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OCT-18-2017 14�13 YRRMOUTH HERLTH DEPT 5�760347 P.03
TQWN pF YARMOtiTH BOAItll ON HEAI�TH
Al'PLIC:ATInN FOR LICENSE/PERMIT-2018
*Please complete form and attach all necessary documents by December 1'S.2(119.
Failure tc>do so will resutt in the return of yoar agplication packet.
ES7'ABLiSHMENT NAML: TAX ID• l� �R•
LOCATTON ADDRESS: Z S•YWw►o TEL.#: " ��
MAILIIVG ADDRESS: 5 0 � �
E-MAIL ADDRE;SS: 0.S h . (, �- (.�GE�s�
OWNER NAME: Tho mGV� hr'1�C C GrrYl►� �.1�
CORPOTtATION NAME t APPLIC:ABLC): Ma�6. v. f.l.G
MANACETt'S NAME: �"�''^'�'g_ �''��C'd4r�a1 '1'L,L.#: ��L 3�b
MAILING t1L)llRl'sSS: 2�v� �_ 2 fc.0 D2.661'� _
POOI.CERTIFICATIUNS: � � "',°�
1'he paol supervisor must be certified as a Poul Operator,as required by State law. Pleasc list the designated � -�—� ���r
Pool OperAtor(s)a»d attach a copy of the certification to this Parm. '`--� N "�a
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Pooi operators must list a minimum of two employ�es currently certified in standard First Aid and Community _.
Cazdiopulmonary Resuscitatinn(CPR),having one certified emp loy�e an premises at all times. Please list the � � �..�
employee4 below and attach eopies of their certificatic�ns to this form.'T'he Heatth Dep�rtment witl not use paxt
years'recorda. Yau must provide new copies and maintain a file At your place of business.
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FOOD PRUTBCTION MANAGF..RS-C•ER'I'IFTCATIONS:
; All foc�d service establishments are required to have at lcast one full-time employee who is certified as a Food �'�
� Protection Maneger,as dciin�d in the St�►te Sanitary Code tor Food Service Establishments, lU5 CMK 5�0_000. �--+-
� Please attach copies of certification to this application. The Heulth Dep�rtment will not use past years'records.
iYou must provide new copies and maintain a file at your establishment. .`: ',�
1. ���C1GS� �I��„�, 2. -�',
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' PERSON TN CHARGE: �
Each food establishment must have at lcast one 1'erson In Charge(PIC)on site durin�;haurs of operation.
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AI.I.ERGEN CERTIFIC:A'1'IONS:
� Alt food service establishments are requireci to have at leasi onc full-time employee who has Aller�en certification,
as defined in the State Sanitary Code for Food S�rvic;e Establishments,lOS CMR 590.009(G�3)(a). Please�ttach
! copies of certification to this application. The Health Department will not use past years'reeords. You must
I provide new copies and maintain a filc at your estahlishment.
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k{EIMLICH CERTIFICATIUNS:
All food service establishments with 25 seats or more must have at least onc employee bained in the Heimlich
Maneuver on the premiscs at all times. Plea:se tist yuur cmployees trained in anti-choking procedures below and
attaeh copies of employee certifications to this form. The Hestlth Department wili oot use past years'records.
'You mu�t provide new copies and maintain a tile at your place of business.
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RFSTAURANT 5EA'1'1NG: TOTAL# ��
OFFTCF IJfiE ONLY �µ'�—'��'��6��
L(1D(:INC: .I
I,ICTiNSF•.R�()UIlttU FEE PERMITA I.I(:F:NS�It�:QUI1tEU FBi: PIiRMPI'# LICENSEREQU�R�n FEi� ELMIT#��,�O�SP—'��"'�B��J
_BBcB b55 CARIN $55 „LMO'T'EL SI10��•��, ��.`SP'��,��Oy
INN $SS C'AMP S55 �SWIMMING PWL SI IOea�l9�Rl� yw�
—LUUCiF $55 I'ItAILEkPARK $IOS � 1 Wi11RLP(NJL $1lOcst.—T
��s�:ev�cE: - - -- �� ('wP��io1KP.�`I-�"lt2-'6y'
LIC�NtiG REt1U1tL�.0 FEE PERMIT A L(C6NSE REQUIRF.� F731i PHRMI'I'# UCI:NSIi RI{(?UIItED FEE PCRMIT#
0-IOOSf:ATti $125 C:()NI'IN�N'I'AL S35 NQN-PRO�IT $3U
_�,�IOOSEATS S2O0 ��( l COMMONVIC. $t,0 �� --WIiULESALE S8U ,., g�����--���J�y
=RGS1D.K!'I'CHt:N $8D
N�;TAIL SERVICE:
I.ICGNSE ItEQU1RED FEF, PF.NMI'1'A LlCENSE REQUIRF.D FTI? PIi1tMi'I'N LICF.NSG RL',QUIRED FEE PCRMIT#
<50.c(�.fl. SSD '•25,0(l�. ft. 5285 VENDING-POOU $25
,-"[25,000 sq.0. 6150 � =PR07.F.N��tiSLiR'I' $40 I'ODACCO S I 10 ^
Nana�cHaxcE: sis AMOUNT DUE _ $7QO,�O
****�PI.F.ASE TURN OVk:R AND COMPI.ETC OTH�;R SIQE OF FpRM°*•�R '
OCT-18-2017 14-14 Y�1TH HERLTH DEPT 508760347 P.04
ADM[IYISTRATION
Under Chapter 152,Section 25C,Subsec.Kion 6,the Town of Yarmouth is naw required to hold issuance or renewal
of any license or permit ta aperate a business if a person ar company does nat have a Certitecate of Worker's
Compensation Insurance. THE A'ITACHED STATE WOIt[CER'S CUMPENSATION INSLTRANCE
AFFiDAV1T MCJST BE COMPLETED ANll STGNED,OR
CLRT.OF INSIJRANCE ATTACHN:T��
OR
WORKER'S COMP.AFFII]AViT SIGNED AND ATTACIiED
Tvwn of Yazmouth taxes and liens must he paid prior to renewai or issuance of your pernuts. PLEASE CHECK
APPROPRIATELY IF PAID:
YES NO
MOTELS AND OTHER LODC�NG ESTABLISHM�I�TS
TRANSIENT OCCUFANCY: For purposes of the limitations of Motel or Hote!use,Transient a;cupaney shall be
iimited to the temporary and short term occupancy,ordinarily and customarily associated with motel and hotel use.
� Transient oceupants must have and be able to demonsKrate that they maintain a principal placc of residence
elsewhere.Transient occupaz�cy shall generally refer to continuous occupancy of not more than thirty(30)days,and
an aggregate�f not morc than ninety(90)d�ys within any six(6)month period. Use of a guest unit as a residence ar
dwellin�unit shall nof be considered transient. Qccupancy that is subject to the wllection of Room Occupancy
Lxcise,as defined in M.G.L.c.64G or 830 CMR b<1Ci,as amended,shall�enerally be considercd 1'ransient.
I'OOLS
' POOL OP�NING:All swimming,wading and whirl�wols which havc been closed for the season must be inspected
jby the Health Department prior to openin�, Cantact the Health Department to schedule the inspection three(3)
, days prior to opening.PLEASE NOTE:People are rTOT allowed ta sit in the pooi area until the pool has been
inspec:ted and opened.
, POOL WATER TESTING: The vwdter must be tcstc;d 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 CLOSYIVG:Every autdoor in ground swunmin�;pool must be drained or covered within seven(7)days of
closm�.
FO011 SERVICE
i SEASOIVAY.FOOD SEI2VTCE OPENING:
Al]fpod service establishments must be inspec;ted by the Health Department prior to opening. Plcase contact the
��ealth Department to schedule thc inspection three(3)days prior to opening.
' CATERING POLICY':
I Anyone who csters within the Town of Yarmouth must notify the'Yarmouth Health Department by filin�;the
mquired Temporary 1'ood Service Applicatian form 72 hours prior to the catered event. Thesc fotms can be
obta�ned at the Health Department,or from the Town's wehsite at www.yarmouth.ma.us under Health Department,
Dawnioadable Forms.
FRUZEATAES5ERT5:
Frozen desserts must be tested by a State certified lab prior to opening and monthly thcreafter,with sfunple results
submitted to the Health Department. Failure ta d�sn will result in the suspension or revocation of your Frozen
Dessert Aermii until the ahove terms have been met.
OUTSIDE CAFES:
Outside cafes(i.e.,outdoot seating with waiter/waitrc,ss service),must have prior approval frnm the Board ofHealth.
OUTDOOR COOKING:
Outdoor caoking,preparation,or display of any focxi product by a retail or foad service establishment is prohibited.
NOTICF.:Permits run annually from January 1 to Uecember:i l. IT IS YOUR RESPONSI�iLITY TO RETURN
THE COMPLFTED RENEWAL APPLICA'T'IOI�(S)AND RF..QiJiRED FEE(S)BY DECEMBF..R 15,2017. f
ALL Rr;NOVATI4NS Tn ANY FOOD ESTABLISHMENT, MQTEL OR POOL (i.e., PAiNTING, NEW
EQUIPMENT,ETC.),MLJST BE REPORTED TO AND APPR�VED BY THE BOATtll OF HEALTH PRIOR
TO COMMENC MENT. RENOVATIONS MAY Rt? 11RE A STT PLAN.
DATE: I� 2S SICNATURE: �
PR1NT NAM�;d't TTTLE: b9flu�t C 1J
a�,,.iaivi�
1
OCT-18-2�17 14�14 YARMOUTH HEALTH DEPT 5@8760347 P.05
�� �I IFP ti.VlIWIFS��awcrsasis vJ lI1lWJ[{\./i/�i�74LL�1
Department ofl�tducf.rdal�ccidents
O�`,�"i.ce of Investigations
` 1 Co�agress Street,Suite l0U
Bastvn, MA 021I4-2017
www.»eass.gov/[lia
Workers' Compensatian Insurance Affidavit: Generai Busit�esses
A,AflI1G��1f IpfOCm811ol1 Please�rint Le�ih1Y
Business/Organizati�n Name:�,a� �[�r�„�� N a ..�i►P ,�op, �.R�s N V ..A�-� 4 "(� L(,,C,
�aa��ss: �2.,2, ��; L�
City/StatelZip: S +�A Q�,'C K {"� OL66�Phone#: ��$ " 3��(� q3U'0
Arc you an empioyer?Ch�k the appropriate baa: Susiness Type(required):
1.� I am a employer with r o n . _employees(full anoU �• � ���
or patt-time)•� 6. �RestaurantBar/Eating Establishment
2_❑ �am a sole proprietor or partnership and have no �. � p�C��nd/or Sales(inct.reai estate,auto,etc.)
emplayees warlcing for rcxe in any capaeiry_
(Tio workers' cornp.insurance required] g- ❑Non-profit
3.❑ 'VVe are a corporation and it,4 officers have exercised 9. [� Entertainm�nt
their right of exemption per c. 152, §1(4),and we have 2�t,Q Manufactv.ring
; na employees. [No v►�orkers' comp. insursnce required]* '
! 4_� We are a non-profit organization,staffed by volunteers, Y 1-Q Health Care
with no enipioyee&- [No wprkers' cotnp. insurance req,] 12-❑ C1tY►er
*Any appliu�nt thst checics bax#i musi aiso fill out the seet'sun below slyawing their workcrs'cnmT�cns:�t.ion policy information.
�"*tf the eorporate officers have exempted theuYselves,but the corporati�n has athor empipyees,a workers'compensation poHcy is rcquircd and tiuc:h�n
orgaaizatian should check box#1.
r am an e�rynluy�r tJ�at i.r providing worker.s'co�apensativ�ansurance for my en�Coycec B�low is tke podtcy information.
� Insurance Company Name:_�.��Rt],S �``��T 11 �I N'�1�ClQ �
!
; ,q
� Insurer's A,ddress: �5�� SuIPE Rt Q'R� N 11 E IJufi� �
�
� city/StatelZip: C�..E V��.(�1{.�'� , d� C�t��(�
Policy#�or Self-ins.Lia.#���_�����O�G1 -- Expiration Date: �
Attach a copy of the�vorkers'compensation poticy dcclaration page(s6owia�the policy number nd piration date),
Failure to seau�e caverage as required under Sec,-tion 25A,of MGL e. 152 can lead to the unpasition of crinninal penalties of a
fine up to$1,504.Q0 and/or one-year imprisonment,as well as civil penalties in the form af a STOP WORI�ORDER and a fine
af up to$250.00 a day against the vialatar. Be advi�xl that a copy of this sta.tement may be forwarded to the Office of
Investigatiatts of the DIA for insurance coverage verification.
r da her ert�,und e p,�(rtS a �thulties nf perJury that fhe i.nfurma�on provBd�d a�bov is true and currec�
Si ature� Date• O L ��
Phone#: (� � �
Officir�l use only. Do►�ot write in this�irea,to b�cor►tpleted hy city or town vf,�cia.�
City or Tawn: Permi#/License#
Issuing Authority(circle one):
1.Baard of$eaith �.�ulidiqg Departmcnt 3.City/Town Clerk 4.X..icerssing Board 5.Sclectmen's Of�ice
6.0#her __
Cont�ct Person• �h��ne#•
www.mass.grn+/dia
TOTAL P.05
i
Yrevious Policy I�umber Policy flumber
NEW S 2263559
SLL�C'I'IV� INSURANCE C01�IPANY Ul� T'IIL SOU'I'I�EAST'
342G"1'ORI'.vGDU'V WAY, CHARL07"TE,NC 28277
DECLARATIONS - COMMERCIAL UMBRELLA LIABILITY COVERAGE
�em One -tiame uf'Insured & Mailing Address Policy Period
SEE COMMERCIAL POLICY CUMMON DECLARATION: IL-7025 Frum: MARCH 13, 2017
To: MARCH 13, 2018
12:01 A.M.,S�andard'I'ime At 1'he
Insured's Mailing Address.
COUERAGE EFF. DATE:MAR. 13, 2017
Producer: Pruducer Number:
SEE COMMERCIAL POLICY COMMON DECLARATION: IL-7025 00-20014-00000
'Vamed Insured is: �TD LIABILITY
Business of the '�;amed Inxured: HOTEL
Limits Of Insurance
Occurrence I,imit 51,000,000.00 Aggregate I.imit Si,000,000.00
Self Retained Limit: S.00
Schedule of Underlying Insurance and Limits
� Standard Employers I.iability or Stop-(�ap Polic�� \io. KWC1085464
' � Employers Liability Policy
' �
M
I N
� Company AmTrust GrouP
_
�
_
�
I'olicy Pericxt F,mployers Liability I;ach Accident $1,000,000
From: MARCH 13, 2017 Disease F;ach F,mployee $1,000,000
� _, To: MARCN 13, 2018 __ Disease Each_Policy �-1,0Q0,000
- Commercial General Liability Policy Policy No. S 226355900
� Company Selective Ins Co of the S
; —
_ Policy Period General Aggregate 52,000,000
_ From: MARCH 13, 2017 Products-Completed Operations $2,000,000
_ To: MARCH 13, 2018 Personal and Advertising Injury I.,imit $1,000,000
= Each Occurrence I.imit S1,000,000
— Automobile Liability Policy Policy No. A 910510300
Company Selective Ins Co of South
Policy Period Rodily Injury and I'roperty
From: MARCH 13, 2017 Damage Combined Each Accident S1,000,000
To: MARCH 13, 2018
Premium Schedule:
Estimated Expusure Rase Rate Rate Per Annual Minimum Premium F,stimated Nremium Due
In the event of cancellation by the Named Insured we wi(1 receive arid retain not less than $200.00
as the Policy Minimum Premium. '
i orms and Ln orsements: E�����:�,�� �����
SEE FORMS AND ENDORSEMENT SCFIEDULE: IL 7028 ; ���g�,�(�.. . '
AUGUST 14, 2017 NORTHEAST REGION
Issue Dale lssuing 011ice Authorized Representative
rx_nnnz im ioa� *u���nen.� ..,,,,"
i , _
64913267
AmTrust Insurance Company of Kansas, Inc.
A Stock Insurance Company
WORKERS COMPENSATION WC 99 00 01 B
AND EMPLOYERS LIABILITY 1 of 5
INSURANCE POLICY INFORMATION PAGE
Ncci Code: 68405
1. Insured: Policy Number: KWC1085464
Maclyn LLC
822 Route 28
South Yarmouth,MA 02664 _Individual Partnership
Other workplaces not shown above: Corporation X LLC
See Extension of Information Page Federal Tax ID:
' Producer:
AmTrust North America,Inc. Risk Id:
c/o HUB International New England,LLC Renewal of: New
299 Ballardvale Street
Wilmington,MA 01887
2. The policy period is from 3/13/2017 to 3/13/2018 12:01 a.m.at the insured's mailing address.
3. A. Workers Compensation Insurance:Part One of the policy applies to the Workers Compensation Law of
� the states listed here:Massachusetts
� B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A.
� The limits of our liability under Part Two are:
� State Bodily Injury by Accident Bodily Injury by Disease Bodily Injury by Disease
$1,000,000 each accident $1,000,000 policy limit $1,000,000 each employee
� C. Other States Insurance: Part Three of the policy applies to the states,if any,listed here:
All states except ND,OH,WA,WY and State(s)Designated in Item 3A.
D. This policy includes these endorsements and schedules:See Extension of Information Page
� 4. The premium for this policy wili be determined by our Manuals of Rules,Classifications,Rates and Rating
Plans.All information required below is subject to verification and change by audit.
a See Extension of Information Page
TOTAL ESTIMATED ANNUAL PREMIUM 11,086
STATE ASSESSMENT 681
TOTAL ESTIMATED COST 11,767
Minimum Premium 401
Deposit Premium 1,786
Issue Date:3/15/2017 Countersigned by:
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