HomeMy WebLinkAboutApplication and WC TOWN OF YARMOUTH BOARD OF IiEALTIi
APPLI�ATION FOR LICENSE/PERNIIT-2018
• *Please complete:form and attach all necessary documents by December IS Z01�
Failure to do so will result in,the retiun of your applicahon pac et.
ESTABLISHMENT NAME: O <
LOCATION ADDRESS: TEL.#: � 61('a
MAILING ADDRESS:
E-MAIL ADDRESS: O �i,5 'U
OWNER NAME: � �
CORPORATION NAME(IF APPLIC LE):
MANAGER'S NAME: t, TEL.#: � � /Ici
MAILING ADDRESS: � (t(,
POOL CERTIFICATIONS: �
The pool snpervisor must be certified as a Pool Operatior,as required by State law. Piease list the designated .T -,-�
Pool Operator(s)and attach a copy of the c�rtification to this form. . � �''��
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Pool operators must list a minimum of two employees currendy oertified in standard First Aid and Community Y� a' >
Cazdiopulmonary Resvscitatian(CPR),having one certified enp loyt�e onpremises at all times. Please list the i �"`' �"
employees below and attach copies of their certifications to this firm.The Health Department will not use past `� � �'-`
years'records. Yon must provide new copies and maintain a fifle xt your place of bnsiness. � � �
1. 2. _.
3. 4.
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FOOD PROTECTTON MANAGERS�CERTIFICATIONS: '° �
All food seivice establishments are required to have at least one full-time employee who is certiSed as a Food
Protection Manager,as defined in the$tate Sanitary Co�for Food Service Establishments, 105 CMR 590.000. �
Please attach copies of ce;tification to.t�is application. The Health Department will not use past years'records.
You mast prnvide new copies and maintain a�file at y�ar establishmen� � '
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hmcs Ct,rmwV-�h _ {—n�d 5�2rv'�ee. �c°�l�cr ,
PERSON IN CHARGE: ° �,s ;p�,;
E a c h foo d e s t a b li s h men t m u s t h ave a t leas t one Person I n C h a rge(P I C)on si te during hours o f o p e r a t ion. . � ;
1. � ' 2. �,�..-�
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GEN CER�CATIC)N�
All food service establishments are required to have at leest one full-time employee who has Allergen certification, �
as defined in the State Sanitary Code fo�Food Service Establishments,105 CMR 590.009(Gx3xa). Please attach
copies of certification to this applicatiop• The Health Department will not use past years'records. You mast
provide new copies and maintain a fi.le at yonr establiahment �
1. c��- h�l (' � 2. �
! c�c��cA�io�� 'e���na� �v0-FivJ1 S-Eri c-� �0�c! SV�s .
All food service establishments wiih ti5 seats or more�ust have at least one employee trained in the Heimlich
Maneuver on the pre�nises at all times.; Please list your enploqees trained in anti-choking procedures below and
attach copies of employee certifications to this form. The Health Department will not use past yeara'reeords.
You must provide new copies and maintain a file at your place of businesa.
1. ►'T�'1� �11��� � � �' Y � 2. �
3. � 4.
RESTAURANT SEATING: TOTAL# � �� �
• OFFICE USE ONLY .
LODGING:
WCENSE REQUIRED FEE PERMIT# !LICENSE REQUIRED PEE PERMIT q LICENSE REQUIRED F&E PERMiT#
� 353 CABIN S55 MOTEL 5110
—INN S54 CANIP $55 =SWIMlvIIDTG POOL SI l0ea
=T.ODGE $SS _—'TRAD,ERPARK $105 _WFIIRI,POOL $IIOea.
L�IC�ENSE REQUIRED FEE PERMIT# �LICENSE REQUIRED FEE PERMPf# LICENSE RE�UIRED FEE pggMlT g �O N F��`I"O��o�-O�1
d-100 SEA1'S �125 CONI7NENTAL S35 NON-PRO TT $30
=>ioo sEaTs azoo �,5 `�co�ox vic. s�o �.��S ='uvxo�sn� sao
—xEsro.xrrc�x aso
RETAIL SERV7CE:
LICENSE REQUIRED FEE PERMIT# ;LICENSE REQi3IRED FEE PERMPP#. LICENSfi REQUIRED FEE PERMIT#
<50sq�ft. SSO >25 000 R. $285 VENDING-FOOD SZS
=QS,OOO sq.R S150 ;�jtaZEN�ESSERT S40 =1'OBACCO S110
NAME CliANGE: ais . • AMOUNT DUE _ $ ?IcO.O�
'"'•+PLEASE TURN OVER AND COMFLETE OTHF.R SIDE OF FORM•••«'
ADMI�STRATION �
' •
Under Chapter 152,Sectioa 25C,Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal
of any license or permit to operate a tiusiness if a person or company dces not have a C.ertificate of Worker's
Compensation Insurance. THE AITACHED STATE WORKER'S COMPENSATIUN INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR ;
CERT.OF INSURANCE ATTACHED �
OR
WORKER'S COl�'.AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth taxes and liens mu�t be paid prior to nenewal or issaance of your permits. PLEASE CHECK
APPROPRiATELY IF PAID:
�YES NO
MOTELS APffD OTHER LODGING ESTABLISffiVIENTS
T1tANSIEIVT OCC[JPANCY: For piirposes of the limitations of Motel or Hotel use,Transient occupancy shall be
limited to the temporary and short term occupancy,ordinarily and customarily associ�ted with motel and hotel use.
Transient s�ccupants must have and bp able to d�nonstrate that they maintain a principal place of residence
elsewhere.Transient occupancy shall geneially refer to continuous occupancy of not more thaa thirty(30)days,and�
an aggregate of not more than ninety(90)days within any six(�month period. Use of a guest unit as a residence or
. dwelling unit shall not be considered tikansient. Occupaiicy that is subjeet to the collection of Room Oceupancy
Excise,as deSned in M.C3.L.c.64G or'830 CMR 64G,as amended,shall generally be considered TYansient
POdLS
POOL OPENING:All swimming,wa{ling and whirlpools wlrich have been closed for tl�season must be inspa�ted
by the Health Departmernptior to e�ing. Contact tlu HealthDep ent to achedule theinepection three(3) �
days prior to opening.PT.RA :People are NOT allowed�t in the pool area u�l' he pool has ban
inspe�ted and opeaed. __ ; . _�___ - _
POOL WATER TESTII�iG: The wa�er must be tested for pseudomonas,Wtal coliform and standari plate count
by a State certified lab,and submitted to the Health Department thrce(3)daYs Prior to openiag,and quarterly
thereafter. . .
POOL CLOS�tG:Every outdoor in gtound swimming pool must be dtained or covcrod within seven(�days of
closing.
FOOD SERVICE
SEASONAL FOOD SERVICE OPE1vING: �
All food service establishments must be ins�ected by the Health Departmeat prlor to opening. Please contact the
Health Department w schedule the inspxtion three(3)days prior to opening.
CATERING POLICY: . : '
Anyone v�+ho caters within the Town of Yarmouth must notify the Yarmouth Heaith Department�by filing tho
required Tempo yFood Service Application form 72�►ours prior to the catered event. These forms can be .
obtained at the He�alth Department,or�om the Town's we�bsite at www.yamiouth.ma.i�s under Health Deparlme�,
Downloadable Forms. �
- - -FROZ�N lfF.�SERTS: - ;_ _— ___ _ ---,
Frozen desserts must be fested by a Statie certified lab prior to opening and monthly thereafter,with sample results
submitted to the I�ealth Department. Faiture to do so will result in the suspension or revocation of your Fro�en
Dessert Permit until the above terms h�ve been met
OUTSIDE CAF�`S: ' .
Outside cafes(i.e.,outdoor seating wittti waiter/waitress service),m�tst have prior approval from the Board of Health
OUTDOOR COOIQNG:
Outdoor cooking,preparation,or dispia+�of any food product by a reta7 or food service establishment is prohibited.
