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Home My WebLink AboutApplication and WC ` ' ��°�F��',��p (�l �' r TOWN OF YARMOUTH BOARD.OF HEALTH _ � � � � � APPLICATION FOR LICENSE/�� ; -�� l�F'/'� ' �� DEC � � ZO�6 . 5��' .2 . n { k`":.,., •;:.�' Y'c._. : . `'°` * Please complete form and attach all necessa�cioc " s�I�`ec'e ber 6 Failure to do so will result in the return of your application pa '`-� ��-'° '�"�'�� ..a ESTABLISHMENT NAME: - �1" � � O �� . �n= AX ID: � LOCATION ADDRESS: �— .�& O �l1 TEL.#: � �'' �f-1 ,�I MAILING ADDRESS: �� !�i r� F;: � , �'� :;" �' E-MAIL ADDRESS: ` ,;,�%�,�,' v:�r��'L � ' OWNER NAME: � CORPORATION NAME ( APPLICABLE): L ,/-� �, -�;�;�.r 'i�l,,►i/ ' �v,�p; LL� MANAGER'S NAME: A��4Ll�d� TEL.#: �c'� `7��' '7gl-� MAILING ADDRESS: 5;�,M� .�,.5 :��JF� POOL CERTIFICATIONS: T�e 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. ---- - --I- __ __ -�-- _ _ _ _ _ _ __- 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. 1. 2. 3. 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 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(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 # — ----��r:s:---- - _ OFFICE USE ONLY — -------- _-- --_ _ -- __ ------- ENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $I10 I� $55 C�MP SWIMMING POOL$110ea. _LODGE $55 =TRAILERPARK $$OS _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 RETAIL SERVICE: �RESID.KITCHEN $80 �7 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 _<25,000 sq.ft. $150 _FROZEN DESSERT $40 _TOBACCO $ll0 NAME CHANGE: $15 AMOUNT DUE _ $_��,�j *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** i3ob�-F-{S ��- L O 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 C PENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth t�es and liens must be paid pr'or 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 thirly(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 prior 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 prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. .w,., ,_.. -. b � __,_.._ . ,. " 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.varmouth.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 COOKING: 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 COMMENCEMENT. RENOVATIONS MAG�..R,E UI�S/�T//1�/H-�PkA 7�, .�/////� �� N /'�y��, DATE. SIGNATURE: j i � � ' PRINT NAME & TITLE: �� f D� �- F�' c�� Rev. 10/12/16 �i1/�'��``�'f=-� ��.1�� i ��"� �;.IC�,�S r ' ' � The Commonweatth of Massachusetts ' Department of Industrial Accidents Office of Investigations = ` ' 1 Congress Street, Suite 100 Boston, MA 42114-2017 � www.mass.gov/dia _ Workers' Compensation Insurance Affidavit: General Businesses A licant Information Please Print Le ibl �.o,d8 ,qrvL� LIE��. �✓/Zl s+�f1;✓L<'r C�r'JOS �-�- ' Business/Organization Name:�g,� ��,�/��g�Rr,�,q� (,,aq/� ,�',�t�,�,,,-r�,�/ �� ,'�,,�; Address:�'.� �/�'4'Gur � �, �K�� .�� f U"' �7 NI�i�+�!G .��e':�,�<�c , ��, ��,,c. ��i21 23� ��c��: 6� y�a�v:,�`rt{ �nr�-t' IA C�7�E_J�. City/State/Zip:j�4r',�,Hv;rtu �r� NfPr ��-7� Phone #: S�D�- -7�� 7��( Are you an employer? Check the appropriate box: Business Type(required): 1.❑ I am a employer with employees (full and/ 5. ❑ Retail or part-tirne).* 6. ❑ Restaurant%Bar/Eating Establishment _ �_i a�ira�u�l�rapri�tur-�r��ze,si�r�;a► �r c —--- - - --- - -- — 7. Office and/or Sa1es(incl. real esfate, 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.