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Home My WebLink AboutApplication and WCT � yP �� s�� TOWN IDF YARMOUTH BOARD OF HEALTH � � � APPLI�ATION FOR LICENSE/PERMIT -2018 `��?�- � ( ""'� * Please complete form and attach all necessary documents by Decem er� � 17. Failure to do so will result in the return of your application packet.� ESTABLISHMENT NAME: � TAX ID: • � LOCATION ADDRESS: -O 6 TEL . MAILING ADDRESS: O R - �Z ; E-MAILADDRESS: � �'1 _`]2,1 6 cr,/�CaO• LdlM.� ; •;; ' OWNER NAME: 1 � CORPORATION NAME (IF APPLIC�BLE): H � MANAGER'S NAME: � TEL.#: [� i MAILING ADDRESS: ' W4 d ; ; ' 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. F--- - - ___ . _ - _ _ - __ __ . I L 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�eir 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 5tate Sanitary Code for Food Service Establislunents, 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�I 1. _ 2. _ ___ _ _ . ALLERGEN CERTIFICATIONS: All food service establishments are requ�ired to have at least one full-time employee who has Allergen certification, as defined in the State Sanitary Code far Food Service Establishments, 105 CMR 590.009(G)(3)(a). Please attach copies of certification to this applicatio�. The Health Department will not use past years' records. You must provide new copies and maintain a�le at your establishment. 1. 2. HEIMLICH CERTIFICATIONS: All food service establishments with �5 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 certification�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# __— __ _ - --- . -- —— - �FFI�� -- --- - --- 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$1 l0ea. _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 �Q�( _CONTINENTAL $35 NON-PROFIT $30 _>]00 SEATS $200 _COMMON VIC. $60 WHOLESALE $80 —RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FE� PERMIT# <50 sq.ft. $50 >25,000 sq.ft. - $285 VENDING-FOOD $25 ' �<25,000 sq.ft. $150 _� _FROZENDESSERT;$40 �TOBACCO $110 �(p NAMECHANGE: $IS � � � � � � AMOUNT DUE _ $_�j8 -�j•OO *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** �a�-��-I3 85--OZ �'P� ��-�3��-6Z a s ADMINISTRATION Under Chapter 152, Section 25C,Subsection 6,the Town of Yarmouth is rnow 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 Compensation Insurance. THE ATTACHED ST�TE WORKER'S COMPENSATION INSURANCE AFFIDAVIT 1VYiJST BE COMPI;ETED AND SIG�TED, OR ' ' ; ' � C�RT. OF IN'SU�ANCE ATTACI=IED( ►/` ` , , , .OR . . ._ � .�: , . WORKER'S COMP. AFFIDAVIT SIGNED ANID ATTACHED ' - � . LL ,. � ': ''t'owil of�arniouth taxes and liens must be paid prior to,renewal or i�suance,of youY'permits. PLEASE CHECK ' APPROPRIATELY IF9 PAIb: � , . , . _ � x. ` ' YES �✓ NO MOTELS AND OTHER LODGING ESTAB�,ISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy sha11 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 occupamcy 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 subje�t to the collection of Room Occupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shal� generally be considered Transient. POOLS POOL OPENING:Ali 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 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 draiined 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 opening. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarinouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to �he catered event. These forms can be obtained at the Health Department,or from the Town's website at www.yairmouth.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 siuspension 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. ; i F 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, MOTEZ OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BIY THE BOARD OF HEALTH PRIOR I TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: �. a`�� ,'�p1'� SIGNATURE: �,�� _._. PRINT NAME &TITLE: � i�,(�,: I1LL�l�— ��r�fi l a�'� Rev. ]0/12/17 , • ' � 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 Legiblv , Business/Organization Name: N� t��,�►.►, (mrp�3F1. a�rmot,�#�h(1�" f(1� Address: �30 �p�,�� 6(�} I � ` j City/State/Zip: �g��}��mA 026"15 Phone#: �0�.362- 29d�3 Are you an employer? Check the appropriate box: Business Type(required): ', 1.(� I am a employer with�_employees (full and/ 5. � Retail or part-time).* 6. ❑ RestaurantBar/Eating Establishment am a s�proprieto�or pd�ri�rship�nt�Yta�e i�o _ - --- - - ' . 7. ❑ Office andlor Sales(incL real esfate,auto,etc.j employees working for me in any capacity. [No workers' comp. insurance required] g• ❑ Non-profit i 3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per a 152, §1(4), and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]* 1 l.❑ Health Care 4.❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.❑ Other � *Any appiicant 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 corporadon has other employees,a workers'compensation policy is required and such an i organization should check box#L j I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. � Insurance Company Name: �� -��1Q� f �H �Vit m�n �mSU3-c.rnC� ��em�-�-1 Insurer's Address: � , O , �y��`��p I City/State/Zip: ��j �j�,/ . t(� - 02 S� :� Policy#or Self-ins. Lic. # O��dcS,�o__�Lt 12L� 1 l 1 Expiration Date: t - l � �p l & Attach a copy of the workers' compensation policy declaration page(showing the policy number and egpiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a . ��P�ta-$-�;Snn.nn �,,,�i.,r„�A_�,��;�priGon�n�s�s-v��-1�s�iu�pena�xies.i.�.th:e form-�f a ST(�P Vil(.)�K.()RDFR�d..�..�ine-_ - 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 of perjury that the information provided above is true and correc� Si ature: Date: �O•a��.OI�' Phone#: ��S'-r'J�-��1r.�l.{ 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 Soard 5. Selectmen's Office 6. Other Contact Person: Phone#: www.mass.gov/dia ACORD� DATE(MM/DDlYYYY) � CERTIFICATE OF LIABILITY INSURANCE 10/2M2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or 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 cert�cate does not confer rights to the certificate holder in lieu of such endorsement(s. PRODUCER �E: T Deborah HaUiaHay G.H.Dunn InsuranceAgency PHONE �r�pg��_�42 F^� 5pg 322_3243 P.O.Box 330 �ac,No�:� 08� Buzzards Bay,MA02532 �pR�_ deborah@ghdunn.com INSURER S AFFORDING COVERAiGE NPIC# wsu�n: MAREfAILER U00000 INSURED NewYarmouthCorpNewYarrrputhRealiyLLC INSURERB: 1 Patricie Way INSURER C: Forestdale,MA02644 INSURER D: INSURER E: i INSURER F: � ! GOVERAGES CERTaFICATE NUMBER: REWS�N NUM�ERa i THIS IS TO CERTIFY THAT Tl-� POLICIES OF INSURANCE LIS7ED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATEO. NOlWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCIMAEM WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, TF� INSURANCE AFFORDED BY TF� POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SFIOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ��R TYPE OF INSUR/WCE �� POLJCY EFF POLJCY EXP LTR � POLICY NUMBER MM D YYY MM/DD/YYYY LIMIT3 � COMMERCIALGENERALLIABIL.ITY EqCHpCCURRENCE $ DANWGE TO RENTED , CLAIMSMADE �OCCIfft PREMISES Ea occuRence $ . MED E�(My one person) $ � PERSONAL&ADV INJURY $ , GEfVL AGGREGATE LIMff APPLIES PER: GEf�RAL AGGREGATE $ POLICY � PRO- ❑ JECT �� PRODIICTS-COMP/OP AGG $ � OTFER: $ � AUTOMOBILE LJABILITY COMBI�ED SINGLE LIMfT $ Ea acddent ANY AUTO �� BOOILY Ih11URY(Per person) $ OWNED SCFEDULED BpDILY INJURY(Per acddent) $ AUTOS ONLY AUTOS PROPERTY DAMAGE HIRED NOl�OW�D $ AUTOS ONLY AUTOS Of�Y Per acddent i $ UMBRELLALIAB �C� EACHOCCURRENCE $ IXCESS IJAB C��E � . AGGREGATE $ DED REfENfION$ � g A WORKERSCOMPENSATION 014005034124117 01l01/2017 01/01/2018 �R oTr+ AND EMPLOYER$'LIABWTY Y�N STATUTE ER ANYPROPRIETOR/PARRJEWE�CUTNE E.L.EACHACCIDENf � $ � �,OOO OFFICEWMEMBERE�L.UDED7 ❑N N/A � � '�'� (MandMorylnNH) . . ._. - . _. .. ... - ... . _ ...-£.L: �� ---� ---��i� � IF yes,describe under �� DESCRIPTION OF OPERATIONS bebw E.L.DISEASE-POLICY LIMIT $ �� DESCRIPT1pN OF OPERATIONS/LOCAT10N3/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Store 773 Main Street Denr�s MA 02638 CERTIFICATE HOLDER CANCELLATION SH W LD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TOWN OF DENNIS THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELNERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRE3ENTATIVE /��/`'�e'!�, "'!i"�� __ _ ____ __—_ __ _ O 1988-2415 AC�RD CORRAF�R,hTION: All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD