�: P o =� �.� � �, �
. , _ . 3
City/StatelZip: �.�cr� v« '�. Y1n/� c��(�(o,� Phone#: �'Dg ��i� 4:���5 C�s�,.�� '
Are y ap employer?C�t�e aFProPriate boz: Basiaess Type(i'e4afred�:
l.L�G i am a lo ex with employees(full a�1 5. ❑Retail
�P Y
or part time).* 6. ❑RestaurantlBar/Eatir►g Establishmem
2-❑ I am�sole prop�ie�or or partriership and have no 7. ❑ ce and/or Sales(i�l.r�aE estate,auto,etc.)
employees worlqng for r�in any cap�city.
[No warkeis'comp.insurance required] 8. Non-profrt
3.❑ We are a corpor�tion and its officers have exercised 9. ❑Entertainme� !
their right of exennption per c. 152,§1{4},and we have ip.Q����
no emQloyees.[No worke.�s'comp.insurance requirad]* 11.[]Health Care
4.❑ We are a non-profit organization,staffed by vol�s,
with na employees.[No workers'comP-u�re4-1 12.�Other
`�r�PPiic�t[�e�bao[#t m�se al�o fin onc the�ion b�Ow showrog eh�ar worloas'�o�twlicy�•
••If We ao�paad�offioeas have exanptod t�velves,b�the oa�poia�ion has other�loYees,a w�as'compms�on Polic�'is rex�inod mid soch an
otgs��ian shoutd c�eck box#l.
1 awe ex a�loy�tkat is pro��w�nrkers' ' x ixsuranoe for�rty employees �low is tke p�olicy iAfor�i�.
Insurance Company Name: ���r'c�,� ` �'l ' �,,�. ��m
�
Insurer's A�ress: �i �.�" �r 1 c.� ���l c��'
�1���: ����,.� ��-f���f,� ���� v���r LL�-�,� ,
J 1
PoIicy#or Self-ins.Lic.# �71 7 '3`�� ��� Expiration I?ate: � l,�S i /��'
Att�ch a oopp of the worgcrs'compe�taa po�cy dedar�t�page(sho�ri�the poli�y act�be�r siad ezpiration date� '
Failuie t�o se�ur�coverage ss req�ured uncier Section 25A of MGL c. 152 can lead to tl�imposition of cximinat penalties of a
fine cip t�$2,540.tn1 andJor one-year im�isonment,as well as civil penalties in the form ofa STCC3?P�ORK ORDER and a fine
of up bn 5250.00 a day against the violator. Be advised that a copy of this s�tement may b�.farwarded to ihe Office of
Y Invesiigations of tbe DIA for insurance coverage verification.
I r�kr.reby cud;j►,uieder t1�e p�s awd pena�es oJ'pa,�r�ry�at t�e in,/'on�on pnav�ed abrn�e' trr�e and corr+a��
i G.i� Date: ' / i� !
�#: ��aF's 3a'i-! 711 �
tJ�ici�l use o�tty. Do uot writee iu tll�is artar,�ri br eor�tdad bp e�ty or town o�'iciaL
City or To�vn• Permit/irc�se# ,
IssaiBg Aet�ority(eircle aae):
1.Bos�rd af Heslri 2_Bnild�Depa�r4neat 3.C'itytTown C`terk 4.Lieeesing Board 5.Sclectme�'s 0i5ce
b.Ot�er
Cogtact Poer�a: Phoae#•
www.mass.�ov/dia
�.�•� BASSRIV-02 H
ACORi7' w►�p.aoorrim►!
�- CERTtFICATE OF LIABILITY INSURANCE �orzar�o�s
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO R�aHTS UPON THE CERTIFICATE HOLDER.THiS
CERTIFICATE DOES NOT AFRRMA7IVELY OR NEGA7IVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTIME A CONTRACT BEYWEEN THE IS.SUMIG INSURER(Sj,AUTHORIZED
REPRESENTATfVE QR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certiflcabe holder is an ADQfT10NAL INSURED,the policy(ies)must have ADDfT10NAL INSURED provisions or be endorsed_
If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement A statement on
th�certificate does not cor�fer rights to tl�e certificate holder in lieu of such endorsemer�t(s). ,
��� coHracr
NANE-
Gowrie Barden&Brett,inc. ��, :1 (800)262-8911 ��nt�c,No�:(860)399�615
70 Essex Road
Westbrook,CT 06498 e-"�"'�'- :info�gOwrie.GOm
orsu s �cc�vez►c� wvc s
crsu�a�:Federal Insurance Com n 20281
w�rt� �r�t s:
Bass River Yacht Club s+su�c:
PO Box 182 �r�o:
South Yarmouth,MA 02664
NiSURER E-
WSURER F:
COVERAGES CERI7FICATE NUMBER: REVISION NUMBER:
THIS IS TO CERT►FY THRT THE POLICIES OF INSURANCE IISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE PQlICY PERIOD '
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCl1MENT 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 POliC1ES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ;
� TYPE OF INSURANCE POLICY NUMBER POLICY EFF POLICY EXP � I!
A X co�RcuLL c,e�ew►�uaexm eac►i occua�wce y 1,OOO,Q00
CLAIMS-MADE �OCCUR J7H42S UWZS/YO1 s OB/Z�O'I7 DAMA6E TO RENTED $ 'I,OOO,OQO '
MED EXP An � $ ��,���
PERSONAL&ADV INJURY E ������
GEML AGGREGATE LIMIT APPLIES PER: GEt�RAL AGGREGATE 2,000,000
POLICY�J� ❑�oc PRo�ucrs-cor�/oP Acc 2'��'�
on�ER: Liquor Liab. 1,000,000
AUTOMOB�E LIA�LITY COMBINED SINGLE LIMff
9�!!�
ANY AUTO B�ILY INJURY PEx erson
OWNED SCHEDULED
AUTOS ONLY AUTOS BODILY INJURY Per axtident
AUTOS ONLY A T�O O LY �������
p► X ur�ula une X OCCUR EACH OCCURRENCE E 3,000,000 ;
occess une cwMSMnoe 74597 ON25/2016 06J25l2017 AGGREGATE g 3,000,�0
�
oEn X �rmoH a � a
A w�c�res cor�nsnn�
AND ENPLOYERS LYIB�IIY �TA ER �
�������TM�aE�� Y� 1 T39318 06/25@016 06/25l2017 EL EACH ACGDENT S ��°� '
OFFICEWMEMBER EXCLt�ED? N/A
t����� E.L DISEASE-EA EMPlO $ �'���
R yes.descri6e wxler r����
DESCRIPiION OF OPERA710NS bebw EL DISEASE-POLICY LIMR S
A Marine General Liabi 323899 I)6/25/2016 06J25/2017 1,000,000 �
A P8d-Regatta 323900 06/25/2016 06/25J2077 1,000,000
DE�TIOt�I�'OPERA710NS/LOCAitONS/VEFi1CL.E3(ACORO 101,Addilional Remarks Schedule.ma�r be attached if mqe space is�equired)
Evidence of Coverage
CERTIFICATE HOLDER CANCElLAT10N
SHOULD ANY�THE ABOVE DESCWBED POLICIES BE CANGELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELNERED IN
ACCORDANCE YYITH'iHE POLICY PROVISIONS. ,
AUif�D REPRESENiA'TNE
.�I (,�.�.�..- ��
ACORD 25�2016J03) O 1988-2015 ACORD CORPORATiON. All rights reserved.
The ACORD name and logo are registered marics of ACORD