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Home My WebLink AboutApplication and WC ��0�� •� � � TOWN OF YARMOUTH BOARD OF HEALTH ° � � APPLICATION FOR LICEN � :k .. •1UN �J� ZO11 ..... � - ��; * Please complete form and attach all nece � mb PT Failure to do so will result in the re#�rn ofyour appli i n . ESTABLISHMENT NAME: TAX ID: LOCATION ADDRESS: � Ct�lUY� TEL.#: � (� MAILING ADDRESS:�. . E-MAIL ADDRESS: � , OWNER NAME: CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME:cS-{' � TEL.#: a- MAILING ADDRESS: 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. 1. 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• � --- _ � f 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.�i�� Q J'I1L�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. �. �'c� � 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 TRAILERPARK $145 WHIRLPOOL $110ea. � — — F FOOD SERVICE: � LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE P� i 0-100 SEATS $125 _CONTINENTAL $35 �'NON_P�RO� ��F_�IT_ $30 >100 SEATS $200 COMMON VIC. $60 VJHOLE��---�$8�` — — —RESID.KITCHEN $80 f RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<2� q >25,000 sq.ft. $285 VENDING-FOOD $25 ,000 sq.ft. $$50 _FROZEN DESSERT $40 _TOBACCO $110 I NAME CHANGE: $�s AMOUNT DUE _ $ � *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** �('��,5—��Ri Z'6Z I ti ADMINISTRATION Under Chapter 152,Section 25C, Subsection 6,the Town of Yarmouth is riow 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 1NSURANCE 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 APPROPRIATELY IF PAID: YES f 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 thirty(30)days,and an aggregate of not mare 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. 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 COOHING: �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 MA RE UIRE A SIT PLAN. DATE: 5 SIGNATURE: PRINT NAME & TITLE: � � ' Rev. 10/12/16 - ��fj� / {/ � The Commonwealth of 11�assachusetts > � Departmeni of Industrial Accidents Office of Investigations � 1 Congress Street, Suite I00 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name:��Q,�(I(Y►�l�In(S �P� �C�C:I.��r�,�� s�� t o s-f�cm�1�;K,rx.u,� �o.�fan7�-t� csdtotD 4 ' M�u►�ddress:�p � -1 �T�c�C1�7�C�n��r-(-, V�� tSa(e'l� , City/State/Zip: Phone #: I, Are you an employer? Check the appropriate bog: Business Type(required): '! 1.Q I am a employer with�_employees(full and/ 5. ❑ Retail � or part-time).* �'(,tJr1�L�y•1�� 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] 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 *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 themseives,but the corporation has other employees,a workers'compensation policy is required and such an , organization should craelc box#L � I I am an employer that is providing workers'compensatio insurance for my employees. Below is the policy information. ' Insurance Company Name: � }(' � Insurer's Address: 1`' � V City/State/Zip: ��i�V , � �i T � ()�S l--'J � � � ��(S�oS�ab�� ' Policy#or Self-ins. Lic.# o � ration Date: i Attach a copy of the workers' compensation policy declaration page(showing the policy number an 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of ; Investigations of the DIA for insurance coverage verification. I do hereby c ify, under the pai andpenalties ofperjury that the information provided above is true and correct. Si ature: Date: ' Phone#: ' � i Official use only. Do not write in this area,to be completed by city or town official � I City or Town: Permit/License# � Issuing Authority(circle one): 1.Board of Health 2.Building Department 3. City/Town Clerk 4.Licensing Board 5. Selectmen's Office 6. Other i Contact Person: Phone#: www.mass.gov/dia op�taMromvvr� q�a� CERTIFICATE OF LIABILITY lNSURANCE �,�,� 5/18/16 THS CERTIFICATE IS ISSUED AS A MATTER OF INFORMQ710N ONLY AND CONFERS NO RIGHTS t�ON 71iE CERTIRCATE HOLDER. T1�8S CERTIFICATE DOES NOT AFFIRNIA7IVELY OR NEGATNELY AMO�D, EXTEI� OR ALTER TF� COVERAGE AFFORDED BY THE POLIqES BELOW. TFBS CERTIFlCATE OF I�ISURANCE QOES NOT CONSTITU7E A CONTRACT BETWEEN THE 1SSUNG INSURER(S), AUTFIQi�ZED REPRESENTAl1VE OR PRODtJCER,AND 11iE CERTIFlCATE HOLDER. iMPORTANT: If the certificate hoider is an ADD1110NAL INSURED,the policy�ies) rrwst be endorsed. If SU�20GA710N IS WAIVED,subject to the tErms and co�ditio�of the policy,certain policies may require an erMorserrnent A sra�emerrt on this certificate dces not ca�fer rights to ihe certificate hoider in lieu of such endorsement(�. PRODUCER CONTACT NAA�E: John F Martin Insurance Agency PHONE 508 398-2277 � p ; t5os) 398-2239 1Q23 Route 28 aoi°��ys, 'immartin321� ahoo.com FO Box 350 INSU(iE S AFfORDING COVERAGE NAIC� South Yarmouth, MA 02664 _q A_ ��Re�a: incy Mutua.l INSUR� IP�JRB2 6: YARMOUTH DENNIS RED SOX tr�Re�c: SASEBAI�L CLUB INC �($�R�D: P O BOX 7S IAIStJRBtE: YARMOUTH PORT, MA 02675 �p�RH2F: COYERAGES CERTIFICATE PIUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICES OF INSURANCE LlSTED BELOW HAVE BEEN ISSUED TO TF1E WSU2ED NAMm ABOVE FOR THE POLICY PERIOD INd�AT�. NQTWITHSTANDNG ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WffH RESPECT TO WHICH TFfIS CERT�ICATE MAY BE ISSUED OR AAAY PERTAdV,THE INSURANCE AFFORDED BY TI-E P�ICIES DESCRIBED HERE�V IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POIJCIES.LAIAITS SHOWN AMY HAVE BEEN REQUCED BY PAID CLAIMS. INSR ----- _.________..------ -� POUCYEFF POLIGYE%P ------.._------- LTR TYPEOFINSURAN� �N yyyp POIJCYWUI�ER MfmlY MNAOIYYYY I.1AS75 GENERALW1�LIlY Y $Q 109334 8/19/16 8/19/1T EqCHOCCUla2ENCE $ ' I, ��0 0�0 X GONMERCIALGEPERALLIABWTY DANIAGETORENTED o • n $ 300 000 CLAfl�-AAADE �OCCUR NED D�(Anyone persm) $ �.O OOO PERSONAL&ADYIN,RIRY $ c�NEwu acc-�Ecn� S Z QOO OOO GEN'LAGGREC�TELp�+11TAPPllESPER PRODUCfS-CONPI�AC� S 2 OOO OOO POLICY PRO- L� $ AUTOMOBIIE LIABILITY CQMIB INED SWGLE L�JfR �- . a accddert $ ANYAIITt? BO�YINJURY(P�pars�} S ALIOWPED SCHEDULED BODILYINJURY(P�acctident) $ AUTOS AUTOS NON-0WNED PROPERTY DAMAGE $ HIREDAUTOS _AUTOS �aocident S U��U� OCCUR EACH OCCUF82ENCE S EXCESSUAB ---CLAIMS-IVIADE AGGREGATE $ DED REfENTFON$ $ WORKERS C�INPEF�ATION WC STATU- QTH- AND 6NPLOYERS'LIABIIITY Y/N MIY PROPRIElC1R/PRRTNER/EXECUTNE EL E1iiCH/\Cq OENf S OFFI�WMEMBER IXCLIAED? � N/A (Wlandafury in NH) Et.DISEASE-EA 9VPLOY S Ifyes describe under DESG�RIPTION OF OPERATIQNS bebw EL.DISEASE-POLlCY L6NR $ �SCRIPTION OF OPERAl70NS/LOCATiONS(VEtGGLES (Attach ACORD 101,Addrtion�RertaAcs ScF�edule,if more space�rsqu red) One Press Box Building One Coneession and merchandise Building CERTIFICATE HOLDER CANCELLATION SHOULD APIY OF THE AB05/E DESCRIBED POLICES BE CANCELLED BEFORE TF� EXPiRA710N DATE THEREOF, NOTICE WILL BE DELIIIERED W DAIIII13 Yarmouth Regional A DANCE WITH'fHE POLICY PROVISIONS. $C�3001 D1S�S1C� 210 Station Avenue a �T South Yarmouth MA �2664 - � '��tl�C� � �O 1988�010 ACORD CORPORATION. All righfs reserved. ACORD 25(201 Q105� The A�CaRD name and fogo are reg' red marks of ACORD Phone: Fax: E-Mail: