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Home My WebLink AboutApplication and WCt � _ . • �, a • TOWN OF YARMOUTH BOARD OF HEALTH �� APPLICATION FOR LICENSE/PERMIT-2018 `" *Please complete form and attach all necessary documents by D,* ecember IS 2017. Failure to do so will result in the return of your application pac tel—�— ESTABLISHMENT NAME: �tl?S 0�'Cl/ S 0� D• LOCATION ADDRESS: �!D 57Yine.�i4./r TEL.#:SOd"-3�/'8-"7(30 MAILING ADDRESS: SOuTN �/fM/N�-+-7N M4 Oa2(o(c'� E-MAIL ADDRESS: ('' I OWNER NAME: (' Ol.. �.,/t�U��'��.��/ ; CORPORATION NAME IF APPLICA LE): �NaliS Vi1�7i�reu7N ��Sil�A�L �tfGGC_ �i s 7t2.�cT MANAGER'S NAME: dOd1t�`Y Ou��S r TEL.#: .�d�'-3S�"7PZG MAILING ADDRESS:�is��_7v�'Ie�c/ ihAE 50uTN %91Z�lwull-1 Mf� G��6�[ i � AOOL 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. p D � �"�' t. z. T �,,: � 3. 4. � � v � � � E"T� FOOD PROTECTION MANAGERS-CERTIFICATIONS: � .,r � 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 wiA not use past years'records. � You must provide new copies and maintain a�le at your establishment. i. �iL�`�1�L �,a-�-CA 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. I. L.�?LL��I �i�4L.[C1 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 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. � l. �L.��/ -�i9Ltn 2. i -- i 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 tile at your place of business. 1. �-'�i�7-�t.' �n 2. '� 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY �oocrNc: LICENSE REQUIRED FEE PERMIT# [.[CENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMiT# B&B $55 CABiN $55 MOTEL $IIO INN $55 CAMP $55 SWIMMING POOL$I IOca. � _LODGE $55 _TRAILERPARK $105 WHIRLPOOL $IlOea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# L CENSE REQUIRED FEE P IT 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 q LICENSE REQUIRED FEE PERMIT N LICENSE REQUIRED FEE PERMIT# �<29q >25,000 sq ft. $285 VENDING-FOOD $25 ,000 sq.ft. $$50 �FROZEN DESSERT $40 �� _TOBACCO $I 10 NAME CHANGE: $IS AMOUNT DUE _ $ **'**PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** go� �-ts-�g��-a3 : , � , i i 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'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR i � CERT.OF INSURANCE ATTACHED OR WORKER'S COMP.AFFIDAVIT SIGNED AND ATTACHED � Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK I APPROPRIATELY IF PAID: a � 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 OPEN[NG:AU 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 Deparhnent 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 opening. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the requ�red Temporary Food Service Application form 72 hours priar 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 MAY REQUIRE A SITE PLAN. DATE: SIGNATURE: PRINT NAME&TITLE: ult`l2S - �tru�S('2�/�c17�,Q��,7�Q Rev.10/12/t 7 r i � The Commonwealth of°Massachusetts Prmt Form Department of Industrial Accidents "�, � ,��' Office of Investigatio�cs � r� 1 Con ress Street Suite 100 �' g ' i ,��' Boston, MA 02114-2017 , � � �_�--�� www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Le�ibly Business/Organization Name: 17ennt5-yarm�ov�'�n ��'jiona-� ��9�. s�� Address: 2�d ��a 1-+rv n �U.�.� City/State/Zip: �S, �ar M.b�}-(-�t �01.�yPhone #: 5b$- 3��5-�?410 Are you an employer? Check the appropriate box: Business Type(re�quired): 1.0 I am a employer with S`�,Z employees (full and/ 5• ❑ Retail or part-time).* 6. ❑ RestaurandBar/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 �duc�+�ohai *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#l, I am an employer that is providing workers'compensation insurance for my employees. Be[ow is the policy information. Insurance Company Name: M.�:.�wt5+ ��Iei�f'c Cal val - � - Insurer's Address: I�{�,5� I�cr..t-!� Dc�-f.c� For+y �l'lVC��[�C f� �v� City/State/Zip: L��/� /�� Policy#or Self-ins. Lic. #�.(j�) l0 4 I Expiration Date: E l8 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify, under the pains and penalties of perjury that the inforrrcation provided above is true and correct. Si nature: Date: �� 02 � Phone#• �v� �J � �� Official use only. Do not write in this area, to be completed by city or town officiaL City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Of�ce 6. Other Contact Person: Phone#: www.mass.gov/dia 1 ; � � i i �dwest Em 1 Ql'$ Individual Self-Insured p � Excess Workers' Compensation and � � � Casu Com � p� Employers Liability Indemnity Policy � �BERKLEY CQMPANY� Schedule Page ; Policy No.: EWC006911 Indemnity Coverage Provided: Specific and Aggregate Excess Workers'Compensation and Employers Liability Indemnity 1. Insured: Dennis Yarmouth Regional School District 2. Mailing Address: 296 Station Avenue South Yarmouth, MA 02664- 3. Named States: Massachusetts 4. Excluded States: None 5. Policy Period: (a} From: 07/01/2017 (b) To: 07/01/2018 Both days start at 12:01 A.M. standard time at the Insured's address shown in Item 2 of this schedule. 6. Specific Retention: (a) Each Accident: $450,000 (b) Each Employee for Disease: $450,000 7. Specific Limit Each Accident: (a) Policy Part One,Workers'Compensation: STATUTORY ' (b) Policy Part Two, Employers Liability: $1,000,000 8. Specific Limit Each Employee for Disease: (a) Policy Part One,Workers'Compensation: STATUTORY (b) Policy Part Two, Employers Liability: . $1,000,000 � 9. Aggregate Retention: (a) Rate as a Percentage of Normal Premium: 293.09% (b) Estimated Normal Premium: $295,510 (c) Minimum Retention: $g4g,7gg (d) Aggregate Loss Limitation: $450,000 10. Aggregate Limit: $3,000,000 11. Classification of Operations: See Endorsement (a) Experience Modification Factor: 1.000000000 (b) Other Modification Factor: 1.000000000 CMB-SCH (8-13) 14755 North Outer Forty Drive, Suite 300 Chesterfield, MO 63017 Page 1 of 2 (636)449-7000 www.mwecc.com 1 � ; ! � � Midwest Em 1 QY$ individual Self-Insured ; � �.A p � Excess Workers' Compensation and � � � � C1St1 Wlll Em lo ers Liabil� Indemnit Polic �y pany p v �v y v �BERKLEY CQMPANY� Schedule Page 12. Premium: � (a) Rate as a Percentage of Normal Premium: 15.08% � (b) Policy Minimum Premium: $40,107 � (c) Total Estimated Policy Premium: $44,563 (d) Deposit Premium: $44,563 (e) Deposit Flat Charges: n/a (fl Total Deposit Premium and Flat Charges Payable as Follows: $44,563 13. Endorsement Serial Numbers: See Endorsement Schedule 14. Service Company: Cook&Company, Inc. P.O. Box 1068 Marshfield, MA 02050-1068 Countersigned MIDWEST EMPLOYERS CASUALTY COMPANY .�;%�'`�•��'` ' `-- Licensed Resident Agent Date Authorized Representative CMB-SCH (8-13) 14755 North Outer Forty Drive,Suite 300 Chesterfield, MO 63017 Page 2 of 2 (636)449-7000 www.mwecc.com �� DENNI-2 OP ID: DS Al CORO� DATE(MM/DD/YYYY) `�j CERTIFICATE OF LIABILITY INSURANCE 10/24/2017 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, EXTENO 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 certiflcate holder is an ADDITIONAL INSURED,the policy(ies)must 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 certificate dces not confer rights to the certificate holder in lieu of such endorsement s. � PRODUCER CONTACT ' Bryden&Sullivan Ins Agency PHONE Kelle A.Sullivan F� � 88 Falmouth Road ac No �c:508-775-6060 ac No:508-790-1414 Hyannis,MA 02601 pDDRESS: Kelley A.Sullivan � INSURER S AFFORDING COVERAGE NAIC il �� INSURERA:MICIW23t E�II lo ers Casual Co INSURED Dennis Yarmouth Regional INSURERB: School District 296 Station Ave INSURER C: South Yarmouth,MA 02664 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POIICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ��7� TYPE OP INSURANCE DDl UBR pOLICY NUMBER MM/LD�DY� MM/DD �P LIMITS COMMERCIAL GENERAL UABILITY EACH OCCURRENCE $ CLAIMS-MADE �OCCUR PREMISES Ea occurrence S MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE E POLICY�PR� �LOC PRODUCTS-COMP/OP AGG $ JECT OTHER: $ i AUTOMOBILE LIABILITY COMBINED SINGLE LtMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALLOWNED SCHEDULED BODILYINJURY(Peraccident) S AUTOS AU70S NON-0NMED P808��DAMAGE $ HIREDAUTOS AUTOS $ UMBRELLALIA6 p�CUR EACH OCCURRENCE $ ! E%CESS LIAB CLAIMS-MADE AGGREGATE $ I DED RETENTION S $ WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LJABILITY STATUTE ER A ANYPROPRIETOR/PARTNEWEXECUTIVE Y�N EWC006911 07/01/2017 07/01/2018 E.L.EACHACCIDENT $ ��0��0� OFfICER/MEMBER IXCLUDED? �N�A (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ 1,000,00 If yes,describe under DESCRIPTION OF OPERATIONS b�ow E.L.DISEASE-POLICY LIMIT $ 'I,OOO,OO DESCRIPTION OF OPERAitONS/LOCATIONS/VEHICLES(ACORD 101,Additlonal Remarks Schedule,may be attached if more space is required) Certificate issued for insurance veri�cation CERTIFICATE HOLDER CANCELLATION YARM003 SHOULD ANY OF THE ABOVE DESCRIBED POLIL`IES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN YARMOUTH TOWN HALL ACCORDANCE WITH THE POLICY PROVISIONS. 1146 MAIN ST S.YARMOUTH,MA 02664 AU7HORIZED REPRESENTATIVE Kelley A.Sullivan O 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD