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! . TOwAT O�YARMOUTH BOARD OF HEALTH '
APPLICATION FOR LICE113SEIPEitMIT-2017
+Please complete form and attach all necessar�+docuu�ents by��a�IG,L�
Failure to do so w�l resuit ia the retum of yoia apglicazton et.
ESTABLISHMENT NAME: '
LOCATION ADDRESS: 0 L.#: Q - 3
MAILIATG ADDRES : � �/
E-MAIi.ADDRESS: 0 S �CC �/7�'U�
; OWNER NAME: L
CORPORA'FION NAME APPLICABLE: O �
MANAGER'S NAME: 9R�S TEL.#: � - Q
� MAILING ADDRE�S: -G
POOL CERTIFICATIONS:
The pool snperviser muat be certified as a Pooi Operxtor,as reqeered by Stata lxw. Piease list tt�desiguated
Pool Operator(s)and attach a copy of the certification to this form.
1. 2. � .. �- c� a�=,
Pool opera#ors must list a minimum o€tevo tmployces cumattly certified ia staadard Ficst Aid and Commturity ;> n � . p,
Cardiopulmonary R,esuscitatioa(CPR),having one cerlified yee onp�mi a#ati times. Please list the � � _. :+
emp loyees below and attach coptes o f their c e r t i fications to t h i s '�f a�m.T l►e H e�h��e nt w 1 1 aef nse pAs+t �_,�
years'r�o r ds. Yom m�s t pro v i d e new capie8 a a d mxia t a i a a S le a t yonr p l a c e e b n a i n e s s. ;J N A=�
1. 2. �'ts o :�~,;�
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3. 4. � � �`''J
FOOD PROTECTTON MANACrER$-CERTIFICATfONS:
All food service establishmeats are required to have at least one fuil-time employee vvhO is certified as a Food �?
Protection Manager,as�ia the Sta�Sanitary Code for Food Service Establ�ts,IOS CMR 590.000. , '. �
Plcase attach copies of certification to this apglir,ation. The Heait�Deparlment wf�i not use�ast yesrs'records. � �
You must provide new copies nnd maistxin a�at yonr eabirlishment �
1. 2. �
�
�
PERSON IN CHARGE: � �
Each food estabiishment must have at least one Person In Charge(PIC)on site during houcs of operation.
� J^���
1. 2. r, ���
ALLEitGEN CERTIFTCATIONS: ��:.`y,
All food service establishments are reqtured to have at lesst one fuil-time employee vvho has Allergen certification,
as�fiaed in the State Sanitary Code for Food Service F.stablishm�nts,145 CMR 590.009{Gx3xa). Please attach
copiss of certification to tbis applic�ion. 'The H��rt�eeat w�not nse past years're�orda. Yon mast
Qrovide new copies aud maiatain a�e at yonr estabiiahe�ea�.
L 2.
HEA4I,ICH CERTIFICATIONS;
All food scrvice estabiishments with 25 seats or more must have at least one emp�traincd in the Heimtich
Maneuver on the pre�nises at all�mes. Please list your eapla trained in ami-cholang procedures belt�w and
attach copies of emgloyee certificstions to this form. 't'�e H� par�ent w�i8 not�e past years'records.
Yom m�st provide new copies and main#aia a 8ie at yonr place u�f 6�ness,
1. 2.
3. 4. �
RESTAURANT SEATING: TOTAL#
OFFICE USE ONLY
LODGING:
LICEATSE REQUIRED FEE PBRMPf N L[CEN36 REQU11tED FEE P&RMI1'# LICENSE REQUIRED FEE PF.RM{T#
B&B SSS CABIN SSS MOTEL t110
INN SSS CAMf' SSS =SWQ�fG POOL&110ea.
� ��.ODC3E SSS _CRAII.ERPARK S105 _,WHIRLPOOL SIIOm.
FOOD SERVICE:
L[CEATSEg�q UtRED FEE PERMLT# LICETfSE REQUIR£D FEE PERMIT A LI(�NSE gQ�� FEE PERMTf#
0-100 SEA't'S S125 `..CONFlNEPfI'AL S35 NUIWPROR �T['�D S30
>I00 SEATS S20U COMMON VIC. S60 —WHOLESAtE S80
=RE31D.KTfCHEN S80
RETAII.SERVICE:
LIGENSE RF,QUIRED FEE PERMff S LICENSB REQUIRED FEE PfiRMIT# LICENSE REQI3IICED FEE PERMff#
=�L�S,000$sq.R 5150 � =FRSfSZ�EN�ESSERT�S4D ��BA�CCO �SiS10 -�'�-I--.F=6C�p
1NAM&CHANGE: SLS AMUUNT DUE _ $ ZCo�.OC
•�srwPLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORMr""• �^r r_� �,�5-�l 5R r�2—
w�z
�4�IP-l 5-�t lo l -0-Z
ADMI1�tISTRATION
Under Chapter 152,Sxtion 25C,Subsection 6,the Town of Yazmouth is now requirodto hold issuanee or reaewal
of any license or peimit to operate a business if a person or com�ny dces not�ve a Ceatificate of Worker's
Compensation Insararnx. THE ATTACHED STATE WORKER'S COMPENSATION INSiJRANCE
AFFIDAVIT MUST BE GOiVIPLETED AND SiGNED,OR
CERT.OF INSURANCE ATTACf�D
OR
WORKER'S COMP.AFFIDAVTT SiGNED AND ATTACHED
Town of Yarmouth taxes and liens m�st be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID: ,� /
YES ✓ NO
MOTELS AND OTHER LODGING ESTABLISiiMENTS
TRANSIENT OCCUPANCY: For purposes of the limitations ofMotel or Hatel vse,Tiansiem occvpancy sl�il be
limited to the temporary and short texm oecupancy,ordinaziiy and custamarily associ�with motel and hotel use.
Traosieat oc�p�ants must have and be able to demonstrate thai they maintain a p�incipaI place af residenca
elsewhere.Transiem occupancy shall genexally refer to continuous occupancy ofnot more tl�n thirty(30)days,and
an aggregate ofnot more thaa ninery(90)days withia airy six(�month period. Use ofa g�est uaiias aresidence or
dwelling unit shall uot be considered transieat. Oecupancy that is subject to t�e collection of Room Occupancy
Faccise,as defined in M.G.L.c.64G or 830 CMR 64G,as amended,shail generally be consit3ered Transient.
POOI.�S
POUL�PENING:All swimuniag,wading aad v�r�nrlpools which have bo�cic�sed f+�the aeason mu�be inspected
by the Health Departmeatpnor to pen�ng Co�ct the Health�ern to adiedek the i�s three(3)
days prior to opegYang.PLF.ASE NQTE:People are NOT ailowed to sit ia the pool area until�has been
iaspected and opened.
P'OOL WATER TESTING: The water must be tested for pseudamonas,total coliform and standm+i plate count
�e��certified lab,and submitted to tEie Health Depertrnent thrce(3)days prior to opening,a�i quarterly
POOL CLOSING:Every outdoor in ground swimming pooi must be drained or coverod within se,wen('�days of
closing. '
FOOD SERVICE
SEASONAL FOOD SERViCE OPENIlVG:
All food service establishmeats must be inspacted by the Health I�epartment prior to opening. Flease eontact the
Healti�Department to scl�dule tl�in.spechon three(3)days prior to opening.
CATERiNG POLICY:
Anyone who caters within the Town of Ysimouth must notify the Yarmouth Health D�parmient by filing tl�
reqwred Tempo Food Service Application form 72 hours prior to the catered evcnz. These forms can be
obtained at tbe H�D�ne�t,or from the Town's website at www=varmouth.ma.us uader HealthDepaztaient,
� Downloadabie Forms.
FROZEN DFSSERTS:
Frozen desserts must be t,ested by a State certifiod lat�prior to �d mcmthty thereafter,with sampk res�ilt�
submitted to the Health Department Failui�e w do so will resul��the suspension or reva�tion of your Frozen
Dessert Permif until the above terms havs been met.
OUTSIDE CAR�S:
Outside cafes�.e.,outdoor seating with waiter/waitress sexvice),must have prior approval fiom the Bosrd of Health
OUTDOOR C�KING:
Outdoor cookiag,preparation,or display of say food product by a retail or food sesvice establishment is prnhibited.
NOTiCE:Pennits run aunually from January i to Dece�nber 31. TT IS YOURRLSPONSIBII.TTY TO RETURN
T'HE COMFLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 16,2016.
ALL RENOVATIONS TO ANY FOOD ESTABLISF�'NT, MOTEL OR POOL (i.e., PAl1�TTIrTG, NEW
EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TE�BOARD OF HEALTH PRFOR
TO COMIV�NCE RENOVATtONS MAY REQUIRE A ITE PLAN.
V
DATE: �I SIGNATt3RE:
PRINT NAME c�T1TLE:
xeV.[a�v�6
� The e�r�nwea#h a,f'1i�1'+�ss��i�s�s
De�vartr�tent of Indu�a�Accirlents
D,�ce of I�vestigatioR.r
� 1 Co��ress S�dreeti Su�te I t10
Boston,MA f1211�2017.
w�vw.�rs�grrv/dia
Workers' Compens��a Insura�ce Affidavit: Geeerai SttsiB�sses
A�ulica�t��c�rmstia� Please Priut Le�r'tblv
Business/Organization Name: 1'D O��P`Y1 P�1. ��Q�� �� (H- 14 �o� ��N�
Address: � � � o�Cp
� City/State/Zi�: �� ���� Phone#: c�d�' ����..��� �
Are yo�an emgloyer?Check t}�e aggropr[ate boz: Bua�ess Type(reqaire�:
1.❑ I am a employer with � emgloyees(full aad/ 5. �tefail
or part time).* 6. ❑R ' g Establishment
2.❑ I am a sole proprietor or p�ip snd havc no 7. ❑Office and/or Sates(inci.real es#ate,suto,etc.)
employees warlcing for me in any capacity.
[No workers'cornp.insw�nce required] 8. ❑Nott-pro£'tt
3.❑ We are a corporation and its offic�rs have exercis�d 9. ❑EnterEa�nment
their right of ex�mgtion per a 152,§1(4),and we have I 0.[]Maau�c�in8
no emp�oyees- 11`10 workers'comp.i�siu�ance required)'
4.❑ We are a non-profit organization,staffed by voluateers, i I•�Health Care
with no employees.[No worlcec�s'cAnzp.insurance r�.J 12.[]Uther
•Any�plic�nt that cha�Cs box#1 must also fill out tl�e sedion below shmving d�eir wa�rkeis'ooa�n PolicY informffiio�.
s"if the co�posate officers have exempted themselves,b�rt the co�porat�has other employees.a vw�kecs'co�on PolicY is r�quired and s�ch an
�sliot�d cha�c bmt#1.
I am aA�loyer th+at is provtding workers'compeirsation i�uroace far my employee� Below is the pol�cy&ifurn�ion.
Insw�ar�ce Company Name: �U GI Yd �°Y1,3"�'Wt1�� ��
Insurer°sHddress:�w l�i��-i � Cl 9n�2.t� �'YI�S�f�►�r���� ��I clhno'ug�.�}- c.l ,j�0 Q�� 1 q�a
CitylState/Zip: �,�4��tyl�—;-�� "==S�`
Policy#or Self-ins.Lic.# rn A v v a���� �P U�✓�i�'�l�0 � � £xpiration Date: d�' t,'�'�0��
Attach a copy of the workers'compessation po}�c.y declaration pa�e(showiag the�ol�t.y aamfier and ezpiratioa date�
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead�o the imposition of oriminal penalties of a
fine up to$1,500.00 aad/or one-year imprisonment,as well as civil penalti�in the form af a STOP WORK ORDER and a fne
of u�to$250.00 a day against the violator. Be advised that a copy of this stat�nent tnay be foruvarc3ed to the Office of
Investigations of the DIA for insurai►ce eoverage verification.
I do hereby certlfy,under tlie nair�.s and peiralt�s of perjury tltat tbe�nformat�iin proviateai above is true and c�rrea�
�i� �C {��-e-� n►�: 1�-��-f(�
#� _ - ( o
Of,�9cial use only. Do not wr#e�in tl�'s mea,to be ao�vleted by city or town of,�cial
City or Town• Permit/Ucense#
Issuin�Authority(circle one):
1.Board of H� 2.Bnildieg Depsrtment 3.City/Town C1erk 4.Licensiag Board 5.Selectnaen's 4Pfice
6.Ot�er
Contact Pers�rn: Phone#:
wvvw.mass.gw/dia
�
Client#:761825 2ATOZ1 °
ACORD,� CERTIFICATE OF LIABILITY INSURANCE DATE(MIWDD/YYYY)
�arzo,s
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON TFIE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY TNE POLICIES
BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTFIORIZED
REPRESENTATIVE OR PHODUCER,AND THE CERTIFICATE HpLDER.
IMPORTANT:If the certlflcate holder Is an ADDITIONAL INSURED,the pollcy(les)must be endorsed.If SUBROGATION IS WAIVED,subject to
the terms and conditipns of the policy,certaln policles may require an endorsement.A statement on this certlflcate dces not confer rights to the
certificate holder In Ileu of such endorsement(s).
PRODUCER NAME:
Dowling&O'Neii Insurance Ag A"�"N�:508 775-1620 � No, 5087781218
973 lyannough Rd,PO Box 1990 E•MAIL
Hyannis,MA 02601 A RESS:
INSURER S AFFORDING COVERAGE NAIC x
508 775-1620
,NsuRER a:Safety Indemnity
INSURED �NsuRea e:Guard Insurance Group
Poojanen,Inc.DBA A to Z Convenience
INSURER C:
88 Constance Avenue
West Yarmouth,MA 02673 INSURER D:
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 CONDITIONOF ANY CONTRACTOR 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 ADDL SUBR POLICY EFF POLICY EXP
�Tp TVPE OF INSURANCE �N R WVD � POLICY NUMBER MMIDD MM/D LIMITS
A GENERAL LIABILITY BMA0023631 5/15J2016 05✓15/201 EACH OCCURRENCE $'Z QQQ QQQ
X COMMERCIAL GENERAL LIABILITY PRE►uIISEg Ea�R°B„� $1 OO OOO
CLAIMS-MADE �OCCUR MED EXP(My ona person) $1 O OOO
PERSONAL&ADV INJURY $Z OOO OOO
GENERALAGGREGATE $4 OOO OOO
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS•COMP/OP AGG $4 OOO OOO
POLICY PR�
JECT LOC $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT �
Ea accident
ANY AUTO BODILY INJURY(Per person) $
ALLOWNED SCHEDULED
AUTOS AUTOS BODILY INJURY(Per accident) $
NON•OWNED PROPERTY DAMAGE
HIRED AUTOS AUTOS Per accident $
$
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS UAB CLAIMS-MADE
AGGREGATE $
DED RETENTION $
B WORKERS COMPENSATION pOWC700042 �P/ZO�G O�ZI2O1 X WC STATU- OTH-
AND EMPLOYERS'LIABILITY �
ANY PROPRIETOR/PARTNER/EXECUTIVE Y�N E.l.EACH ACCIDENT $SOO OOO
OFFICER/MEMBEA EXCLUDED? � N/A
(Mandatory in NH) E.L.DISEASE-EA EMPLOVEE $rJ�OOO
If yes,describe undar
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $SOO OOO
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Addkional Remarks Schedule,iT more spece is require�
Insurance coverage is limited to the terms,conditions,exclusions,other limitations and endorsements.
Nothing contained in the certificate of insurance shall be deemed to have altered,waived,or extended the
coverage provided by the policy provisions.
CERTIFICATE HOLDER CANCELLATION
Cap,e Associates,I�IC. SHOU�D ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
345 Massasoit Road ACCORDANCE WITH THE POLICY PROVISIONS. �
Eastham,MA 02642
AUTHORIZED REPRESENTATIVE
-�'?'.�..�. `G;^—"'�—:
�1988-2010 ACORD CORPORATION.All rights reserved.
ACORD 25(2010/05) 1 p}1 The ACORD name and logo are reglstered marks of ACORD
#S170404/AA170403 CBD