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� � TOWN OF YARMOUTH BOARD O��I�AI�T�I �y � �
� � � APPLICATION FOR LICENSE/PE � � �- ` � � "
� � R�� �' MAR 0 3 2017
� , � .
� `°� * Please complete form and attach all necessary do�c,"um y ecem e 16 2016.
� Failure to do so will result in the return of your application pack . HEALTH DEPT.
� ESTABLISHMENTNAME: CI�Pc �D ��}m;(;,� 12�s�2� TAXID: �- -�—
; LQCATION ADDRESS:_5/ Z- � 2-f� TEL.#: S`c"i�- 77/-G'/Uf
4 MAILING ADDRESS: P� 13 c�)c �f-�l � �WY?t2.Yht�v�,� t�1'l4 ��J3
E-MAIL ADDRES S: )'��, vn cc�-v- �w,c:._ � q y»a.o( , c:a�
; OWNER NAME: .�cf t f'V�r+r�/�vn►�-
' CORPORATIONNAME (IF APPLICABLE): S�-n�b8 q 2 �v1,�4-iU��j�t�k.� �v��
� MANAGER'S NAME: _.,/o E yh r� /�,rz v�-m,,�, TEL.#: R?�-3 7.�-�-�v�-
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� MAILING ADDRESS: P� r3 d�c � g�r 1.c.i. !�r�.vKv i,�'L, 1�22� 0 2-�,73
I
; POOL CERTIFICATIONS:
� The pool supervisor must be certifed 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.
� 1. �ool %eC1�n �'v c,� - d��'� S� ��►-c..s c� w 2. ���+ ���� Pcsc..I�.�rs�
� 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
i 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.
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FOOD PROTECTION MANAGERS - CERTIFICATIONS:
All food service esfablishments 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 �le 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-chokmg procedures below and
attach copies of employee certifications to this form. The Health Department will not use past years' records.
I�I You must provide new copies and maintain a file at your place of business.
1• 2.
3. 4.
RESTAURANT SEATING: TOTAL#
�
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
B&B $55 CABIN $55 1 MOTEL $110 ( -6 Z
, _INN $55 CAMP $55 ' 2 SWIMMING POOL$110ea. Q Q"ja
_LODGE $55 TRAILERPARK $105 �WHIRLPOOL $110ea. �
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE P RMIT LICENSE REQUIRED FEE PERMIT#
0-100 SEATS $125 �CONTINENTAL $35 ���0 NON-PROFIT $30
>100 SEATS $200 _COMMON VIC. $60 WHOLESALE $80
—RES1D.KITCHEN $80
RETAIL SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_<50 sq.ft. $50 >2�,OQ0 sq.ft. $285 VENDING-FOOD $25
_<25,000 sq.ft. $150 =FROZEN DESSERT $40 TOBACCO $I 10
NAME CHANGE: $is AMOUNT DUE _ $ `I"�5•O�
**x**PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM ���-'�s"�6�IQ'"�Z
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ADMINISTRATION f
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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 COMPENSATION 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 prior to renewal or issuance of your permits. PLEASE CHECK
AFPROPRIATELY 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 y
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 thirty(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 j
E
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. N
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 farm 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 establishr�ent 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 COMIVIENCEMENT. RENOVATIONS MAY REQUT A SIT PL/ . , ±
� L���LI�'-�' �
DATE: �j �i '7 SIGNATURE:
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PRINT NAME &TITLE: r��s e„G, �� OdG�1 f'i�.'�!-�.<,,� �= �v,�c,,.�
Rev. 10/12/16
' � ` .� The Commonwealth of Massachusetts
;
' . Department of Industrial Accidents
Office of Investigations
` 1 Congress Street, Suite I00
Boston, MA 02I14-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Apnlicaat Information Please Print Legiblv
� Business/Organization Name: S�" cQ��,,� {�q,��c,.,.,��7- Q13� ��,�,( F',�ly ,�5�?.f'
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Address: 5�z Y�, �,
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i ty p: , �'VW _ �� 73 Phone #: Q J�r-3 '7s -s�y�v
; Are you an employer? Check the appropriate bog: Business Type(required):
± 1.� I am a employer with_��employees(full andl 5. ❑ Retail
� or part-time).* 6. ❑ RestaurantBar/Eating Establishment
' 2.❑ I am a sole proprietor or partnership and have no �. � Office and/or Sales(incl. real estate,auto, etc.)
? employees working for me in any capacity.
� [No workers' comp. insurance required]
8. ❑ 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 �b-�
*Any applicant that checks box#1 must aiso fill out the section below showing their workers'compensation policy information.
