The URL can be used to link to this page

Home My WebLink AboutApplication and WC! Sr�a�toN P.N� Cov3-J�JvC�Jc,� � � � �� TOWN I�F YARMOUTH BOARD OF HEALTH � � APPLI�ATION FOR LICENSE/PERMIT -2018 � � * Please complete form and attach all necessary documents by Dece - S�'011.'� �' ' Failure to do so will result in the return of your application p . �� ESTABLISHMENT E: " . TAX ID: LOCATION ADDR:�� . . O TEL. Q MAILING ADDRESS: ' v�ca � E-MAIL ADDRESS: �/` � .�',a/1R.. OWNER NAME: ' 4... CORPORATION NAME (IF APPLIC�ABLE):7"�,�� . MANAGER'S NAME: ' ' � TEL.#: O ZK- MAILING ADDRESS: ' 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. � _ -- -- ;---- - . __ _- -- . ; 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 tl�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: i 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. L 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 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 applicatiou�. 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 �5 seats or more must have at least one ernployee 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. L 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 $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 —RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE'REQUIRED FEE PERMIT# LICENSL REQUIRED FEE: PERMIT# <50 sq.ft. $50 >25,000 sq.ft. $285 VENI�ING�FOOD•$�5 •� �<25,000 sq.ft. $150 �Ii' _FROZEN DESSERT $40 �TOBACCO $I 10 NAME CHANGE: $15 ` ` AMOUNT DUE _ $ 260.Ob *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** a�o�-�s--(.at2-o3 �o�tnP�S"'��(,-c�3 4 . 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 Compensation�Insurance. THE ATTACHED ,STATE WORKER'� CO�VIPENSATION INSURANCE AFFID�AVIT MUST BE COM�`LETED�AND SI�1�E'D; OR` Y ` ' ` . <` . ; .. • � , w < , . . . . .a . ' .`CERT: OF INSI�'RANCE ATTACHEDC�f '� °`'., OR� . . . 4 ' WORKER'S COMP. AFFIDAVIT SIGN�D AND`2�TTACHED' '° , . Tawri of'Yarrriouth taxes and liens must be paid prior to xenewal Or�ss�iance dfyour`'permits. PLEASE CHECK a APPROPRIATELY IF PAID:� - ' . , � x . . YES v NO MOTELS AND OTHER LODGING ESTAB[.ISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occup�.ncy 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 rnlaintain 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: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 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 dra�ined 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 Heaith Department to schedule the inspection three (3) days prior to opening. 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 �he catered event. These forms can be obtained at the Health Deparfmment,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 s�spension 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 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 RETIJRN THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 15, 2017. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTE�, OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BIY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQU SITE PLAN. DATE: I[�•aZ�. ;t01'�'1 �IG1�.ATURE: PRINT It1AME &TITLE: � I S h�l 5 hu K 1T��C°.�� l Rev. 10/12/17 ` . _. � The Commonwealth of Massachusetts _ Department of Industrial Accidents Office of Investigations ' 1 Congress Street, Suite 100 ' Boston, MA 02114-20I7 . � www.mass.gov/dia Workers' Compensation Insurance Affidavit: Ge�eral Businesses � Applicant Information Please Print Legiblv � Business/Organization Name: � ',� � '�rn {�/.� . ��.C�J Ge, Address:��'��{� ��u�„ i City/State/Zip:�,l,�q�{-�, mA _b�66 c.�_ Phone #:__5�$•��9�-"1�'d� Are you an employer? Check the appropriate box: Business Type(required): 1.� I am a employer with_ T employees(full andl 5. � Retail or part-time).* 6. ❑ RestaurantlBar/Eating Establishment — - -- -- - - - _ -- -- - -" am a'sore propne�or or p 'ership anfl`�iave no - - 7. ❑ Office and/or Sales(incl. real estate, auto, etc.) employees warking 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 organizaxion,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 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 my employees. Below is the policy information. Insurance Company Name: �g �e}(�1 p� � �4-( '�U�� "(rrS1,C�[^,�� 4 2�trt1 � Insurer's Address: �.p_ b�f �30 City/State/Zip:��7 Gt�r�.� �_T� '(`�� 02��2 Policy#or Self-ins.Lic. # p\i�oo�o=5�\2�-t 1�`'=F Expiration Date: 1 - 1 -2n�� 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 �ne up�o D T;�OG:B�an�/or orie=year impnsonmen�as weT1 as"civil penal�ies in�e forrn of a�i v�'w i anc�a firie ' of up to$250.00 a day against the violator. Be advised that a copy of this staxement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify,under the pains and penalties of perjury that the information provided above is true and correct. Si�nature: Date• �d• '�•20l'� Phone#: �".�$-�2Sd-.�� 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 Office 6. Other Contact Person: Phone#: www.mass.gov/dia '`�ieQ� CERTIFICATE OF LIABILITY INSURANCE °A�;��°;;""' �,.-- THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS CERTIFICATE DOES NOT AFFIRMATNELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTtTUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: Ifthe 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 pollcy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s. . PRODUCER N�� Deborah Hathaway G.H.Dunn InsuranceAgency �pg 3�_3�42 P.O.Box330 PHONN � � (NC.No):��-�'� ' Buzzards Bay,MA02532 �pR�; deborah@ghdunn.corn � INSURE S AFFORDING COVERAGE WYC# iNsuReR n: MA RETAILERS �ppppp INSURED TTcen Corp dba Station A�e Cornenience Paresh Patel INSURER B: 457 Station A�e Sarth Yarmouth,MA 02664 INSURER C: INSURER D: INSURER E: + � INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY TFIAT THE POLICIES OF INSIH�ANCE LISIED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD � INDICATED. NOlWITHSTANDING ANY REQINREMENT, TEf�A OR CONDITION OF ANY CONTRACT OR OTI-�R DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICAIE MAY BE ISSUED OR MAY PERTAIN, 71-� INSURANCE AFFORDED BY Tl-E POLICIES DESCRIBED F�REIN IS SUBJEGT TO ALL l}f TERMS, EXCLUSIONS AND CONDI110NS OF SUCH POLICIES.LIMITS SI-IOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. �� TYPE OF INSUR/WCE ��s�� POLJCY NUMBER MM%�DDIYYY MM'%D Y FYYY LIMITS COMMERCIALGENERALWIBILITY EACHOCCURRENCE $ DMM� E T RENTE CLAIMS�MADE �OCCUF2 PREMISES Ea occurrence $ . MED EJ�(My one person) $ PERSONAL&ADV IWI�tY $ - GEfVL AGGREGATE LIMIT APPLIES PER: . � GEPERAL AGGREGATE $ PRO- POLICY JECT � �� PRODUCTS-COMP/OP AGG $ OTFER: $ � AUTOMOBILE LIABILITY COMBIPED SINGLE LIMR $ Ea acadent ANY AUfO BODILY IKIURY(Per person) $ � OWNED SCFEDULED AUTOS ONLY AUTOS BODILY INa1RY(Per acddent) $ � PROPERTY DAMAGE AUTOS OPLY AIJTOS O Y Per acddent $ � $ UMBRELLA LIAB �C� EACH OCCURRENCE � $ EXCESS LIAB C��E AGGREGATE $ DED RETENTION$ $ , q WORKERSCOMPENSAiION 014000502216117Tteen 01/01/2017 01/01/2018 AND EMPLOYERS LIABILJTY Y�N STATUTE ER� '. ANY PROPPoETORIPARiNERIE�CUTNE � �FlCEWMEMBEREJCLUDED? � N/A E.L.EACHACCIDENT $ SOO,OOO (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ �� If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ �� DESCRIP710N OF OPERATIONS/LOCATIONS/VEHICLES (FuCORD 101,Addltlonal Remarks Scheduls,may be attached if more space Is required) . CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFa2E THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN TO�MI OTY�IY10Uth ACCORDANCE WITH THE POLICYPROVISIONS. 1146 Rt 28 Sa�th Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE J��'� �� O 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD