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Home My WebLink AboutApplication and WC , 1 � . x A s,�.., ,�4..�,r-�F �J � � � e-.�..,.. •. .._��`, t_r�.�o i al��,�.� TOWN OF YARMOUTH BOARD�DI+z I�E�AALT�I �� € � � APPLICATION FOR LICENSE/PERMI 2 ' (j�T � O ZO1� � ' � �� * Please complete form and attach all necessary docum��rtsC�e ber 1 S 2017.�„ � Failure to do so will result in the return of your application p�cl ��_�"�-��_�'�� ESTABLISHMENT NAME: �- TAX ID: LOCATION ADDRESS: iCJ • U� . 6' EL.#: -O.S`7�' MAILING ADDRESS: S�� /12z j'�, .53� . D: S4q-,e��u� , /1�_. a�-(6 So E-MAIL ADDRESS: — OWNER NAME: �it�S'�i1�'/ � CORPORATION NAME (IF APPLICABLE): ,e G=v`�6a� MANAGER'S NAME: �Z.�S'wo ; e�e Scr'// �_ TEL.#:� -..3 -�'! —G�f' J MAILING ADDRESS: �D . �„,„-�,� . �� f 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. 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. 2: PERSON 1N CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. i. Z. 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. 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 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. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# __ _ _ __ _ _ - __ _ - OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $110 INN $55 CAMP $55 SWIMMING POOL$110ea. LODGE $55 TRAILER PARK $105 WHIRLPOOL $I l0ea. 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 — — —RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE ERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �<SO sq.ft. $50 —�l0 >25,000 sq.ft. $285 VENDING-FOOD $25 _<25,000 sq.8. $150 —FROZEN DESSERT $40 TOBACCO $110 NAME CHANGE: $i s AMOUNT DUE _ $ U ZJ •Q C+ *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** got�.�-t�-a��--oy � , ADMINISTRATION Under Chapter 152,Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license ar 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 CERT. OF 1NSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth t�es 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 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 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 pseudornonas,total coliform and standardplate 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 SE�ZVICE � 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 opening. CATERING POLICY: Anyone who eaters 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 Department, 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 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 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., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MA QUIRE A SITE LAN. . DATE: ��7 SIGNATURE: � � �' PRINT NAME & TITLE: ��P,j -- �t�,�,s��J��. /r.e�':g/,e,`.�'1 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 Le�ibly Business/Organization Name:�l�,J,�� -�-�'�s �c , / - - Address: �� /i�o./It c�i�. ,�,�e�'- oa.GL y City/State/Zip: ��D� Phone #: ��'- .�9 f�— ��74" Are you an employer? Check the appropriate box: Business Type(required): 1.[� I am a employer with � employees (full and/ 5. [�Q] Retail or part-time).* 6. ❑ Restaurant�Bar/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 corparation has other employees,a�vorkers'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: 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 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,�d6.��i analor one-year imprisonment, as weii as civil penalties in triC iorr�i of a STOr wvr�Zn"vRi��R and a iitie 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 tify, under the pains and pena[ties of perjury that the information provided above is true and correct. Si ature: � e Date: /D 3d / Phone#: .�?��- �9 5�— C�S' 7S Official use only. Do not write in this area,to be completed by cit��or town officiaL City or Town: Permit/License# Issuing Authority(circle one): �. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone#: www.mass.gov/dia Oct 3B Z817 89:39:88 EDT FROM: FZM/176ZBB78�56 MSG# 1492686588-BB6-1 PAGE 683 OF 8B4 '�`�"'�� CERTIFICATE OF LIABILITY INSURANCE i�7i3oi2�i'� �,_,,,_.. TH19 CERTIFICATEIS 198UED A9 A MATTER OF INFORMATION ONLY AND CONFERB NO RIGHTS UPON THE CERTIFICATE HpLDER.THI9 CERTIFICATE DOES NOT AFFIRMATIVELV OR NEGATIVELY AMEND,EXTEND pR ALTER THE COVERAGE AFFORDED 8Y THE PpLICIEB BHLOW. THIS CERTIFICATE OF IN8URANCE DpH9 NpT CONSTITUTH A CONTRACT BETWEEN THE ISSUING INSURER(S�,AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPpRTANT:If the certlflcate holdsr Ia an ADDITIONAL INSURE�,the policy(lee)must have ADDIl10NqL IN8URHD provlslone o�be endorsed. If BUBROGATION IS WOUVEo,subJect to the terme and condltlona of the pallcy,certaln pollclea may requlre an endoresment. A etatement on thls certiiicete doea not confer ri hto to the r.ert'rficete holde�in li2u of auch endoraamen e. arrmucr� con�rac NAM1E: ?AYC:IEX INSi1RANCE AGE1lCY ING �,v�.n,�,;,,y: ;,ar;,��o�: (6EE; 44�-61i2 210705 P: F: (8�38) 443-6112 �'�"` aoo�esa: �0 B�n ��015 iNsuzER�s�a=FOFoinocw�Er:aoE tiFics 5AV t1NTCNIC TX 782 05 IV3URERA: Twifl City -ire �ns Co r;,r=� .:- ��K-`, "" - � w��xsa N3UREi6: . . , . . .... _. IVBUFEZC: YA\iKEE CRAFTERS INC iusu�eao: pD BQi� L�J'6 IUSURERE: f . _ �r.. SOUTH YAR�ICUTH N1A Q2�E9 ��au�E,F: =-w- ' �`___...._b COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THH POLICIHS 0= INSURANCE LISTED BELOW HAVE BEEN ISSUE6 TO THE INSURED NAMED ABOVE FOR THE POLICY PER106 INDICATED, NOTWITHSTANDING ANY RHQUIREIVENT, TERM OR CONDITION OF ANY CONTRACT OR OTHHR DOCUMENT WITH RESPECT TO WHIC'rl THIS CER7IFICATE MAY BE 156UED GR MAV PER7AIN, TrIE IN6URANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS 6UBJECT TG ALL T�E TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY iAVE BEEN REDUCED BY PAID CLAIM&. �;�.s-^ 7YPECF4�:YFR�,V�CE eoot soert p[JLlCYA'LMBfR POL!('YEFF ruucvear U,fqITS eratmavnv COMMERCIAL GENERAL LIA&LITY EACM OCCURRENCE CLAIMS-MAOE ❑DCCUR DAMAGETDREMED PRENIBFB EB oCcurcence btED EXP(Any one perem) PERSON4L4dDVIWURY GEN'L AGGREGATE LIN•1T APPLIES PER: GEhERAI AG6RE:i4TE POLICY PR� LOC pRGCUCTc.COf�1p�GPkGO �JECT� 6THER COatBiuED SIN6LE Llh��l' AUTOMOBILE LIABILITY !Ea eooldc�f RNY AVTO � BDDILV IWURv(Fer prrson; DWNED SCNE6IJLED BOOILY IM1LURY�Fer accltlent; AUTOS ONLY AUTDS HIRED NOn-OYYNED PROPERI'OMIAGE AUTOS ONLY AUT09 t)NLY ipceml�enll UNBRELLA LIAB OCCUR EACH OCCURRENCE exCE98 LIA6 CLAIMS-MADE AGGREGATE DEC NE7EhTIDNi H'!lXNL'R��'CYJA1v�(h:1/7fltv X . .1A'VL';NYLUICH,)"L/1tlfUIY S7�TUTE _ ER ANY FROFRIETOR;PARTNER'E%ECUTIVE YIN E.L EACH ACqDENT �1 d O� C}O O OFFICER'�'E.uBER EXCLUDED7 p�,� � �MondororylnNN) ❑ 'i5 ta�G NZlh61 �5��6/201'! C�/;G/2�'_8 E.L.DIBEABE-EAEn7pL0YEE '1�� It yoe,doecriCe undcr E.L.DISEASE-PDLICY UbUT `J Q�� l(�Q DESCftIPT10N OF OPEFWTION6 Delow OEBCAlPTIONOFOPEF,ITfONB/LOCAT10N8/VEHICLES�ACOA01U9,4tltlIt100lI Rltflll'K6 OC11ltlUll,mey W aaicMatl tt moro�De�a ie roauirW� Those usual to tne Insured's apErGtions . CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE Town 0_` Yarmouth He�lth Department DELIVERED IN ACCORDANCE WITH THE POUCY PROVISIONS. 1�tt:1. pr�G'� Murphy /�uTHORfZEOREPREBENTATIVE 119 6 RCt1TE 2 8 �t'�-'7� �/uG"�,rr✓„c�"-cr� SOUT:i YARMO;IT:i, Mt1 02'069 �1988•2015 ACORD CORPORATION.All rlghts reserved. ACORD 2S(2016103) Tha ACORO nama and lo�o are regiatered marks of AGORO Uct 38 2817 89:39:Z6 EDT FROM: F2M/176ZB878456 MSGtt 149Z6B65BB-BB6-1 PAGE B84 �F 884 AGENCY CUSTOMER ID: LOC#: '��-�� ADDITIQNAL REMARKS SCHEDULE PaBe_ pf _ AGENCY NAMEDINSURED PAYCH�X IN5URAI�CE AGENCY INC PDUCY NUMBER YANKEE CF<AFT��RS I ATC SE� ACO�D �5 P� BC7� z 96 CARRIER NAICCOOE SOUTI'.. YARMOUTH L7A OZ�07 SEE ACORD �5 EFFECTIVE DATE: SEE ACDP,D [S ADDITIONAL REMARKS TH19 ADDITIONAL REMARKS FORM IS A BCHEDULE TO ACQRD FpRM FORMNUMBER: ACORD 25 fORAATITLE: CERTIFICAT�, CF LIABILITY II�SURANCE Brian �I. He,slip Asst_ Heal�h Agent ACORD 101(2014J01) �2014 ACORD CORPORATION.All rights reserved. The ACORD name and logo are reglstered marks of ACORD Oct 3B ZB17 89:38:28 EDT FROM: F2M/1762Be78456 MSGtt 14926865BB-BB6-1 PAGE BB1 DF BB4 ,_._.............................:........ ^..� � ;,: �l�#��`� ,.. ;:��::;;.. % ,.. The Hartford FAX COVER PAGE To: From: The Hartford Date: 10�'30�17 09:38:01 A�f Re: Certificate of Insurance for policy # 76ti��EGNZ16G1 [CONFIDENTIAL] Total Pages: 4 including cover page PRIVILEGED AND CONFIDENTIAL:This electronic communicstion,including attacfiments,is for the exdusive use of addressee and may contain proprietary,confidential andlor pnvileged informatiori. If you are not the intended redpient,any use,copying,disdosure, dissemination or distribution is strictly prohibited. If you ar�not the intandad recipient,please notify sender irnmediately by phone,dEstroy this communication and all capies. Pd^t��: Hello, anached is the requested certificate of insurance for policy # 76�aEc`JZ�661. HavE a great c�y! ��` , �C€��ty �Co�k�r�4! Caa;tom�r�Syj�Gr�„Ya€�%.Spt'ci�)�,�t., , .,` ` ; :> ;`. � ; 6u�in I�5 UParrc�.�`irnnca�ir��r titr��' , ,�' . � � ,�- � - ,. , _, ; , :, �.. ,�. �, < ; � 9�98�,�t��FCF�C} ; .. , , , �.:, ,, ,.: _ . ., ,:, :.. .... < , , . 'Tfi�:..:,.: -h�;H:�iif�rcf Fii7anciaf S��i,�F�:Gr�u�.In�. ;Q"E��h1v35[.i�;f=':3�kI')rlva�l;.`Jf��i�2C'f�r-" (=1�.-,qr� �"":�:"��"��°"�� IICT�Cil1.l`dl"1.'i..3:?;i '"'"''y�'"�$'r'�� F� 1��.)Y.)./,`��.��'�� 4A;�,} �'�' �'..i�t)..C�.t7-:..�j'E'S�' t'�.ale E:rr;,�iC�ger�c:�.::F,rkic�;�:(:7tr��:Er,:;rtrr,rc�.e:orr, ��,.,�n�^�n��.kh��ll;:�i't�C'tr�Ci��'!'I L1�M:1i J.(Fi i"i'i:i.'ipiti.��l.i!?�itf 1 i'?�1J,:�If CC7((1 ;n�tAfl(v C?��If'.':i-[(CJ'?Ur�!f:''.ri;,7ltj�A'(e Register toda�� at ti��vuf.thehartford.com,servicecenter and discover the ease of paying your bill, enrolling in �,utoPay, requesting c��:s`t+#ic:��~�te.c af ir�^t�r.�.n��:; ric«�.i.r�� documents or Going Paperless. Oct 3B 2817 89:39:84 EDT FROM: FZM/176ZB878456 MSGtt 149Z6B65B9-BB6-1 PAGE 8B2 OF BB4 i�e car�aboutmeetrngyourservice expEctations_Did I provr�eyou with agreat HartfordExperrence?Pleasefeel�free to send uny feedbackon my s�rvice to Brendan Hartrrett C�,Dth2hartford.corn