**If the corporate o�cers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an
organization should check box#1.
' I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information.
i
j Insurance Company Name: �� lu� c� � !�t ,/-�r�� , L N
Insurer's Address: �7 6 ���„�.,,�.,,,z,v S�.
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City/State/Zip: � � �Zl,�v,�h /i1t�. � t 4 2r c�
Policy#or Self-ins.Lic. # S/-�u.� L -7 � � 3 c�� Expiration Date: /G�/ �/�7
' 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
fine up to $1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
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,und the pains an enalties of perjury that the information provided above is true and correct.
Si ature: Date: 3�
Phone#: �J 7�' 3 7.S`— S��`L
Officiul use only. Do not write in this area,to Le completed by city or town officiaL
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office
6. Other
Contact Person• Phane#•
www.mass.govidia
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co�.ra CERTIFICATE QF LI�►BIL.ITY INSURANCE °"'�`4���
THS CER71FtCi4TE IS ISSUEQ AS A NIATTER t�F II�ORMa'TiON OI�Y AND GONf�RS l�ID I�IG}iTS iJPdN THE CEF�flFtCATE NOLDER TI�qS
CE/27lFICATE DOES NOT AFFi1�WIATlVELY UR IYEGATIVELY AMH�, EXTEND OR AL'F�R 7F� COVERAGE AFFORDED BY 7HE ROLIqES
BELt?W. THtS CERTIFEGATE OF INSURANCE DO�S NCTT CQNSTiTU'tE A C�NTRRCT BE7WEE{�t THE �gSl�NCs INSURER{S),Al7TNORIZED
RERRESEM'A'C1VE OR PRODiJCER,AND THE CERTlRCATE HOLDER.
1�ttPORYANT; if#he ceRificatie hokier is an ADD111QNAL INSiJRED,the policy(i es}mast be endorssed if SU�OGA tlN iS WAiVEi?,subject to
the temts and condltiar�s ofthe i��Y,certain policles may ret�ire an endorsement. A stat�ment on tl�s certificate does not c��rigtrts t�ri�e
certifrcafe hnider in tieu of such enclorsemen s). '
PaooueaR
Choice Insurance en ru�n�: .___..._....,_m__.�._ __ ..__._ .._�_� __ .__,__ �_____._.. _____. __._�_._
+�9' �Y', Inc. PHONEM fjZS 34 -48 3 ,Fnx� . (978) sa5-1oo�
376 Summer Str�et ;
Fitchburq, r.u� aia�a �s: �r,oi��c�no���-insurance.com
_----__ INSUiPE�S1AFfORWPIG_COV'ERAGE � _..NAfC*,
it,�R�n:NorGuard Insurance Co. _.
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Sanc�ar Management, InC, __ -. � ____��,_ � _ .. �__ ___ __:� __ _.___
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Cap� Cod 2n�l�table Park ar�Rat c:
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W�st Yarmouth, MA 02673 rasur�eeE; . _ _. . . _ . .
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INSIJRER F:
CbVERAGES CERTIFICATE NUMBER: REViS10At NUMBER:
THi5 IS TtJ GERTtFY Tl-IAT 11iE P�IC�S O�INSURANCE USTED BECQW HAVE BEEN tSStJEO TO TME tNSt1RED Nqpll�qBpS/E FOR THE P(X,ICY PERlQD
iNQICAT�. NQTWiTtiSTANDIAJG ANY RECtINREAAENf7",TERM Oi2 CONDITtON OF ANY GONTRAC7 UR OTH�R DOCt1MENT WlTH RESPEC7 70 WHICH TN}S
GERTIFtCATE N�4Y 13E ISSiIEp QR MAY PERTAIN, THE IN�URANCE AFFORDED BY TI-E POLICIES DESCRIBED HEREIN tS SUBJECT TO ALL THE 7ERMS,
F_XCL�t3PiS AND CdN€JIT10N5 tiF SU(�i POUCIES.L�v}ITS SMOWN MAY HAUE BEEN REDUCED 8Y F/�UD CiApUS.
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CERTIFiCA7E HOLDER �qp}������p�
SHOULD ANY QF Yi�lE ABOVE!'�SCR}BEp POLFCIE3 BE CANCELIED BEFOI�
TNE EXPIRAXION DATE T1iEiiEOF, Np710E WIL(. BE DELIVERED �I
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Ak�YHOfmYBD REPI�SENTAiN�
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ACORD 25 f��'�d�) The AGORD r�ame and logo ere regis�redmarks�f ACOi2D
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