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Home My WebLink AboutApplication and WC . � , REt��W o�o r��A�- � � TOWN OF YARMOUTH BOARD OF H ALT 1k��5� I�Jt`3 � � APPLICATION FOR LICENSE/PERMI -2� � 5 2�� ; ....• * Please complete form and attach all necessary docu ent�� 1 01 � ! Failure to do so will result in the return of yo � ��g ; I ESTABLISHMENT NAME: � TAX D: - � I LOCATION ADDRESS: R ��c TEL.#: ,SD - - ' MAILING ADDRESS: c � 7: i E-MAIL ADDRESS: r��( c� o� G�'� a ss c�s ct - �;v�,�or� i OWNER NAME: �I i- � Y� C'/e � � a3 �o/ CORPORATION NAME (IF AP LICABLE : v rn i s as �� i� :�'n C . MANAGER'S NAME: �Q� n TEL.#: -� , MAILING ADDRESS: � POOL CERTIFICATIONS: i The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated I Pool Operator(s) and attach a copy of the certification to this form. l. 2. 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 belbw 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. I 1. 2. ( PERSON 1N CHARGE: I 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 E copies of certification to this application. The Health Department will not use past years' records. You must f provide new copies and maintain a file at your establishment. i 1. 2• ( HEIMLICH CERTIFICATIONS: � All food service establishtnents 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. � 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: i LICENSE REQUIRED FEE- PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# I B&B $55 CABIN $55 MOTEL $110 �INN $55 ��o CAMP $55 _SWIMMING POOL$110ea. � _LODGE $55 _TRAILER PAIZK $105 _WHIRLPOOL $110ea. ; FOOD SERVICE: ' LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE P RM1T LICENSE REQUIRED FEE 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 � '_-<25,000 sq.ft. $150 _FROZEN DESSERT $�€0 _TOBACCO $110 NAM��H�3NGE: $is AMOUNT DUE _ $ g0.Q� '.� � **x**PLEASE TURN OVER AND COM�LETE OTHER SIDE OF FORM***** ,, �f- C�co(2�c1 ly7 i �1 � '`��' CERTIFlCATE OF LIABILITY INSURANCE s�a�2'oi;' THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RiGFFTS UPON THE CERTIFICATE HpLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NfGATIVELY AMEND, EXTEND OR ALTER THE COYERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUT� A CONTRACT BETWEEN THE ISSUINti INSURER(Sj, AUTHORIZED REPRESENTATIVE OR PRODUCER,ANb THE CERTIFICATE HOtDER. IMPORTANT: If the eartHicate hoider is an ADDITIONAL INSURED,th�policy(iea)rr�ust be endorsod. If SUBR4GATION IS WANED,subjact to the tarms s�d conditlons of the�Itcy,cartatn policiss may requlre an tndorso�rwnt. A statemsnt on thFs certiflcate do�not confar righb to thr certiBcatR holder in Ilau oi such endorsomen s. PRODUCER Idichaal Cali '. NP'P Property & Caeualty Sarvices, Iac. �NE . (617)405-1526 F� ,(617)8�7-1423 141 Longwater Dr #101 INSURE S AFFORDINfj COVERAGE 11A1�/ 1QOL'WBZl. HIA �2�61 INSURERA:PHIL�DFiLPHI� INSURANCSS �.'��5' wsure�o x�surt�fes:8erkshire Hathawa Ina Grou Co�apaas Roee Hospitality, Iac. n►suR�c: 277 Maia Street. Rt. 6A wsuReao: ' NISURER : Yaz:nouth Port MA 02675 RF; COVERAGES CERTIFICATE NUMBER:CL1762751470 REV1310N NUMBER: THIS IS TO CERTIFY THAT THE POUCIES OF INSURANCE LlSTED BELOW HAVE BHEN lSSUED TO THE INSURED NAMEO ABOVE FOR THE pOL►CY PERIOD INDICATED. NOTWITHSTAt�iNG ANY REQUfREA�NT,TERM OR CONDITION OF ANY CONTRACT OR OTHER QOCUMEMT WITH RESPECT TO WHlCH THIS CERTIFICATE MAY BE ISSUED OR tuEAY PERTAIN,THE INSURANCE AFFOROEO BY THE POLiClES DESCRIBEO HEREiN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCFi POtIGES.IlMIT3 3HOWN MAY HAVE BEEN REDi/CE�BY PAID CLAIMS. TYPE OF WSURANCE POl.1CY EFF POLICY EXP LMIRE GENERAL WBILITY EACH OCCURRENCE S 1�OOO�OOO ��....'. X COMMERCfAL GENERAL LU181LlTY ` A CLA�MS-MADE �OCGUR /2B/2017 /28/2018 �Eaoceurtsnce S 100.00� ��... A�EO E%P M Eme eraon S $i��O aerssowa�a n�v iruuRr s i,000,060 GEn�wu AGGREt�re s 2,000,QOO �M�p'C'C'��5�� PROpUCTS-COMPRIP AGG $ Z�OOO�OOO X Poucr �O' ioc y AUTOMOBILE LUlB1UTY � I LE ANY AUTO . BODILY INJt1RY(Per persan} S ALL OVVNED SCHEpULEO AUTOS ��p$ BODKY INJIAtY(Par acddaM) S HIREO AUTOS A�j17ag�� PROPERTY DAMAGE S S X wiers�w►u�e occuR �►a+occu�� s 1,000,000 A EXCESS WIB ��y� AGGREGAT£ S 7C ,� io,00 /Ze/aoi� /ze/soie g wo�ascorrp�sxnon s wc srnTu• on+- AND EMPLOYERB'LIABILRY Y!N � ANY PROPRtETpRfpARTNER/f�(ECUTII�E E.L.EACHACCIDENT Z 500 OOO OFflCER/ME1�ER EXCLUDEO? ❑ N 1 A ��.. (Manuaowy tr�tp1) xC833337 El.DISEASE-EA EMPLOYE E 500 000 Nysa,deacnbe under /Z8/2019 /28/Z018 �E RIPTION OF OPERATIONS below E.L.WSEASE-pqLICY LIMIT S SOO O OO �SCRIPTIOW pF OPERAT1pNS 1 tOCATW1i3!VEWCLES(Atbch ACORD 701.Addftlpeud Rsmarks 8ch�dule.N morc apa¢e�s�r�) CERTIFICATE HOLDER CANCELLATION mflorio0yarmouth.ma.u8 gHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BE�ORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIYERED IN TowII of YiT'1p01itb, MA ACC01tDANCE WtTH THE POIICY PROVISIONS. Atta: MaryAlice Florio 1146 �OYL9 28 AUTMORIZEDREi+RE8ENTATIVE South Yarmouth, MA 02664 Daaiel �Phyte/DANW .�- / ".,��_ -�� AGORD 25(2010/05) �1988-2010 ACORD CORPORATION. All►ights reservsd. INS025�so�oosy.oi The ACORD name and logo are registered marks ot ACORD � � � . . .. ...5 . -3 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 MUST BE COMPLETED AND SIGNED, OR CERT. OF 1NSURANCE ATTACHED OR � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED ; l Town of Yarmouth taxes and liens must be paid prior�o renewal or issuance of your permits. PLEASE CHECK � APPROPRIATELY IF PAID: YES� NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: Far 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. 1 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 ar 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 �losing. FOOD SERVICE SEASONAL FOOD SER�ICE 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 Departrnent, 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. ; i OUTSIDE CAFES: � Outside cafes(i.e.,vutdoor 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 IRE A SITE PLAN. ' DATE: /5� / SIGNATURE: � '� PRINT NAME & TITLE: �n�or�- � ✓�rn�lT�e� �(�iG'�ur / Rev. 10/12/16 i , , !� The Commonwealth of Massachusetts -g�� Department of Industrial Accidents I� Off ce of Investigations �1'C.0 C�S� , � ' ' 1 Congress Street, Suite I00 ��P�Ly 6�� j Boston, NfA 02114-2017 : � www.mass.gov/dia '�S�� Workers' Compensation Insurance Affidavit: General Businesses f Applicant Information Please Print Legiblv � � Business/Organization Name: ��t �ss s ' ' � � • ' Address: �77 �,�.�e � G� �t � c� acc � �/4" i aa�7 S- City/State/Zip: � u�i �r� � Od �SP�one #: jp/7-,�5� .�"�S� Are you an employer? Check the appropriate box: Business Type(required): 1.[�I am a employer with .3 employees(full and/ 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] 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 are a non-profit organization,staffed by volunteers, with no employees: [No workers' comp. insurance req.] 12.�ther �n n *Any applicant that checks box#1 must also fill out the section below showing their workers'compensa6on policy information. , **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an ', organizafion should check box#1. i I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. I� Insurance Company Name: '7u� � ! 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 ' 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cert' ,under the pains and penalties ofperjury that the information provided above is true and correct. � � Si ature: Date: /$� o�D> i Phone#: �� y5�9' �S7 Official use on[y. Do not write in this area,to be completed by city or town officiaL i� City or Town: Permit/License# I Issuing Authority(circle one): � t 1.Board of Health 2.Building Department 3. City/Town Clerk 4.Licensing Board 5. Selectmen's Office ', 6. Other I � Contact Person: Phone#: ' f www.mass.gov/dia