�Other�rzc�pt%C�� j �E.,i��,�l �� '�L1l�� *Any applicant that checks box#1 must also fili 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#L I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: Insurer's Address: City/State/Zip: Policy#or Self-ins.Lic. # Expiration Date: Attach a copy of the workers' compensation policy declaration page(showing the policy number and ezpiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a __ �'me-u�-t�$2,Sf3�.$E}a,.c�f�-c�:s�-y�ar ir�pri��, . . . . €�ra,-Q�-si vP Z�Vfl�OIZDE��:d a f�r.� 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 pain and enalties of perjury that the information provided above is true and correct. e Si ature: Date: i� I> b Phone#: D �- � / Official use only. Do not write in this area,to be corrapleted by city or town officiaL City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3. City/'I'own Clerk 4.Licensing Board 5. Selectmen's Office 6. Other Contact Person• Phone#• www.mass.gov/dia - —''�'1 LOVEAND-01 LRUO '4�R�� CERTIFICATE OF LIABILITY INSURANCE °�'�`"�"°°""�"' 11/2/2016 THIS CERTIFICATE IS ISSUED AS A MAiTER 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 U�e certificate holder is an ADDITIONAL INSURED,the policy{ies)must have ADDITIONAL 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 this certificate does not confer rights to the certificate holder in lieu of such endorsemen s). PRODUCER CT R55 Howard Street rance Agency P�E � �,No�:(508)588-5148 �uc,rb,�:(508 583-4400 West Bridgewater,MA 02379 INSURE 3 AFFORDING COVERAGE NA�C# �Ns��a:Burlin ton Insurance iNS�RE� INSURER B: Love and Light Nourishing Foods DBA Gingerbread Lane �NSURERC: Gluten Free 25 Gingerbread Lane �►�� Yarmouth,MA INStAtER E: IN3URER F: COVERAGES CER7IFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES.DElP1SURANGE LISTE{�BEiOWkL4VE-BEEN1SSUfiD-�QIFfEINSllREQNAM�D�1[�F9R-.7'}lE.Fip1(CYP�Rl�D INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO NMICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUB,IECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. �� TYPE OF INSURANCE ADDL SUBR pp��CY NUMBER ��Y EFF POLICY EXP LIMITS A X �MMERCiAL GENERAL IJABILJTY EACH OCCURRENCE $ �rOQO,OOO CLAIMSdNADE �OCCUR 5546512135 10N0/2076 �0/��/2��7 DAMAGETORENTED �QD��Q� PREMIS S a occ rrei ct� $_ MED EXP M one $ 5,�� PERSONAL 6 ADV IN.riJRY a 1,�Q�+�� GEN'L AGGREGATE LIMITAPPLIES PER: GENERAL AOGREGATE $ 2�000�000 X POLICY❑JECT �LOC PRODUCTS-COMPlOPAGG $ Y�OQO�OOO OTHER: $ AUTONIDBILE UABILITY COMB�I.N�ED SINGLE LIMIT s • ANY AUTO B061LY INJl1RY(Per person $ - OWNED SCNEDULED AUTOS ONLY AUTOS BORDILY INJURY er accident $ A��ONLY AUT�NLY PPer��t AMAGE S U11�RELLA LIAB pCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS�tdADE AGGREGATE $ DED RETENTiON$ WORKERS COR�ENSATION PER OTH- AND EMPLOYERS'LIABILJTY Y�N STATU ER pAN�Y PROPREIET8OERR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ (ManCEdat ry in NH)EXCLUDED? � N/A ifyes,desaibe undw E.l.DISEASE-EA EMPLOYEE $ DESCRIPl10N OF�ERA710NS below E.L.DISEASE-POLICY.LIMIT DESCRIPTION OF OpERATIpNg I LOCATIWJS/VEHICLES(ACORD 101,Adtlfflonet Remarks Schedule,may be atmched ff more space is re�ired) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEfORE Town of Yarmouth THE EXPIRATION DATE THEREOF, NOTICE Will BE DELIVERED IN Board of Health ACCOROiANCE WITH THE POIICY PROVISIONS. 1146 Rt 28 South Yarmouth,MA 02664 AUTHORI�D REPRESENTATIVE �� ACORD 25{2016/03) O 1988-2015 ACORD CORPORA710N. 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