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Home My WebLink AboutApplication and WCi � , t ; ��..�.;�a� � ��,�:��'�v� i � TOWN OF YARMOUTH BOARD OF HEALTH APPLICATION FOR LICENSE/P �, �� `� NOV � C� t�O1T ; � � � ; _ ; * Please complete form and attach all necess c p � ' `�� r 1 �,� .� Failure to do so will result in the return o your app�fication pac . �n ESTABLISHMENT NAME: ` "T ID: LOCATION ADDRESS:1,//( Q�te ,,��' tri�.�� 1�c,y��/��, t1�i;J TEL#Y�"o8)�.�� -j7/,�.1, MAILING ADDRESS: Z— v L lv c � E-MAIL ADDRESS: ��Ph�4 Q do v� � /c/c��• co� � OWNER NAME: CORPORATION NAME (IF APPLICABLE): /4t MANAGER'S NAME: Ccv'►�r � TEL.#: ,Sp MAILiNG ADDRESS: / rGc a�n c- cz,�r� o,r { 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, 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. i 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 estabGshment. I / / 1�C1� I�Y �c-14 a�Cj 2: �v.SC.. °"�' �� PERSON IN CHARGE: � � Each food establishment must h�ve at least one Person In Charge (PIC)on site during hours of operation. 1� �LV t(�1� SG�4 �dU 2. ALLERGEN CERTIFICATIONS: All food service esta.blishments are required to have at least one full-time employee who has Allergen certification, as defined�in the State Sanitary Code for Food Service Establishtnents, 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�CcVI �� j4o��U 2 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. Flease list your employees trained in anti-choking procedures below and attach copies of employee certifications to this forrn. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. �C'cV�� C�'l C�Cscl� 2. �lli� �UI�S 3. 4, RESTAURANT SEATING: TOTAL# /!'7 OFFICE USE ONLY LQDGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTBL $110 Il�1N $55 —CqMp $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 CONTINENTAL $35 NON-PROFIT $30 �>100 SEATS $200 � �COMMON VIC. $60 �.�( —WHOLESALE $80 RE1'AIL SERVICE: —RESID.KITCHEN $80 LICENSE REQUIRED FEE R�RMIT# 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 $40 _TOBACCO $110 NAME CHANGE: $is AMOUNT DUE _ $ o�<c O. �O � *****PLEASE TURN OVER AND COMPLETE OTHER SIDE 0F FORM***** �'jO�F��7�3`l�v��4� � , � , i 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 j �ompensation Insurance. THE ATTACHED STATE WORKER'S COIVI�ENSATION INSURANCE � 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. PLEA�E 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 elsewhere.Transient occupancy shall generally refer to continuous occupancy of not more than thirry(30)da.ys,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 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 OPEI�IING:�11 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 inspecNon 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: T'he 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 G 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 OPE1vING: � 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 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 State certified lab prior to opening and monthly thereafter,with sample results j 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 Boazd of Health. � I , OUTDOOR COOKING: � Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. � ( I NO�'ICE: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 15,2017. j F ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW � EQUIPMENT,ETC.),MUST.BE RBPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: �l�O C�17 SIGNATURE: ��fG� ��-��,f Q�C� ; i PRINT NAME&TITLE: ,� C�.v i G�� Cr�,�'C��C� � ! Rev.10/12/17 � � � i �—� __ � ' ` � The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ' ` I Congress Street,,Suite I00 ; � Boston,MA 02114-20I7 ' ~ www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses ! Applicant Information Please Print Legiblv Business/Organization Name:_L� p�c,l/� L��` ��, C�'L� �j� ,czC � ' Address: G��_�pv�C .�� City/State/Zip:I,�i�S� ��+-i�Uf� !1°1 � C�2 Phone#:�,��- �r��, Are you an employer? Check the appropriate boz: Business Type(required): I l.�I am a employer with employees (full and/ 5. ❑ Retail or part-time).* 6. �'RestaurantBar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no �. � O�ce and/or Sa1es(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'compensadon 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 m employees. Below is the policy information. Insurance Company Name: L,;�j�GTf/ �f✓j��vG l /`v�/�l� �ir S'1,,L�i c /,79�,� _� Insurer's Address: � L�S �t�SE-Nt�L�i $71 ��, /y City/State/Zip: �t�L�1��/� ; /1/! � C��/�''/ �/ — ,� Z 3 t� Policy#or Self-ins. Lic. #��,�� Expiration Date: t� '- l� �O l� 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 andJor 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 the pains and penalties ofperjury that the information provided above is true and correct. SiQnature�V�� v"Ir-�i CJ-� Date• Phone#: 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 Health 2. Building Department 3. City/Town Clerk 4. Licensin�Board 5. Selectmen's Office 6. Other Contact Person: Phone#• www.mass.gov/dia ! Lonnie weoer r�iamoaem� tlii � 11/VJ/GV1 / 11 :VG:�J aM -�i�� .�� ACAPUI9 OP ID: DK .4CORox CERTIFICATE OF LIABILITY INSURANCE DATE{MMIDDiYYYY� �--�� vast2a�7 '; THIS CERlIFICATE 15 ISSUED AS A MATTER OF INFORMAl10N ONLY AND CONFERS NO RIGH15 UPON THE CERl1FICATE HOLDER.THIS CERlIFICATE DOES NOT AFFIRMAl1VELY OR NEGAl1VElY AMEND, EXIEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERliFICATE OF INSURANCE DOES NOT CONSTI'iUTE A CONTRACT BEIYVEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTAliVE OR PRODUCER,AND THE CER7IFlCATE HOLDER. IMPORTANT: If the certificate holder is an ADDI110NAL INSURED,the policy(fes)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 iieu of such endorsement�s). PROWCER CONTACT Rodman InsuranceAgency,Inc. eu►Me: Evan Tobasky 145 Rosemary St. Bidg A ac N E :781-247 7800 ac N,�:781-444-0090 Needham,MA 02d94-3238 Eva n Tobas ky noatEss: INSURER(S)AFFORDING COVERAGE NAIC• � ,n��A:AM Trust j INSURED La aya dba ariac 1 INSURERB:LIb@�/MU�UaI 1 West Yarmoufh Locafion ; 705 W 7th Ave Suite A-3 ��nz�c:StarsEone National Insurance Spokane,WA 99204 �nsuz�xo: INSURER E: INSURER F: ; COVERAGES CERIIFICATE NUMBER: REVISION NUMBER: � THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE Lf5TE0 BELOW HAVE BEEN ISSUED TO THE INSURE�NANED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDffION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE 15SUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLU510NS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN NfAY HAVE BEEN REDUCED BY PAID CLAIMS. j gR TYPEOFINSURANCE L7R POLICYNUMBER MNRID/YYYY MIQOIYVYY uMRTs iB X COMMERCIALGENERALLIABILITY � � EACH OCCURRENCE S �OO,OO � CiA1MS-MADE aoCCUR BKS56755089 0611812017 06118f2018 pREMISES aoccurre�e S 100,00 i � X LiquorLiability MEDEXP(Anyoneperson) s 5,0 PERSONAL 8 ADV IN JURY s �,OOO,OO � GEN'L AGGREGATf UMfT APPLIES PER: GENERAI AGGREGATE $ Z,OOO,OO � POUCY��C �LOC PRODUCTS-COMPlOPAGG S �,�0,� OTHER: 5 � AUTOMOBILE I.IABIUiY C I � INGLE ll � (fa acciderrt � . ANYAUTO BODILY�1JURY(Per person) S . ALL OWNED SCHEDULED BODILY QJJURY(Per accideM) 5 � � AUTOS AUTOS N ON-0WNED PROPERTY DAMAGE HIREDAUTOS AUTOS (Peraeciden a � S I X ��8��VAB X OCCUR EACH OCCURRENCE S �,OOO,OO I (�, EXCESS LIAB CLAIMS-bWDE 80198T160AL1 06118l2077 06118/10�8 AGGREGATE ; �,��,� i i OED RETENTION y � WORKERS COAPENSATION - � AMD EMPLOYERS'LIABILITY STATUTE ER A nt�r aFtO�rt�rOwPntt�EwE�CurIVE Y�N SWC1158568 08115/2017 08t1512018 E.L_fACH ACCIDENT S 5�0,0 Of�ICERRAEMBEREXCLUD�? �N1A (Mandatory in NH) E_L.OISEASE-EA EMPLOYEE ; 300,0 It s,descrbe�mder D�SCRIPTION OF OPERATfONS below E_L DISEASE-POLICYLIMR E rJ�,OO DESCRIPiIONOF OPERATIONS/LOCATIONS!V6i1CLES(ACORD 101,Additionai Rertwrks Schedulc,may be athched if more space ia required) - : 416 Main Street, Route 28, West Ya�outh, Mass. CERTIFICATE HOLDER CANCELLA110N WESTYAR SHOULD ANY OF 7HE ABOVE DESCRIBED POUCIES BE CANCELLED BEfORE Town of WestYarmouth 7HE EXPIRA710N DATE TFIEREOF, N0710E YYILL BE DEWEREO IN West Yarmouth,MA ACCORDANCE WIIH 7t1E POLICY PROVISIONS. AUhIORIZEO REPRESQiTA71VE �� 1988-2014 ACORD CORPORA'�tON. AII rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD