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Home My WebLink AboutApplication and WC � # '�`` ': RECEIVED � ,..� � �,, � TOWN OF YARMOUTH BOARD OF H�LTI�� 'c �� +� � APPLICATION FOR LICENSE/EE 6- D EC �� 1� w * Please com lete form and attach all necess '�� De mber 1 S 2017. � P �Y � i � Failure to do so will result in the return ofyour application t � i ESTABLISHMENT NAME: ► ID: ` / I LOCATION ADDRESS: -[' TEL.#: ' �� ! MAILIN_G,�A �R�'SS� � � E-MAI�ADDRESS: ` (�. , Cca.. vr,�._� OWNER NAME: � a o'l CORPORATION NAME (I PLIC LE): U � r'1 d r� �--1.e.�„ MANAGER'S NAME: ' � � TE .#: MAILING ADDRESS: S�. POOL CERTIFICATIONS: ' The pool supervisor must be certified as a Pool Operat.or,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. ; j 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 atta.ch copies of certification to this applicatior�The Health Department will not use past years'records. You mu provide new copies and maintain a file at your establishment. 1. � .. ��,'Q" �� 29� 2; � � Gi �t.. - �..�1:4^' PERSON IN CHARGE: Eac od establishment must have at least one'�Person In Charge(PIC) on site during hours of operation. 1. � �/'� 4 � (�.•," ' 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 '; pro i e new copies and maintain a file at your estabGshment. : 1. �i c� � � 1� �� .(� 2. �� r,� 1 , HEIMLICH CERTiFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich 1Vlaneuver on the premises at all times. Flease list your employees trained in anti-chaking 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 LUDGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQLTIRED 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: L�CENSE REQUIRED FEE PE IT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �0-100 SEATS $125 #1 CONTINENTAL $35 NON-PROFIT $30 >100 SEATS $200 �COMMON VIC. $60 �Qj —WHOLESALE $80 —RESID.KITCHEN $80 RETAIL SERVICE: ,r LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq.ft. $50 >25,000sq ft. $285 VENDING-FOOD $25 ' <25,000 sq.ft. $150 _FROZEN DESSERT $40 _TOBACCO $110 NAME CHANGE: $i s AMOUNT DUE _ $ ��S�� *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** (� oy-r-t�-65�Q--�t � I . . . . . ... � � . � '� �.. ADMINISTRATION ' Under Chapter 152,Section 25C,Subsection 6,the Tovcm 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�orker's Compensation Insurance. THE ATTACH�D STATE WORKER'S COMPENSATION IN�URANCE ; AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR / � ✓ �CERT. OF INSURANCE ATTACHED � OR , WORKER'S COMP. AFFIDAVIT S NED AND ATTACHED Town of Yarmouth taxes and liens must be paid prio o 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 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 occu anc shall enerall refer to continuous occu anc of not more than 30 da s and � P Y g Y P Y �i�Y� ) Y � � 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 sha11 not be considered transient. Occupancy that is subject to the collection of Room Occupancy Excise, as defined in M.G.L. c. b4G or 830 CMR 64G, as amended, shall generally be considered Transient. POOLS - POOL OPElvING:�11 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) I days prior to opening. PLEASE NOTE: People are NOT allowed to sit in the pool area until the pool has been � inspected and opened. j � 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 elosing. FOOD SERVICE , SEASONAL FOOD SERVICE OPENING: ' All food service establishments must be inspected by the Health Department prior to opening. Please contact the Health Deparhnent 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 C requ�red 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.varmouth.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 Pertnit until the above terms have been met. � � i 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. � NO'�'ICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETLJRN ; 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 UIRE A SITE PLAN. i DATE�� O�� SIGNA �� - � PRINT NAME& TITLE: �`C. I Rev. 10/12/17 � V L"� �4�C�Q �--��1 T ��'G� II, r � ' � The Commonwealth of Massachusetts � � Department of Industrial Accidents Office of Investigations ' ` 1 Congress Street,-Suite I00 ' Boston, MA 02114-2017 ; www.mass.gov/dia � � � � ' Workers' Compensatioa Insurance Affidavit: General Businesses � '_. A licant Information Please Print Le 'bl � I Business/Organization Name: � d�� D n � l l� , ; � �- -�� i Address: � � � �� l- ' �I City/State/Zip: � 1`��'� � ��\ hone #: � �� Are yo an employer? Check the appropriate box: Business Type(required): 1. I am a employer with employees(full and/ 5. ❑ Retail. or part-time).* 6. estaurantlBar/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 I� 3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment I� 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 informa6on. **If the corporate o�cers 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'co pensation insurance for my employees. Below i�the policy information. Insurance Company N ��l�' �/GZ/�� 'fl/�1.��, �.—�V , � Insurer's Address: '� V��`�'Q'c l� �/� � City/State/Zip: C�'b � � �-�-� � 3 Policy#or Self-ins. Lic.# �� Expiration Date: /� �7 �"�� 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 , 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 $250.00 a day against the violator. Be advised that a copy of this staxement may be forwarded to the Office of Investigations of DIA for insurance coverage verification. I do hereb ' , ains and penalties of perjury that the information provide above is true and correct. Si e: Date: O : � Phone#: �J(J(�' ��( � ��/ Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office ' 6. Other Contact Person: Phone#: ' www.mass.gov/dia i i � �..1 � � '`�c�� CERTIFICATE OF LIABILITY INSURANCE °A�`""�'°�'' »�r�o�� 7HIS CER7'IFlGIATE IS ISSUED AS A MAITER OF INFORMATION ONLY AND CONFERS NO RICiHTS UPON THE CER1'IRCATE HOLDER.TH{S CER'TIFlCATE DOES NOT AFFlRMAIiVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLlCIES BELOW. THIS CERTIFlCATE OF INSURANCE DpES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUlNG tNSURER(S}, AUTHORIZED � REPRESENTATIVE OR PRODUCER,ANQ THE CERTIFlCATE HOLDER. i IAAPORTANT: If the certlflcate holder is�ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsad. 1 M SUBROCiATION IS WAIYED,subject to the�erma and CancNtlons ofi tlte policY,certa�n Pcllcles may requtre an endOrsement A Statenlerlt On tNs certltic�te does not conier to U�e catlfMate holder in Iku af such s. �tOD�' Jim Lo hiin �'i0V@I��, I(1C. �NE . � �-�3 FAX 100 Ave.of the . customer.servk;eC�tcoverwaliet.com ' Americas, Floor 16, �� ; New York,NY, 10013 ,��;NorGUARD Insurance n 31470 I INSupEr� Penguins On MaG� + 94t Main St weuRER 9: � SOuth YanTwuth.MA 02864 IN�C: � United States �URER D� MISURER E• F: COVERAt3ES CERTIFlCATE NUMBER: REVI$lON NUMBER: THtS!S TO CERTIFY THAT THE POLIC(ES OF INSURANCE USTED BELOW HAVE BEEN ISSUfD TO TtiE iNSURED NAMEd ABOVE FOR THE POUCY PERIOD INDICATED. NOTMATHSTANDING ANY REQUIRENtENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITFt RESPECT TO WHICH THIS '� CERTIFIC�ITE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE PaLICiES DESCRIBEQ HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND COM�TIONS OF SUCH POUCIES.UMITS SHOVIAV MAY HAVE BEEN REDUCED BY PAID CUUMS. � 7YPEOFIt�tIRANCE p��Ep � �P uNYTg ' COMMEI9CIAL OENERAL LIABIUTY EACH OCCURRENCE S CU1IMS�AME �OCCUR s S N�D EXP one ersan S.— -- PERSONA!8 ADV INJI�ZY S GEN1 AGOREGATE LiMIT APPUES PER (3ENERAL q�3REC,q7p S POUCY❑JEC�T �� PRODUCTS-COMP�PAGCi S na�: s �uro�en.e une�crrr s ANY AUTO BODlLY INJURY(P�person) a _" A�U'�fOS�ONLY SAUTOSUlEO { sa3da�) S BODILY MIJURY Per HIRED NON-0WNED OPERTY AMAGE $ AUTOS ONLY AUTOS ONLY � S � UI�RELLA Wt8 p�CUR EACH OCCURRENCE S EXCE6S WIB C�q�qqpE AOOREGATE S E A u�o�xw.ov��une�u�rr X ANYPROPRIETORIPARTNERIEXECUT►VE Y/N ROWCH7OZB9 ELEACHNCCIDENT S 1�,000 qFFlCERlMEMBEREXCU�ED9 YQ Ni� 11/fl7/201 11/07/201 (MandaWry�n 1� E.L DISEASE-EA Et�Lo 5 1 , DE �R�OF� RA bebw E.LDISEASE-POLiCYLidIT 3 �,OOO DESCRIP710N�OPERATIONS/I.00ATIOIiS/VElpCLE8(ACORD 101.AdditlorW Remsrks Sd�4ds,mry be aAfaehad/�pore fpaee is req�drs� GERTIFtCATE HOLDER CANCELLATION PfOOf Of COY@�Sg2 �pV�,p qM(pp�E ABOVE DE$CRIBED PO�ICIES BE CANCEL�ED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIYERED IN ACCORDANCE WITH THE POLICY PROVIStONS. AUTNOR�AEPNESENTA7IVE �1588-2015 ACORD CORPORATION. Ati righ�reaerved. ACORD 25(2016Jb3} The ACORD nems end logo ar�e register�ed marlcs of ACORD