HomeMy WebLinkAboutApplication and WC ��� TUWN OF YARMOtITH BOARU OF HEALTH
APPLICATION�C}R T.IC�;NSE/PERMIT-2017
*PIease comptete form and at#ach all necessary documents by De mher 16 2tII6.
Failure to do so will result in the return of your applicatton pac et.
ESTAF3I.ISNMB�v'T NAM�: '
L(7C�ATIt�N AI)DRESS:IGr �� � TEL.#: -�S'�'y,(
MAILITtiG AI�DRESS: r s^f
E-MAtL AI3DRF.,SS: ra�'e.rY,�-fcp�t s � o v^,C
OWNETt NAiviE: �r_ �' r y.�/' _.._
CORPORA'I`IC)N NAME{IP APPLICABLE}: .�//�-
MANAGER'S NAME: c..i., s;L v.? TEL.#: K� �''�f,�
MAILING E1L}I�R�SS: � .
PC7QL C�ERTIF'ICATION5;
The pool supervisor must be cectiCed�s a.P'ool Oper�tar,as required by State law. Plettse ts'st thz designated
PaolOperatar(s and attach a copy af the certafication ta this form.
i, ���� '-
Po�l operators must Iist a minimum of twa employees currentl}�eertitisd in standard First Aid and Cornrnunity �' p ��
Cardiopulmonary Resuscitatinn(CPR),having one certified enzployce on premises at all times. Please list the � m ��.
employees beiow anc�attach copie�af their certificacicsns to this form.The Health Department wtIl na#u�e past �- n #��,;
years'records. You must provide new copies and maintarn�file at your piace of business. � —+ ,�
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FOt)1�PRO"C�CTION MANAGERS-CERTtFiGATI4NS;
All faad service establishments aze required to have at least one full-tirne empioyee who is certificd as a Food
Protection Manager,�ss defined in the State Sanitary Code f�r Faod Service Establishrnents, 105 CMR 590.000.
F(ease attach copies of aertzficatinn to this application. The I3eatth Dep�rtment will not ase past years'records.
Yau must provide new copies and maintain a file at yaur establishment.
i._ -l�L�-`� S 1 L-U�" 2.
��� $�
p�Rsar�1�ex���: �.r�.-��•.�
I=.ach faod establishment must have at teast one Person]n Charge(PIG)on siie during haurs of ogeratian. ` pf�
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ALLERGEN CERTIFICATIONS: �"
Ail faad service establishments are re.quireci ta have at}ee�st ane full-iime employee who has Allergen certificatian, �_ '� "�
as defined in the Sta#e Sanitary Code for Foad Sarvice Fstahtishments,105 CMR S90A09{Ci}{3){a). Piease attach �
copies of eertification ta ihis application. The Health Depaclment wrll not nse past ye�rs'records. You must �^",
provide new eogies aad maintain a fle at your establishment. � `� �„
i. � i�L`� �J L V/9 2. `- �'r,
�-IEIMLICH CERTI�ICATIC}NS:
AII faod service estabiishments�rzth 25 seats or more musi have at(east ane empiaye.�trained in th�IIeimlich
�,4aneuver an the premises at all times. Plea�e list yaur employees trained in anti-chois.ing procedures belUw and
attach copies of employee aertifications tc�this form. T6e Hcalth Department wiil nat use pest years'recnrds.
You must provide new eopies and m�intain�file at your plase of business.
1. .�/...��- 2.
3. 4.
R�STA(.JRANT 9�A"�'ING: TOTAL,#
OFFICE CiSE ONLY
L.OdGtNG:
I,CENSE REQLIIREU FEE P'RMIT f! LtCENSE REQ[iIRED FEE PERMIT#i i,1C�NSG RGQGTkFD FEE PERtvi1T#
f3&B $55 .�Q�eol CABTN S55 MO?'EL 5110
____ �.d___r.�
$55 C'r1tv1P SS5
_. 4 SWTMMCIVG Pt3()C.$1 t{tea_.______
�LQDGL" S55 �� �--'I`RAILERPARK �tt�5 � �WHtRt,hOtTL $ilOta
FtXI�SERYICE:
�`t1-�SEA��SiRi:D $� p���l '['-�UMMREQ�IRF.�J �� p������ I.[R,SID O•��fRED SF�EE PERMIT#t
f
RETA[L SERYICE:
L1CF".NSE RGt}UIItEI) EEE PERMIT# t,ICFNS@ REQUIR�:D PEE FF.RtvIIT i� LICENSB kEQQIREI) FEE PER�VIIT#
<50 ft. $50 >?3.fl00sq IT. $285 VENBING-F(X7I3$25
___
-"<25,0 sq.$. SIS(3 _.___ __. �FROZEI�'i3ESSERT $40 ----�._ —TOBACCO SI 10 _..------
nA�r�cxn�v�E: �is AMUL'iV'T�UE _ � Z`f� ..00
*"**•PLEASE TURlV OVER AND COMPLETE OTHER STDE 4F FORM*'�**" �����.I��.,Q�7�a.�.��
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Under Chapter 152,Seetion 25C,Subsectian 6,the Town of Yarmouth is naw reyuired tn hold issuance ar renewal
of any Iicense ar permit to c�perate a business if a person ar ca�npany does not have a Certificate af tA�arkex's
Campr;nsatian Insuraz�ce. THE ATTACHED STATE WOIttCER'S C4MPENSATTUN tNSU'RANGE
AF�'[DAVI'T MUST BE COMPLE7"FD AND,�',tG1�ED,OI2
CERT.OF I'�tSURANCE A"ITACHED L�
UR
W�RICER'S CC?MP.AFI�TI7AVIT SiC'7I�3ED ANT3 ATTACHEI7
'I"o�vn of Yacmauth ta�ces and liens must be�aid prior to renewal or issuance of`your permits. PLEASE CHECK
APPRC}PRIAT�LY IF PAIll:
YES� �T�_�..4
MO'I`ELS AND OTHF,R LODGING ESTABLISHMENTS
TRE�NSIENT OCCUFANGI': For pwpc�ses nf the Iirnitations af Motei or Hotel use,Transient occupancy shall be
liniited ta the temporary and short term accupancy,ordinarily and customarily associated with motel and hotel use.
Transient occupants must have and be ahte ta dernonstrate that they n�ainiain a principat place of residence
eisewhere.Transient oer,upancy shall�;eneralty refer to continuous occupancy of not more than thirty(30)days,artd
an a�regate af nat more ihan ninety(90}days within any six(S)mvnth perial. Use nf a guest unit as a residence or
dwelling unit shall not be considered transient. C)ccupancy that is subject to the collectian of Room f3ccupancy
i:xcise,as de�neti in 11�1.G.L.c.64G o��$30 CMR b4G,as amended,shall general�y be caDsidered Transient.
PO�LS
POQL OPENING:All sw�imming,wading and whi�ipcx�ls which i�ave been closed far the seasc�n must be ins�cted
by the Health Department prior to agening. Cantact the Health Depactinent ta schedule the inspection three(3}
ti�ys�rior ta opening.PLEASE NtJTE:Peaple are NqT atlowed to s►t in Yhe pnol are�until the paal har been
inspected and opened.
POQL WAfiER TESTING: 'T}�e water must be tesfed for pseudomonas,tc�tal calzfarm and siandard plate count
by a State certified lab,and submitted to the Health llepartment three(3)days prior tir opening,and quarterly
thereafter.
P{3UL CLQSING:Every outdoor in grc�und swinuning pool must be drained or cavered within seven(7)days of
ctnsing.
FOOD SEKV[CE
SEASC?NAL Ft�OD SERVIC`E(?PENii+TG:
Akl foc�d servies establishments must be inspected by�he I�ealtlx L7e�artment prior ta opening. Please contact#he
Health Dep�rtn�ent ta scheduie the inspection three(3}days prior to opening.
CATERING POLICY: �
Anyane who caters within the Town c�f�'almouth mus# notify the Yannouth Eieatth Departnaeni by filing the
required Temp��rary Food Service Application farm 72 hours prior io the catered event. These forms can be
obtainerl at the Health Department,ar fram the Tc�wz�'s wehsite at www.yarmouth.ma.us under Health Deparknent,
L3ownloadab(e Forms.
FROZ�:;N DESSERTS:
Frozen desserts must be tested by a State certified!ab prior to apening az�d rraontlily ti�ereafter,with s�unple results
submitted ta the Heaith L7epartn�ent. Failure to dc�so wiil resutt m the suspension or revocation of your Frozen
Dessert Permit until the above terms have been met.
OUTSIDE CAFES:
t)utside cafes(i.e.,outdoor seating with wai�err'waitress sen�ice),mu,st have prior appmval fram the Board of H�th.
OUTDOUR CC)(}KiNG:
' Outdoor caokin�,preparatiar�,or display of any f`ood product by a r�tail or food sen�ice estabiishment is prohibited.
' iVOTICE:Permits run annually from January 1 ta December 31. CT�S YOUR RESPIJNSIBILITY TO RETtIRIV
THE Ct)MPLETED RENEWAL APPLtCATtC7N(S)ANI3 FtF,C�tJIRED FEE(S}BY DECEM$ER 1 b,2016,
' ALL itENOVATI0N5 TC} ANY FQOD E3TABLISHMENT, I�SOTEL t}R FQOL {i.e., PAIN'I"ING, NEW
' Et�UIPM�Ni",E7'C.),MUS'I'BE REPUR1EL71'U AND APPRQVEI�BY'I'H�Bt7ARD t�F HEALTH PRIOR
' '1`O�'OMMEN��MEN`1". RENOVATIONS MAY UI ,'ry�iT�PLAN.
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1�,ATE: /Y SIGNA"I'LlKE• J 1�--'""-�
PKIN't`NA.ME 8c TITI,F,: 4.G.� Sl t.V✓�_-: �'I 11,�C.�_ �O L�
x�Y.ea��zr�6 ����°�'��!'"'�—
� Tk� +�nr»mnnwettlth �f Mr�ssuchusetts
Department vf In�iuustrial A�ci�letri's
U�ce vf Irrvestigatinns
� 1 +�'angress Street,Suite 1 t111
1�vstor�,.1�1A Q211 d-2U17
►�ww mass.gt�vlrtia
V{�'arkers' Comp�nsa#i+nn Insarance Affid�vit. General Businesses
A licant Inforrnation Please Pri�t Le ib1
Busin�ss/Organizatian Name:���u� T�� ���.✓��p�.��a����._
Address: �� � ��� � �
n -�
City/Statel�ip: U (�B d� Phvne#. .� �� ��� ����
Are ou an e�ployer?Check the apprnpriate t�x: Business Type{required}:
1.� 1 am a em loyer w�ith��ernpic�yees�(fi,�ll ar�cll �. Q Retai]
o -time .�` fi. ❑ Resttwrant7BarfEating Establishment
2.❑ I am a sole pro�rietor or partnership atid have n� 7. ❑Office andlar Sates{incl,resi estate,auto,etc.}
employe�s wa�rking far me in any capacity.
[No warkers' aomp,insurance r�uired] 8. �Non-profit
3.❑ We are a corparation and its s��cers have exercis�d 9. (,� Enterta�nment
their right Qf exemptior�per c. 152,§1{4),and we have I0.(,� iYfanu#'acturing
no e�nployees. [Na woxkers'cc�mp, insurance required]* ��.� Health Care
4.❑ We are a nc,n-profit c�rganization,stat�ed by voluntears,
with nc�emplc�yees, [�to workers' r.c�rrtp.insuranc�r�q.] 12.�Other �__��r�a�-�'Sf
"At+Y ap�licant t6ae checks box#�i must alsa fitl out�2►e section be1oK+shvwing tt�eir worlcezs'cumpe�satio�pols`cy information.
*'"i€the cdarporate offit�rs have exempted thems�lves>hut the corpctratiots 3�as ather�mployees,s workers'ctisnpensatic+n perlicy is requ%�d e�ad s�h an
or�anizaLion should eheck box#1.
I arn an emptvyer ticcat is prnv�'dang workers'e�rry�ensarion fnsurance fvr my empfapees. Betaw 3s th�policy inforn�ativn.
�
insurance Company�+iame: ,�,�'�tJ P�-f�'�
Insurer's Address: f S� �r {�� �aa�5 �i�'�e �l0
cytylstatelzip: ���mvx.,�o �/J►'�n�c'. �'C� �� �'C� � --.��f1 9
Policy#or S�If-ins.Lic.#�(J� `�'� �� l '� �xpiratian Date:
At�tach a copy af tt►e workers'compeosation pnlicy declaratiou page(shc►wing the policy namber and eapiratiou d�te}.
�'ailwre t�s secure coverage as requirEd und�r Section 25A t�fMGL c. 152 can le�d tQ the imp�rsition tsf�rimiz�al pena�tz�s pf:�
�Sne up tzr$1,SU0.{}tl andlvr one-year imgrisonment,as well as civii penal�ies in the form of a STt}P W�RK CiRDER and a fi�e
nf up to SZSb.fl4}a da}t against the vinlator. Be advised that a copy ofthis statement rnay be forwazdeci to the Uf�ce of
Investigations of Che DIA for insexrance cov�ra�e uerificatian.
I�to herehy c�erti ,ut�der the pains ared penalties afperjrrry thut the lnforrr�ivn prvviried abave is true nad correct.
�
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Ph ne#: (�
!�'.f.f��cial use anly. lhr nr�i wr�te�this area,tv he completed by clty or tawn af,f�inL
City ar Towa: PermitJi�icense#
Issuing Authority(cirele ane}:
1.Boawd of Healt6 2.Bailci�g Depsrtmeat 3.CityfI'own Cierk 4.Licensing Board 5.Selectmen's Uff��
6.t)t6er
Contact Person: Pl�c�ne#:
www,mass.govldia
�'►�o� CERTIFICATE OF LIABILITY INSURANCE DATE�MMIDDM'YYj
11/30/2016
THIS CERTIFICATE IS ISSUED AS A MATTER 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 the certificate holder is an ADDITIONAL INSURED,the policy�ies) must 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 endorsement(s).
PRODUCER CONTACT
NAME:
AUTOMATIC DATA PROCESSING INSURANCE AGCY INC PHONE F�
A/C,No,Ext: 877 677-0428 NC,No: 877 677-0430
1 ADP BLVD MS 625 E-MAIL
ROSELAND,NJ 07068 ADDRESS:s cbicad ave�ers.com
�H77�F)77-O42H __ _ _ ___ __INSURER(5)AFFORDING COVERAGE .___ _ _1_ NAIC#
INSURER A:THE TRAVELERS INDEMNITY COMPANY OF CONNECTIWT ���� ��
INSURED INSURER B: � '��
SILVA,HOLLYTHE BLUSHING
OYSTER BED&BREAKFAST iNsurtea c:
_._ _. __._
168 RT 6A INSURERA:
YARMOUTH PORT,MA 02675 iNsuRER e: '
--_ __ _ _ __ __ _ ,__ _
INSURER�F: ''�
COVERAGES CERTIFICATE NUMBER: 068369101�31533 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POIICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR 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 TtRMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR ADD SUBR POLICY EFF POLICY EXP
TYPEOFINSURANCE INSD YWD POLICYNUMBER ___. . (MMIDD/YYYY)____.(MMIDD/YYYY)__._ LIMRS
LTR . __. --- —� �--- -- _. __
__. _._. ___.__ . _ . . -----
�� EACH OCCURRENCE $
COMMERCIAL GENERAL LIABILITY � DAMAGE TO RENTED
CLAIMS-MADE �OCCUR � PREMISES Ea ocarrence $
MED EXP An one erson $
PERSONAL&ADV INJURY $
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $
POLICY �PR� �LOC � PRODUCTS-COMP/OP AGG $
JECT
OTHER: $
� COMBINED SINGLE LIMIT $
AUTOMOBILE LIABILITY (Ea accident)
BODILY INJURY(Per person) $
ANY AUTO
ALL OWNED AUTOSULED � BOOILY INJURY(Per accident) $
AUTOS
HIRED AUTOS NON-OWNED � PROPERTY DAMAGE
AUTOS (Per accident) $
$
UMBRELLA LtA6 OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE - AGGREGATE $
DED RETENTION$
$
' A WORKERSCOMPENSATION NIA UB-7F611801-16 04/05/2016 04/05l2017 X STATUTE '''.ORH-
AND EMPLOYERS'LIABILITY Y/N
ANY PROPRIETOR/PARTNER/EXECUTNE ❑ � E.L.EACH ACCIDENT $'I OO,OOO
OFFICERIMEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $1 OO,OOO
(Mandatory in NH)
If yes,describe under E.L.DISEASE-POLICY LIMIT $500,000 �
DESCRIPTION Of OPERATIONS below
DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 107,Addkional Remarks Schedule,may be attached ii more space is required) �
CERTIFICATE HOLDER CANCELLATION
SILVA,HOLLY THE BLUSHING SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
OYSTER BED&BREAKFAST THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
168 RT 6A ACCORDANCE WITH THE POLICY PROVISIONS.
YARMOUTH PORT,MA 02675
AUTHORIZED REPRESENTATIVE ('�` I � • ��'�
O 1988-2014 ACORD CORPORATION.All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD