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Home My WebLink AboutApplication and WC �J �� , �* ► TOWN OF YARMOUT OF,� ALTH � . �-t�p–APRtI. � � APPLICATION FOR LI ��2017 APR 04 2�11 ; `.. ; * Please complete form and attach d �'° `by Dec be Failure to do so will result in the return of your application PT ESTABLISHMENT NAME: TAX ID: LOCATIONADDRESS: 252 (Yl��,c� �. ��a.4aa�nneuJ-0� .mAo2�23TEL.#: �g.szy.��ty '' MAILING ADDRESS: 252 Ma_i�,n �}-: �il .�lc;��i►. +(�A. n��'�� ; E-MAIL ADDRESS:_ ��5 H� 12,�� 6 �'�-(c3..Gi0 0.GoM__ ' OWNER NAME: i�i 5 hc..� �h uK 1�. ' CORPORATION NAME (IF APPLICABLE): NQ,W G4.,R� [o� MANAGER'S NAME: ' � TEL.#: U MAILING ADDRESS:� (�Gi�r-it�1�S lrl,��'C.4 , ar+e9f��G, 1'Y1R-02b44 POOL CERTIFICATIONS: The 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. l. 2. 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. -__.��-- L _ 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. l. 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# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $110 _INN $55 CAMP $55 SWIMMING POOL$110ea. _LODGE $55 TRAILER PARK $105 WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FE� PERMIT# 0-100 SEATS $125 _CONTINENTAL $35 NON-PROFIT $30 _>100 SEATS $200 _COMMON VIC. $60 WHOLESALE $80 —RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 �QS,OOOsq.ft. $150 �L _FROZENDESSERT $40 �TOBACCO $I10 .� NAME CHANGE: �is � AMOUNT DUE _ $ 2�0. �U *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** � � : 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 COMPENSATION INSURANCE AFFIDAVIT�M'UST BE COMPLETED AND SIGNEll, OR I CERT. OF"1NSURANCE ATTACHED �1� OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior 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 ar Hotel use,Transient occupancy sha11 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 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 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. PO4L CLOSING: Every Qutdoor m groLtnd swimming pool r�ust be drained or co�ered�ithin seven(7}days of closing. 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. rP 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 MAY REQUIRE A SITE P AN. DATE: �-{—! -?p� '�► SIGNATURE: "�--� PRINT NAME & TITLE: U►5 h� �j�11�! (C�4 — ��io��"�' Rev. 10/12/16 . � � The Commonwealth of Massachusetts _ Department of Industrial Accidents Offiee of Investigations ` 1 Co�zgress Street, Suite 100 Boston, MA 02114-20I7 � www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legiblv Business/Organization Name: �y.Q� �'�,� � �-p��G,�e, Gcd �a�S • Address: 2�32_ T�lc�nac�c� ^�s']3�'�o,e� City/State/Zip:�.�a�e�, �a.oz6�3 Phone #:�.-rj�p�.524 33�1 t! Are you an employer? Check the appropriate boz: Business Type(required): 1.� I am a employer with 2. employees(full and/ 5. � Retail or part-time).* 6. ❑ RestaurantBar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no �. � O�ce and/or Sales(incl. real estate, 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 a 152, §1(4), and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]* 11.❑ Health Care 4.❑ We axe a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.❑ Other *Any applicant that checks box#1 must also fill 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#1. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: �p} Q.