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a � TOWN OF YARMOUTH BOARD OF HEALTH
APPLICATION FOR LICENSE/PERMTT-2018
I � *Please com lete form and attach all necess documents b c niher 1 S 2017.
� Failure to do so will result in the return of your applicari �i pac et. �^
ESTABLISHMENT NAIv1E: + `
� LOCATION ADDRESS:,,��/ ��s� �Sj'� G1.�. UA_v-�'7'l�. .TEL.#: h7�-'�?'S-�sD��Q
! MAILiNG ADDRESS: .�YYte.
E-MAIL ADDRESS: V Ct�rwtau�-�-{• L�� ����G�oCI .A�YY�
OWNER NAME:
CORPORATION NAME( APPLICABL ):
MANAGER'S NAME: �''1 TEL.#: -��'— U
MAILING ADDRESS:
POOL CERTIF'ICATIONS: �' �
The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated �
i Pool Operator(s)and attach a copy of�he certification to this form. s=T� Q ',
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1. 2. � ��
Pool operatars must list a minimum of two employees currently certified in standard First Aid and Community ; '- -�I '
Cazdiopulmonary Resuscitation(CPR�,having one cert�ed employee on premises at all times. Please list the � � rv
employees below and attach copies of the�r certificarions 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. , =�r
1. 2. ',
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3. , 4. � _..,_
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� FOOD PROTECTION MANAGERS-CER ICATIONS: "��}�
All food service establishments are raquired to ave at leas ne full-time employee who is certified as a Food ���
Protection lvfanager,as defined in the�tate Saazu ary Code f ood Service Establislunents, 105 CMR 590.000. ��
' Please attach copies of certification to 's applica'on. The ea th Department will not use past years'records. �.
You must provide new copi nd intain a e at you,est blishment. ��- � "
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PERSON IN CHARGE: ����--�. �
Each food establishment must hav a t one Per n In harge(PI on site during hours of operation. t�} ,�'' �'
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1. 2.
ALLERGEN CERTIFICATIONS:
All food service establishments are re ired to have at 1 t one full-time empioyee who has Allergen certification,
as defined in the State Sanit a ry Code or Food Service E tablishments,105 CMR 590.009(G)(3)(a). Please attach
copies of certification to this application. The Health D partment will not use past years'records. You must
provide nevv copies and maintain a fule at your establishment.
1. 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 a11 times. Please list your employees trained in anti-choking procedures below and
attach copies of employee certifications to this form. The Health Degartment witt not use past years'records.
You must provide new copies and rruaintain a file at your place of business.
1. 2.
3. 4.
RESTAURANT SEATING: TOTAL#
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEF. PF.,RMIT# LICENSE REQUIRED FEE PERMIT#
B&B $55 CABIN S55 MOTEL 5110
—INN $55 —CAMP S55 _SWIMMING POOL$1 l0ea.
=7,ODGE $55 _TRAILER PARK $t05 _WHIRI.POOL $110ea.
FOOD SERVICE:
I,iCENSE REQUIREb FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED PEE PERMIT#
0-100 SEA'I'S 5125 _CONTINENTAL $35 NON-PROFIT $30
>I00 SEATS 5200 COMMON VIC. $60 WHOLESALE $80
=RESID.KITCHEN S80
RETAIL SERVICE•
LICENSE REQUIRED FEE ERMIT LICENSE REQUIREU FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
1 <50 sq.ft. S50 ��q >25 000 ft. $285 VENDING-FOOD $25
_<25,000sq.ft. 5150 _FR87.,F.N�ESSF,RT$40 =TOBACCO S110 �6II
NAME CHAIVGE: S15 AMOUNT DUE _ $ �(00.Op
t*•**PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*****
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ADMINISTRATION
j Under Chapter 152,Section 25C,Subsection 6,the Town of Yarmouth is now required to hoid 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
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CERT.OF INSURANCE ATTACHED �
OR f"
WORKER'S COPvIP.AFFIDAVIT SIGNED AND ATTACHED
i 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 A1KD OTHER LODGING ESTABLISHMENTS
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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 customazily 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 ihirty(30)daqs,and
I an aggregate of not more than ninety(94)days within any six(6)month period. Use of a guest unit as a residence or
. dwelling unit shali not be considered tiansient. Occupancy that is subject to the collection of Room Occupancy
Excise,as defined in M.G.L.c.64G or 830 GMR 64G,as amended,sha11 generally be considered Transient.
POOLS
POOL OPE1�tING:All swirnming,wading and whirlpools wluch have been closed for the season must be inspected
by the Health Department prior to opening. Contact the Health Department to sc6edute the inspection three(3)
days prior to opening.PLEASE N07'E: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. '
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 opemng.
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 forms can be
obtained at the Health Department,or from the Town's website at www.yarmouth.ma.us under Health'Depariment,
Downloadable Forms.
FROZEN DESSERTS:
Frozen desserts must be tested by a State certified lab prior to opening and monthly thereafter,with sample results
submitted to the Healfh 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 CAF�S:
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 15,2017.
ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTTNG, NEW
EQUIPMENT,ETC.),MUST BE REPORTED TO AND APP OVED BY THE BO ALTH PRtOR
TO COMMENCEMENT. RENOVATIONS MAY REQU A SITE PLAN._
DATE: E! 'T I� __SIGNATURE: �
PRINT NAME&TITLE:�'/r.�'U� �, ��(,�( f'�, �1��4���/�'�
xx�v.�onvn
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� The Commonwealth ofMassachusetts
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/Or anization Name: U�l2S /V
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Address: �� �6�� �8 �1��� � �
City/State/Zip: �� �T'Yii ULt 6o��O��one#:
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� Are you an employer?Check the appropriate box: Business Type(required):
�
� 1.� I am a employer with�employees(full and/ 5. �Retail
i or part-time).* 6. ❑ RestaurantBar/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 requiredJ 8• ❑Non-profit
3:�0 We are a corporation and its officers have exercised 9. ❑ Entertainment
their right of exemption per c. 152, §1(4),and we have 10.0 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 ofticers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an
organization should check box#L
I urri an employer that is providing workers'compensation insurance for my employees. Below is the policy information.
Insurance Company Name: �u1rC. �151�i .�2 YV�c�,$ ►��-��,1 � ��y���'1!S �(J� � r(IK��
Insurer's Address: �.(� ��G �5 � I �"�' 1 �a-�a--
City/State/Zip: �jY�t�`�'�.P . �4 C�a t$S
Policy#or Self-ins.Lic.# d 1 y 6616 ��S Expiration Date: L i� �l�
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration 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�n'hereby certify,under e pains and penaltie jury that the information provided above is tru'e and correct.
Si ature: � Date: 1
Phone#: " '1 '
nfficial 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.Buiiding Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office
6.Other
-� :;Contact Person: Phone#:
www.mass.gov/dia
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i1/08/�017
7HiS GER7tFlCAT� t5 iSSUEd AS A MATTER OF 1AtFOR�1{ATtON ONI.Y AND CON�ERS t�t? RIGWT3 UPC1N THE GER7tFiCATE HOLDER.7N19
C�RTIFlCAT� Dt}�S N43T AF�IRlUTA7tVE1.Y OR NEGATtV�LY AMENp, EXTENO OR ALTER THE CC?YERAGE AFFORD�D BY THE POUCEES
BE�OW. THIS C�RTIFICAT� QF 1N5UFtANGE DOES NOT C�N6TtTUTE A C{)NTRACT B�TWEEN THE t3SU3NG iNSURER{S), AU'FttOR17.ED
ftEPRE�Eh1TATiVE t7R PRODUCER,AND THE G�R7I�IGA7�Ht�1.D�R.
lWIPORTAtV1': Sf the certiflcafe holder is an AODITfONAL INSURED,the poUcy(Ees) must be ertdorsed. If SUSROGA'fiON IS WAIVED,suhject to
; the terms and ccnditicns of the poNcy,certafn palicies may require ar e�dorsemet�t. A statemant on this aertSfieate daes not canfer Nghts tc tha
' tertificate halder in Ueu of suah endarsernent s.
PROOUCER
YVM.�.�orhek�nsurance Agency a� �E F
341.Ptymouth Street �4i
Haiifax,'I�IA b2339 no re�ss:
Scott C Casagrande
INSVRE S AF�4ROIfiH3 Gf3VERAQE NAIC t1
FNsu��n:Acadia lnsu�raace Cam an 31325
;,��Nsu�, LlJK�S LtQt10FtS,INC.�ETAI. aNsure�a�: ,
.,. § 20 Springer Lane an�su���c:Massachusetts Retail Merchants
� West Yarmou#h,MA 02673
tasureER o•
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C{1: �RAG�S CERTlF�CAT�Nt7MBER: REVCSION AIUMBER:
� - THIS!S TQ CERTIFY THAT THE POIt�lES OF INSU£2Ai�fCE USTED BELQW HAVE 8EEN tSSUEQ TQ THE iNSUREa NAMED ABOVE FOR TME PflLICY PERIflC
IhFDICATEo. NdT5M7HSTANDINC3 ANlf EtEQU1REMENT.TERM OR CQN017K}N OF A,NY CC7NTFL4C7 OKt OTNER DdCUMENT WITN REBPECT TD WHICFI TNt�
� CffRI'lFICATE MAY BE ISSUED OR MAY PERTAIN, THE ttsSURANGE AF�OR�ED 8Y THE POLICIES DESCF218ED HEREtN IS $U�JEC7 70 AlE THE TERMS.
E�Et�13Sf4idS ANp Gt�N�1T10NS OF SUGH POLICfE5.UMii'S SNOWht MAY HAVE BEEN REOUCED 8Y PAtD CiAitutS.
rvps aF�+�suw�Hc� Poucr�uMa� M�7D01YY 1�OBlVYYY urar�s
� GENERAI tJABiGIT1' EACN OCCURRENCE s 1,OOO,t
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�Oi�F.RED LOCATZflN: 511 MA22i 3TRE�T, 6 20 S�RZ�fGElt I�A2�tE, WEST YARMOUTH, MA
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':���2"FIFiCA7E HQLUER CANCELLATIQN
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. SHC}tJLD ANY�f THE A80VE DE5CRi8E�!P�LfC1ES 6E CANCEEtED BEFORf
TOWM QF W�ST Y,4RMOUTH Ti1E �XPtRATION DATE THEREdF, FJ4TiCE Wti.t BE DEllYERED 1P
. ACCOROAttCE WITH Tt{�POLkCY pR0V19taNS.
WEST YARM�UTH,MA Q2&73
AtfPH9RIZED REFRESENTAT{VE
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