NOTICE:Permits nm annually from J�nuary 1 to December 31. IT IS YOUR RESPONSIBILITY TO RET'[JRN
Tf�COMPLETED RENEWAL APP�.ICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15,2017.
:
ALL RENOVATIONS TO ANY FOIDD ESTABLI$HIvIENT, MOTEL OR POOL (i.e., PAIlJTING, NEW �
EQUIPMENT,ETC'.),MUST BE REPURTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR
TO COMI��NC . RENOVAT'IONS MAY REQUIRE A SITE PLAN. .
DATE:� �' SIGI�IAT[JRE:
PRIlVT NAME dc TfTLE: . ;
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��� ROMACAT-0Z LYEN
ACORO� CERTIFICATE O� LIABILITY INSURANCE °��jNMM°0"""'
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TH18 CERTIFICATE IS 188UED AS A MATTER OF INFORMATION W�ti.1f ANO CONFERS NO RIGHTS UPON'1'HE CERTIFICATE NOLD�R.THi�
CERTIFICATE DOES NOT AFFIRMATNELY OR NE(i/►TNEL1f AMEMD, �o oR �u.�R rHe covew►ae �oROEa sr n��ouc�a
BEI.OW. THIS CERTIFICATE OF IN8URANCE DOE8 NOT CON8TRUTE A CONTRACT BETWEEN 7HE ISSUMl6 INSURER(i�,/►11THORQED
REPRE8ENTATNE OR PRODUCER,AND THE CERT�ICATE HOID�R.
piAPORTANT: If the certi(icate holder k an ADDITIONAL N�1fURE0.q�e poiky(iss)must have ADCITIONAL INSURED previsia�s w M�ndon�d.
If 8U8ROGATtON IS WAIVED, subJeet to tM brms and eondiqa�s ot tM polky,cKtaln pollcies may nqufn�n�ndors�nwnt A sql�n�eM on
this eertifleate does not�onf�r N hts to tM c�rdflcab hoWK 1n Yw N sw� s.
p�pp��Lk�ns�/1 0 62
HUd iMemational New England ; 50d 676-1971 f •�66 41b-6E35
22Z M�ik�n Boubvard
FaN Riwr,MA 02721
Ni AFFORDINO COVERA� NAIC•
NINMlER A:ApeaMt�d 4�rIM d Mw�eMnNb 1�Ins�Cwy�n a.�7�
� N16tM1Elt R:
Roman Cathoile Bishop of FaN Riv�r, ��:
Corp.Sole
P.O.Box 2577 �o:
Fail River,MA 02722 Nau�t t:
ratNe�t f:
THIS IS TO CERTIFY THAT THE POLICIES OF Md8tM/1NCE ItSTC�BELOYV MAVE BEEN ISSUED TO THE INSURED NAAAED ASOVE FOR TtE►OIiCY PERI00
INDICATED. NOTWRHSTANDING ANY RE�UIREt�NT, TERM OR CONOITION OF ANIf CONTRACT OR OTHER DOCUI�NT WtTH RESPECT TO NIFNCH TM15
CERTIFICATE MAY BE ISSUED OR MAY PERTAMI, Tt� MSURANCE/1FFORDED BY THE POLICIES DESCRIBEb HEREIN IS SUBJECT TO ALL THE TEItM.S,
EKCLUSIONS AND CONDITIONS OF SUCH POt.��8.LII�TS SHOMVPJ N{AY HAVE BEEN REDUCED BY PAID CIAIMS.
� rne oF wsuw�ce � roucr� �f �ucr� �
eoMr�euu.�ae�unaurr �►a+occ� s
CIAN�AS-MADE �OCCUR �AMA" TO l�NTED 1 S
MED EXP one
PERSONAL 6 ADV NlJUItY f
CiEN'L ACiGREGATE Ltld1T APPLIES PER: GENERAL Al3�iREGATE E
POLICY�.�CT ��� PRODUCTS•COMP/aP AOO i
AtROl1�E IWLRY *
ANY AUTO BODILY NJURY P�r �rwn
�LY AUTOS �� BODILY NJURY Pa�oddMR
AUTOS ONILY Al7TOS ONLY a� 5
UM�I�LtJ1 LW OCCUR FACH OCCURItHK� i
EXCEtf LW CLAIMS-MADE Aci0RE0ATE i
DED RETENTION i
A ����"inr T
�9�EX�DR�E�UTIVE Y❑ N/A �'A 0�/01I2017 09/01/Z01 Q E.L EACH ACC NT �����
p E.LDISEASE-EAEI�LO �����
It ,aesa;ne wwer 1�Ot10,000
. I Y
OEfCIlRTION OF OPERATIONS/LOCATIONS/VENICL[S(ACORD ti7 ArNtl�mi RNnrlcs ieMdrU.nny E�ripeMd N mer�sp�a k nqul►ed)
/�:St.Pius X School,321 Wood Road,So.Yarmoud�,M/�02664
F A H R N
SHOULD ANY OF THE ABOVE DESCRIdED POlIC1E8 BE CANCELLED BEFORE
Town of Yarmouth,Hsalth Divklon T� ��►TION DA7E THEREOF, NOTICE WM.L df DELNERED M
ACCORDANCE WITH THE POUCY PROVISIONS.
1146,Route 28
South Yarmouth,MA 02664
AYTMORIiED REPREiENTATNE
ACORD 25(2016103) �1988 2015 ACORD CORPORATION. AN rfphts nserv�d.
The ACORb narrN and bpo arR rpistend marks of ACORD
, ,
� �\ l/iG VV//W/iV/LWCI{iL/�VJ LI1tLJJ{L�.ILKJGLLJ � -�-�
\
� Department of Industrial Accidents
�
� O�ce of Investigations
' 1 Congress Stree�Suite 100
Boston,MA 02114-2017
� www mass gov/dia
Workers' Compensatfon Insurance Afftdavit: General Businesses
�palicant Information Please Print Legiblv
' Business/Organization Name: S� {� I)�_� Sl., �/l U(� 1
� Address: �t7-� � �U C� �L
City/State/Zip: c�', L c��?hone#: ��� �I 0 , � �I `a
Are you an employer?Check the a propr[ate box: Business Type(reqaired):
1.[�I am a employer with �� employees(full and/ 5. ❑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 vvork�tg for me in any cspacity.
(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 1 O.Q Manufacturing
no employees.[No workers'comp.insurance requiredJ*
4.❑ We are a non-profit organizarion,sta�ed by volunteers, 11.0 Health Care
with no employees. [No workers'comp.insurance req.J 12.Q Other
•Any spplicant tl�at checks box#I must also fill out the section below showing their workera'cot►�ensation policy infornoation.
•'If the cotporate officers have exempted tt�emselves,but the corporation has other e�loyees,a workers'compensation policy is c�uired and such an
organiasUon should check box#1.
I am an employer that is providing worke�'con�pensation insurance jor my em loyees. Below is the policy information.
i Inawance Company Name: �� G�-n�'C,(�,"�(mGl_(_��,(a 9 Yl�G�,1'�. ,
'I Insurer's Address: �� 1"�, `t�1'��'�(� ���
c��fsc�c�iz�p: �c�.11'Q�v�e�' . (�W 6'�=19- (
Policy#or Self-ins.Lic.#Ill�I�I�'�(`�.(Z, D OIo�Q � D��lL} Expiration Date: � (� ���( �
i Attach a copy of the workers'compensation poHcy decinration page(showing the policy namber And ezptration 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 S 1,540.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 5250.00 a day against the violator. Be advised that a copy of�is statement rnay be forwazded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby c ,under th and p alties of pery'ury that the inforenation provided above is e and correcx
S' ature: ����� Date: �� � �
#: �� � c�"G �''U/�f �
Official use only. Do not write in this area,to be compdeted by city or town o,f,�ciaL
Ctty or Town: Permit/Lfcense#
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: Phoae#:
www.mass.gov/dia
' i