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� TOWN OF YARMOUTFI BOARD OF HEALTH
��� APPLIG'ATION FOR LICENSE/PERMIT-2018
` *Please eomplete form and attach all necessary documents by December IS 2DI7.
Failure to do so will result in the return of your applicahon pac et.
ESTABLISHMENT NAME: Y �C�J MOv� d c! • - s���i�4
LOCATION ADBRESS:��,9 Rov7� 2-8' SDvrl �.�ao��7s( TEL.#: I,— �
MAILINGADDRESS: 0 5ou1'fi O ` '3 O
�ov5lf tJ•1�rTS O `-' �C
E-MAIL ADDRESS: L,�1�,L" 22�O , /�.
OWNERNAME: oa S'6" {.v�Tc��v�A�o�6 � :� C..:
CORPORATION NE1ME(IF APPLICABLE): j:-� � ,j
MANAGER'SNAME: l��c- J� •� TEL.#: —2 2- Sa3� � ,.; �
MAILING ADDRESS: d/iAQPG.�,v 1 �V ��/�•�v.."?'+�6!'tT�R?9 O�-G-7�S" ��:_j --`
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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. ��Rr-�,•_
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 alI times. Please list the �
employees below and attach copies of Yl�eir certifications to this form.The Health Department will not use past `
years'records. You must provide new wpies and maintain a file a#yonr place of business.
��y
1. 2' � �
3' 4. r,.�
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FOOD PROTECTION MA2�tAGERS=CERTIF'ICATIONS: ��
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 S#ate Sanitary Code for Food Service Establishments,105 CMR 590.000.
Please attach copies of certification to t�is application. Tha Health Department will not use past years'records.
You must provide new copies and maintain a file at your establishment.
L 2.
PERSON IN CHARGE: '
Each food establishment must have at least one Person In Charge(PIC}on site during hours of operation.
�. 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 CMIi 590.009(G)(3)(a). Please attach
copies of certification to this applicatian. The Health Departmentwill not use past years'records. You must
provide uew copies and maintain a fle at your establishment.
1. 2.
HEIMLICH CERTIFICATIONS:
All food service establishmenis with 25 seats or more must have at least one employee trained in the Heimlich
Maneuver on the premises at all times:` Please lisi your employees trained in anti-chokmg procedures betow and
attach copies of employee certifications to this form. The Health Depar[ment will not use past years'records.
You must provide new copies and maintain a file at your place of business.
l. 2.
3. 4.
RESTAURANT SEATING: TOTAL#
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT# L[C�I�ISE kEQUIRED PEE PERMIT# LICENSE REQUIREQ FEE PERAIIT#
B&B $55 CABIAi $55 MOTEL $110
[NN $55 CAMP $55 _SWIMM[NG POOL SI IOea.
LODGE $55 _TRAILERPARK $I05 _WHIRLPOOL $t10ea
FOOD SERV[CE: $Q�F�«���O�
L[CENSE REQUIRED FEE P6RMIT# 1 LICENSE REQUIRED FEE PERMIT# L CENSE REQUIRED FEE ��T#�
0-t005EATS $125 —CONTtNENTAI. $35 � NON-PROFIT $30 �'F'�'--�,'33
>l00 SEATS 5200 COMMON VIC. $60 WHOLESALE $80
— — —RESIA KITCBBN $80
RETAIL SERYICE:
LICESSE R�QUIRED $�EQ PERMIT# LICEAISE REQUIStEi� FEE PERMI C# LICHN6E REQUIRED FBE PERMIT#
sq >?i;000sq A. $285 VENDING-FOOD $25
—<?5,000 sq.fl. $150 _FROZEN DESSERT$40 _7'OBACCO 5110
NAMECHANGE: $15 AMOUNTDITE _ $ u��-OU
*tk*"PLEASE TURN OVER AND COMPLETE OTAER SIDE OF FORM*'*""
ADMINISTRATION
Under Chapter 152,Section 25C,Subsection 6,the Town of Yarmouth is now required to hold issuaztce or renewal
of any license or pemut to operaze a business if a person or company does not have a Certificate of Worker's
Compensation Insurance. THE ATTACI3ED STATE WORKER'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR
CERT.OF INSI.7RANCE ATTACHED
OR , /
WORKER'S CdIvIP.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 Al*tD OTHER LODGING ESTABLISFIlVIENTS
TRAI�'SIENT OCCUPANCY: For p�arposes oFthe limitations ofMotel or Hotei use,Transientoccup�ncy 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 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 shall not be considered tcansient. Occupancy that is subject to the callecYion of Room Occupancy
Excise,as defined in M.G.L.c.64G or 830 CMR 64G,as amended,sha11 generally be considered Transient.
POOLS
POOL OPENING:All swimming,wading and whirlpools wtrich have been closed for the season must be inspected
by the Health Department prior to opening. Contact the Health Department to schedule the inspecfion 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 colifarm and standard plate count
by a State certified lah,and submittea to the Health Department three(3)days priox to opening,and quarterly
thereafter.
POOL CLOSING:Every outdoor in gound swimming pool rnust 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 Depariment prior to opening. Please cantact the
Health Department to schedule the inspeetion three(3)days prior to openang.
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 forrus can be
obtained at the Health Department,ar f�om the Town's website at www.Xarmouth.ma.us under Health Depar[ment,
Downloadable Forms.
FROZEN DESSERTS:
Frozen desserts must be tested by a Sta#e cert�ed lab prior to opening and monthly thereafter,with samgle results
submitted to the Healfh Depariment. Failure to do so witl result in the suspension or revocarion of your Frozen
Dessert Permit until the above terms have been met.
OUTSIDE CAFES:
Outside cafes(i.e.,outdoar seating with waiter/waitress service),must ha�e prior appmval from the Board of Heaith.
OUTTIOOR CO�HING:
Outdoor cooking,preparation,or display of any foad product by a retail or food service establishment is prohibited.
NOTICE:Permits run annually from Jauuary i to December 31. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED RENEWAL APPLICATION(S)AND REQt1IRfiD FEE(S}BY DECEMBER 1S,2017.
ALL RENOVATIONS TO ANY FQOD ESTABLISF�v1ENT, MOTEL OR POOL (i.e., PAINTiNG, NEW
EQUIPMENT,ETC.),MUST BE REI'ORTED TO AND APPROVED B HE OARD OF HEAL'TH PRIOR
TO COMMENCEMENT. RENOVA'FIONS MAY REQUIRE A SI
BATE: ��'—GJ ''I� SIGP+TATURE:
PRINT NAME&TITLE: 5 S��YN �ve
Rev.IOl12/17 � .
,
� � � The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
` ' I Congress Street, Suite I00
- ' Boston, MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Le�iblv
Business/Organization Name: �, tii� tJ?r-f ..�p 5� �a1( 'Z2 �
Address: '7�� �.dv?'� a�$�
City/State/Zip: �7�U`� ��i�D�17�t �Ie�P�e#:
Are you an employer? Check the appropriate bog: Business Type(required):
1.[�I am a employer with�_employees (full andl 5. ❑ Retail
or part-time).* 6. �Restaurant7Bar/Eating Establishment
2.❑ I am a sole proprietor or partnership and have no �, ��ce and/or Sales(incl. real estate,auto, etc.)
employees working for me in any capacity.
[No workers' comp. insurance required] g• �on-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 o�cers have exempted themselves,but the corporation has other employees,a workers'compensa6on 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: �C,�(,� �-�Cl� �
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 certify,under the pai nd nalties ofperjury that the information provided above is true and correct.
Si ature: 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.Licensing Board 5. Selectmen's Offce
6. Other
Contact Person: Phone#:
www.mass.gov/dia
� NOVA Casualty Company
A STOCK INSURANCE COMPANY
;oNr:�:��� 726 Exchange Street,Suite 1020,Buffato,NY 14210
1-866-633-6945
WORKERS COMPENSATION AND EMPLOYERS' LIABIL�TY INSURANCE POLICY
INFORMATION PAGE
NCCI Company No. 14191 POLICY NO. LFR—WK-10001335-00
RENEFiAL OF: LFR—WK-0012469-2
ITEM 1. NAMED INSURED AND MAILING ADDRESS: AGENT NAAAE AND ADDRESS:
YARMOUTH MOOSE LODGE #2270 LOCKTON AFFINITY, LLC.
PO BOX i86 P.O. BOX 410679
SOUTH YARMOUTH MA02664-0186 KANSAS CITY,MQ 6414i-0000
LODGE2270@MOOSEUNITS.ORG AGENT NO. 10071
LEGAL EMTfTY: NON PROFIT ORGANIZATION
OTHER WORI�LACES NOT SHOWN ABOVE: SEE NAME AND LOCATION SCHEDULE
ITEM 2 POLICY PERIOD: From: 12-15-2017 To: 12-15-2018
Effective 12:01 A.M.Standard Time at the Insured's mailing address.
iTEM 3. COVERAGE:
A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensatwn Law of the
states Iisted here:
MA
B. Employers'Liability lnsurance: Part Two of the policy applies to work in each state listed in Item 3.A. The
limits of liability under Part Two are:
Bodily Injury by Accident: $ 100,000 each accident
Bodily Injury by Disease: $ 500,000 policy fimit
Bodily Injury by Disease: $ 100,000 each empbyee
C. Other States Insurance: Part Three of the policy applies ta the states,if any,listed here:
AT•T• STATES EXCEPT ND, OH, WA, WY AND STATES DESIGNATED IN ITEM 3A
D. This Policy includes these Endorsements and Schedules:
SEE SCHEDULE OF FORMS AND ENDORSEMENTS
ITEAN 4. PREMIUM: The premium for this Policy wifl be determined by our Manuals of Rules,Classifications,Rates
and Rating Plans. All information required on the Workers Compensalion Classificafion Schedule is subject
to verification and change by premium adjustment or audit.
Minimum Premium: $ 212 (MA} Total Estimated Policy Premium: $ 894
Audit Period: ANNUAL Deposit Premium: $ 894
Issuing Office:WINDSOR, CT
Issued Date: 10-09-17
WC 00 00 01 A 0615 `tricludes coPyri9hBed maieriat of Natiorel Council on Compensation Insurance
with iYs perr�sion"
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