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� TOWN OF YARMOUTH BO ��'����¢�"�
ARI� �'�H$ALTH - -
APPLICATION FOR LICENSE �".��01$ � ��T :� 1 Z(���
* Please complete form and attach all necessa�ocu�nen�s by I�c '��ber 1 S 2017.
Failure to do so will result in the return of your application ac �'�.
ESTABLISHMENT NAME: ou� S�n S v�z E Yi� �n e T • ��rn� p►� to��(,(L..,
LOCATION ADDRESS: �o `�`� �o�. � TEL.#: ��O$7 60�6�d0
MAILING ADDRESS: o t�� �r�vt oc,t. Y►'lq p G
E-MAILADDRESS: � dr� P� 3 aL ,
OWNER NAME: er� a
CORPORATION NAME (IF APPLICABLE): �Ex►r �j'.e� S�s �`rc.� �o r,q � n e
MANAGER'S NAME: fYJ A►z.u�L �.�'rt�c n t'�P TEL.#: �
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.
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.
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FOOD PROTECTION MANAGERS - CERT�FICATIONS: �
All food service establishments are required to have at least one full-time employee who is certified as a Food
Protection Manage�, 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 fde at your establishment.
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PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge (PIC)on site during hours of operation.
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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. '
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HEIMLICH CERTIFICATIONS:
All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich '
1Vlaneuver 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.
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RESTAURANT SEATING: TOTAL# �I z/ '
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OFFICE USE ONLY
LUDGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
B&B $55 CABIN $55 MOTEL $110
II�1N $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 FEE PERMIT#
�0-100 SEATS $125 ( 1� _CONTINENTAL $35 NON-PROFIT $30
>100 SEATS $200 �COMMON VIC. $60 �O WHOLESALE $80
—RESID.KITCHEN $80 '
RE'1'AIL SERVICE: '
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# '
<50 sq.ft. $50 >25,000 ft. $285 VENDING-FOOD $25
<25,OOOsq.ft. $150 _FROZEN�ESSERT $40 _TOBACCO $110
NAME CHANGE: $is AMOUNT DUE _ $ /�S.QQ
*****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 i
AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR ;
�
�
,
CERT. OF INSURANCE ATTACHED
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 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 t
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 sha11 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 p�ior to opening, and quarterly
thereafter. �
POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of !
elosing.
FOOD SERVICE
SEASONAL FOOD SERVICE OPENING:
All food service establishrnents 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. f
i
CATERING POLICY:
Anyone who caters within the Town of Yarmouth mus� 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:
Frozen desserts must be tested by a Sta.te 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 RETiJRN �
THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15,2017.
I
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 PLAN. �
DATE: /�-��-/ 'j SIGNAT'URE:
PRINT NAME&TITLE: � � �Y"
Rev.10/12/17
�
• �' � The Commonwealth of Massachusetts
_ _ Department of Industrial Accidents
Office of Investigations
' ` 1 Congress Street, Suite 100
Boston, MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legiblv
Business/Organization Name: �o�y ��'c�v�S �YA����c i�I � V1�
Address: �oZ� �u.� � � SoCQ � .%Ar�vt o v�� �'i ✓� 026��
City/State/Zip: /� � ,tJ 2('�' c./' Phone #: �O� �6 O - �� 00
Are you an employer? Check the appropriate box: Business Type(required):
1.❑ I am a employer with employees (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]* 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 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: � � RC�ct�L �e r e 1-(o,h �S W e �r p u Q `� n e �
Insurer's Address:_ �O l�J �� g,� �2.2— �22Z
City/State/Zip: (�j,( t� 1 �'��E'P ►n'1 � 0 2 l $5
Policy#or Self-ins.Lic. # C> 1 �{ �S Q7�3 2c.� �l l `�' Expiration Date: 0 I�O 1 � 201�
Attach a copy of the workers' compensation policy declaration page(showing the policy number and egpiration 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,under ains and penalties of perjury that the information provided above is true and correct.
Si ature: Date: ���3f Zo I
Phone#: 8 — �6 ��
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 fIealth 2.Building Department 3. City/Town Clerk 4.Licensing Board 5. Selectmen's Office
6. Other
Contact Person: Phone#•
�vww.mass.gov/dia
FISFC3RMATLt'.rN FAG£ REl+iEWAL AGRSEMEtiT
:sts�rez: PR4t3U�R: A+aenL� 9�8
MA Aetail Merctsants WC Graup Znc. 3ames & �ullivan Z�susar.c�
PO St»c 85�2T2-gZ22 885 M83n 5t.
BraiAtree. MA 0�165 T�wkehury. MA Q187b
iCazrier Code• 343551 L".srrier Policy #: 014Dt1543324�i2�
� Caz'rier P�ior Po:icy �t: 01400�f333200�i6
i. The Zneured: �our Seasar.� Tsattc�ria lnc
M,ai2ing A3dxess: 1Q'77 Rte 28
S Ybtrmout23. �IA 02�64
Fe�n: �
Othar aor#rplacea naL Shoxxs above: Tyge tsf Susiness: Corporat ioas
Nt3 t�THER WDRKFi,ACES FOR 't'HIS F(3LICY Risk �;
2. The po3icy �seriod ie £xa�s 22:�i a.m. a:s 1/U2/2�1� to 2�:Ji a.ra. on il�1i16918
at the insuzed's ma�iling aedc�ress.
3. A. Worieera Camg�ensa�io� insuranee: Fart � of the go�i�y agpiiee to the Morkers
Compeneatirsn Tr».�r of the states iist.ed here:
!SA
B, Smploy�rs L1�ility Zn3ura�c�: 3?art 'I�ra af �.he po?icY a�sp2ies ta rror�C in each
atate liete� in ILcsn 3.A. The Iimits of auz liabiiity under P�rt Twa are:
Bodi�y Fn3uzy by Acei�erit S 100.�00 _ each accider.s
Badily Zr.jury by Aisease $ 500.�OL1 _ gfllicy li�eit
Bodily Znjuzy by Disease S 100.�00 _ esch eranioyee
C. Othe_ States Zneuraace:
[�. T}�is pcsTi,�y includsa these endorsemgncs aad sch�dules:
tiCDt3000RC401/ls1 WC000348 {04!$d) WCQt}04I4�D7i903 y,TC000422BtQ1j151 i3C2�030ita4jB43
iiC2dfl30ZgQ5/B61 WC20tl3ti3HtDTf397 WC�9034bB(06/I3} WC20i�9a5t06/OI! i+1CZ006U3At0'1/081
4. Tk�e premiu�a tor this po�icy �cill be determined h�y our i�anua'-s of Ru3es,
�iassificatioas, Rates �nd Ratizt9 Fians. A1I infoz�ation ree�uired be�vw is subject
ta vezifiCatiozi and change Ly audiL.
C's.aesiFication� Code Pzen:ium Basis Ra[e Fer Bstimated
iya. Tota�. Estir�aLed S1i�o of A�nus'�
A.*�nua3 R�eratian R�mtxaera�iar. Fremium
S$fi SCSEDt7t�E O� OPBRATSaNS
Tvtal Bstimated Annual Fre�ium S 1,3t?4.fl0
Mir_imum Fr�mium S 2i7.Qi} Sxpenae Car.sta.�t S .00 Bepasit P=emium S .�30
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SCF€EE}UI,E QF OPERATZONS FOR: FAGB: 1
��**: PR�MMIUM ZNFORMATI�N FG1R t�lA «'`***
Four Seasons Tra�toria lnc Carrier Pa3icy #: fl14005033240117
1t37� Rte 28 Fein:
S Yar�outh. MA U2664 DIV #: OOQ00 E/Z� Nurabeer: {}DOOOt�OQ01
Code Classification Payrall Rate Pr���
9079 Restaurant l�oc 143, 224 . fla 1 .09 I, S61.t}Q
1. 561.C�(}
Manual Pre;aium 15.OQ$ 234 .00
Rat� Deviation 1,261 . 00
Merit Ratin�g 1, 261.00
S�an.dard Premium 1.263.4�
Norn�al Premium
Exgense Constant 43 .0�
Domestic Terrorism C .�30 1, 3�4 . �0
A�nu�l Premium �l.qp
DIA P�seasment t00930? 2 . E?70Q� / 2 . 0700� I.335.40
Total.
Merit Rating
.95CIC1 1/�1/2Q1?
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