�}�1(e''2b, ,�'�'• �. j�U•rcn��f'1�Su�'4MCe �.EiCt�JnGy � Insurer's Address:�_d. � ��Q City/State/Zip: �y Z2Cl�b�4 . i�� 25�3 2-- Policy #or Self-ins. Lic. # ��y(�0�cL��21•� I I 1 Expiration Date: �.. �-�� Attach a copy of the workers' compensation policy deelaration page(showing the policy number and egpiration date). Failure to secure coverage as required under Section Z��f hgGL c. 152 car.!ead to the impasition 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,under the pains and penalties of perjury that the information provided above is true and correct. Si�nature• � A �� t��— Date• 1-� •201�7 ; Phone#: � • Z.,�I - (,l Official use only. Do not write in this area,to be completed by city or town officiaL City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3. City/Towu Clerk 4.Licensing Buard 5. Selectmen's Office 6. Other Contact Person: Phane#• �.vww.mass.gov/dia ''`�c�� CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 0313120'17 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RKiHTS UPON THE CERTIFICATE HOLDER THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAt3E AFFOtmED 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 certiTicate holder is an ADDITIONAL INSURED,the policy�iss)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WANED,subject to the t�rms and conditions ot the policy,certain policies may require an endorsoment. A stat�ment on this certificate does not conter r' hts to the certificate holder in lieu of such endorsement s. PRODUCER N�E T Deborah Hathav�y G.H.D�n Ins�rarxeAgency a22-3242 P.O.BOX�O PHONE . �� NC�No):��'�ZA3 &¢zards Bay,MA02532 ,�oREss: deborah�gFxkm.can INSUR 8 AFFORDINGCOVERAGE NAICtM iasuReR n: MA RETAILERS �ppppp INSURED New Cape Cod Cwp dba C�e Cod Farms IN9URER B: 1 Patricis V1kiy Forestdale,MA02644 IN3URERC: INSURER D: INSURER E: I R RF: COVERAGE8 CERTIFICATE NUMBER: REVISION NUMBER: 1HS IS lD CERTiFY THAT Ti-E POL�CIES OF INSURl1NCE LJSlED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABO�VE Fq2 TI-E POLICY PEPoOD IIdDiCATED. NOlW1T}iSTANDING ANY REQUREMENT, TERM OR Cq�DIT10N OF ANY CONTR4CT OR 011-ER DOCUuEM WITH I�SPECT Tt�WHCH THS CERIIFICATE MAY BE ISSUED OR MAY PERTAIN, TFE INSURANCE AFFOF�DED BY TI-E POLICIES �SCPoBED I-EI�IN IS Sl.BJECT TO ALL 11-E lERMS, EXCLUSIONS A!�CONDI1101uS OF SUCH POLIGES.LIAMTS SI-IOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ��R TYPE OF INSURANCE �� POUCY EFF POLJCY EXP POLICY NUMBER LIMITS COMMERCIALGENERALLIABIUTY EACHOCClA2RENCE $ CLAIMSMADE �OCCUR DAMAGETORENrED PR Ea occurrence S NED D�(My one person) S PERSONAL 8 ApV INJLRY $ GENL AGGREGATE LIMfT APPLIES PER: GEN92AL AGGREGATE S POLICY ��T � LOC PRODIICTS-CONP/OPAGG S OTFER: $ AUTOMOBII.E UABILITY CONBIhED S'INGLE LIMIT a xMent ANY AUTO BODILY INJIhiY(Per paroon) S OWNED SCF�DULED AUTOS OrLY AUTOS BODILY INJURY(Per acdden� $ HRED NON-01M�ED PROPERTY DAMAGE AUfOSOhLY AUTOSOPLY p S $ UMBRELLAL44B OCCUR EACHOCCURRENCE $ EXCESS LIAB CUUMS-MADE AGGREGATE $ DED RETENr10N$ $ A WORKERSCOMPENSATION 014005034124117 Q4f�'� �/��$ � OTIi AND EMPLAYERS'�IABIUTY Y�N STATIlr ANY PROPRIETORlPARTNER/EXECUINE E.L.EACH ACCIDETIT S J�,�O OFFlCER/MEMBER EXGI.WED? ❑N N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ rJOO,�O R ea,dascribe under — IPT N OF OP62ATIONS bebw EL.DI9EASE-POL.tCY LIM�T S �� DESCRIPTION OF OPERATIONS/LOCATION3/VENICLES(ACORD 101,Addkbnat Remarks Schetlule,may bs attached if more space Is requlred) Stare 252 Main Street V1kst Yarmouth MA 02673 CERTIF�ATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLIqES BE CANCELLED BEFORE THE EXPIRAT�N DATE THEREOF, NOT�E WILL BE DELNERED IN Town of Yarmo�dh ACCORDANCE WITH THE POLICY PRONISIOMS. 1146 Rt 28 South Yarmouth,MA 02664 AUTNORIZED REPI2ESENTATIVE� �� m 1888-2016 ACORD CORPORATION. All rights reservad. ACORD 26(2016/03) The ACORD name and loqo are registered marks of ACORD