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Home My WebLink AboutApplication and WC , ' � �� TOWN OF YARMOUTH BOARD OF HEALTH ' � � APPLICATION FOR LICENSE ��L � � 2�1] ; � i `" * Please complete form and attach all necess r 1 Failure to do so will result in the ret yo li i ac . �E�T � ESTABLISHMENT NAME: �. ��(vv�v`4H Uv��-�e d -e-�odi s� TAX ID: i LOCATIONADDRESS: 3�g � 3�tL1 c�\c� Mc�iv� S�F„ S.�Iotw�aV�-�ntMViTEL.#: 50�.3`1$, `1`18a j MAILING ADDRESS: ��w�� ' ' E-MAIL ADDRESS: S.��c�<�o,y��,�,�� ve.�:�-z�,��v��-� OWNER NAME: Sa �\a-c mo�,i.� Vt1�, CORPORATION NAME (IF APPLICABLE): — MANAGER'S NAME: ��,�n.�d. S^ne.�\�y_ �oca�c.\ oF '��,�e.es, �r.u�c TEL.#: Samc, � � MAILING ADDRESS: Sqw�e. ' POOL CERTIFICATIONS: The�a�ol s�pervasor must�e certified as a�Pool f�gerator,as xequir y State law. Please list the desi�nated � Pool Operator(s) ancT attach a copy of the certification to this iurm. � � , 1. i � Pool operators must list a minimum of two employees ently certified in standard First Aid and Community Cardiopulmonary Resuscitation (CPR), having one c ified employee on premises at all times. Please list the � employees below and attach copies of their certific ons to this form. The Health Department will not use past years' records. You must provide new copie nd maintain a file at your place of business. ; L 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. p � 1, ��Y�\e �w��\�� 2. �q ��w�qv� 3� ��v.e_ A�us�� PERSON IN CHARGE: _ .____ � Each food establishment must have at least one Person In Charge (PIC)on site during hours of operation. � � 1. �o�nr� 5w�.�.\uv��, 2. �Uc� �F'�w�h � 3.. �P au\�v�e, vs�� 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. �i.a by e• �cke�'f-1�e.�c�y 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 i attach copies of employee certifications to this form. The Health Department will not use past years' records. i You must provide new copies and maintain a file at your place of business. E 1. S�`v�v� �O�v�can eX . I�a t � �J\°► 2. �QYr-i e� Mu•� h ( 3. �.h�c�s ��c\Ltv c-�cc, �a ��+ ao�g 4. h��a�. �ve ., RESTAUR.ANT SEATING: TOTAL# OFFICE USE ONI,Y 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 $1IOea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# ICENSE REQUIRED FEE �� 0-100 SEATS $125 _CONTINENTAL $35 �NON-PROFIT $30 �1 >100 SEATS $200 _COMMON VIC. $60 WHOLESALE $80 RETAIL SERVICE: —RESID.KITCHEN $80 I LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMtT# LICENSE REQUIRED FEE PERMIT# � _<50 sq.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 � <25,000 sq.ft. $150 _FROZEN DESSERT $40 _TOBACCO $1]0 i NAME CHANGE: $ts AMOUNT DUE _ $ �30,d� j I *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** k � � l Y 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 � k CERT. OF 1NSURANCE ATTACHED i �R � i WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED f I � Town of Yarmouth t�es and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK � APPROPRIATELY IF PAID: ' � YES� NO , , � k 1VIOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or 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 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 r 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. , _ _ . . _ __ __, _ _ i 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 m�st 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.yarmouth.ma.us under Health Department, ' Downloadable Forms. � FROZEN DESSERTS: I Frozen desserts must be tested by a State certified lab prior to opening and monthly thereafter,with sample results '�i 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: II 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. ALI, RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOAI�D OF HEAL H PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQU A SIT PLA � DATE: �j"' � "� SIGNATURE: PRINT NAME & TITLE: ��c�ci�c�, Sv�e.��ev , e�a��, �oa ��`Cus�rS. ' Rev. 10/12/16 7 . "` ' ' ' � The Commonwealth of Massachusetts _ Department of Industrial Accidents Office of Investigations ' ` 1 Congress Street, Suite 100 Boston, MA OZll4-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Le�iblv Business/Organization Name: S, ��,.�w�,c�,�1� Uln�� M�1-�.,c��S� �.0�rch Address: 3i$ } 3 a� 0\� Mo�iv� S-t� City/State/Zip: 5, t,�,� � M� OZs3(� Phone #: S�$�3�$,°1'-18� � Are you an employer? Check the appropriate box: Business Type(required): L�`I am a employer with " '`�J empioyees(full and/ 5. ❑ Retail � or part-time).* 6. ❑ RestaurantlBar/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]* ' 4.❑ We are a non-profit organization, staffed by volunteers, 11.❑ Health Care i 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 I organization shoWd check box#L I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. i Insurance Company Name: �C2� �, �,�u�rch,�v�c. t Insurer's Address: '�� e��YY�qr �"�Yee� City/State/Zip: `-..9�e.l� � � � t`�l$�1 � _ - Polic #o�Se�f-i�.�.-# � �o �;�C15�s��$�,�g t _� _ , . _ __ C�� _ ; Y ., �.. _ . . _ _,+.�x�irativ�r$ate_�-� �,-� -� - � Attach a copy of the workers' compensation poticy 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of i i Investigations of the DIA for insurance coverage verification. � � � I do hereby certify, under the pains a d pena[t'es of perjury that the injormation provided above is true and correct. ; i i Si ature: Date: � �' '� � , Phone#: SO$� �J`�g• `��o"Z Official use only. Do not write in this area,to be completed by city or town officia� i City or Town: Permit/License# � Issuing Authority(circle one): � 1. Board of Health 2. Building Department 3.CityJTown Clerk 4.Licensing Board 5. Selectmen's Office 6. Other i Contact Person: Phone#• www.mass.gov/dia � , . ' • . � ��Q� DATE(MMIDDIYYYI� � �,,.,�.- CERTIFICATE OF LIABILITY INSURANCE ��o,s � 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(iea)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 Wendy Radwan,APJ,AIS,CSRM Fred C.Churoh,Inc. NAME: 41 Wellman Street � PHONE 978 3227167 FAX (g7g)454-1865 Lowell,MA 07851 A/C No xt: AIC No: (800)2257865 � E�AAAIL wradwan�fredcchurch.com ADDRESS: INSURER S AFFORDING COVERAGE NAIC p INSURER A: Church Mulual Insurance Company 18787 INSURED INSURER 6: New England Conference The United Methodist Church INSURER C: P.O.Box 249 276 Essex SVeet Law�ence,MA 01842-0449 � IN3URER D: INSURER E: � INSURER F: ; COVERAGES CERTIFICATE NUMBER:sss�s REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES 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 TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. �� TYPE OF INSURANCE ADDL SUBR POLICY EFP POLICY EXP POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS GENERAL LIABILRY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMA TO RE ED PREMISES Ea occuRence $ CLAIMS-MADE �OCCUR MED EXP(My one person) $ PERSONAL 8 ADV INJURY S GENERALAGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG $ ' POLICY PR� LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accideM ANY AUTO BODILY INJURY(Per person) S ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accidenQ $ NON-OWNED PROPERTYDAMAGE HIRED AUTOS AUTOS Per accident a a UMBRELLALIAB OCCUR EACH OCCURRENCE $ EXCESS W18 CLAIMS-MADE AGGREGATE S DED RETENTION $ WORKERS COMPENSATION X WC STATU- OTH- AND EMPLOYERS'LIABILITY A ANY PROPRIETOR/PARTNER/EXECUTIVE� E.L.EACH ACCIDENT s `�,000 '' OFFICER/MEMBER EXCLUDED? N/A 026125007858581 1/1/2016 1/7/2017 (Mandatory in NH) � E.L.DISEASE-EA EMPLOYE y �'�� If yes,describe under DESCRIPTION OF OPERATIONS bebw E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Alhch ACORD 101,Addidonal Ramarks Schedule,if more spsce is required) � � Evidence of Insurance for the South Yarmouth United Methodist Church which is part of Hie New England Mnual Conference of the United Methodist Church. � CERTIFICATE HOLDER CANCELLATION South Yarmouth United Mell�odist Church 322 Old Main Street � SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCEILED BEFORE ' S.Yarmauth,MA 02664 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. i . AUTHORIZED REPRESENTATiVE ', .---"7,�-�.�..r 3d , n�,_.._.__......_, � Client# Msc n Cert Holder# a01988-2070 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD '