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TOWN OF YARMOUTH BOARD OF HEALTH
1, APPLICATION FOR LICENSE/PERMIT-2019
\ vi *Please complete form and attach all nemsary documents by Dec nber 15 201$.
NOTE:ALL BUSINESSES WITHLIOUOR LICENS,S MUST RETURN FORMSBY NOVEMBER Bd.
Failure to do so will result m the return of your application packet.
ESTABLISHMENT NAME: R 0i FiA910 1'-y Itto Ua c in DA,Ir TAX ID: /)
LOCATION ADDRESS: I Q(o r/ Pe X r TEL.#: /_'�O.5-399-6-477
MAILING ADDRESS: //L¢ K/4 TpR^N s,S Fk'0
E-MAIL ADDRESS: R Ti4Ph/KO Cd 4.1 0 407 N€T-
OWNER NAME: P 'TF/i CAirt-P,?D
CORPORATION NAME(IF APPLICABLE): /2110A' F,*a7I 1-1> /0el1,d m?N iS
MANAGER'S NAME: P -Tf+A C4 F/� TEL.#: S'O CS- 3,4 4-/q ti)
MAILING ADDRESS: St 1'3/111"1 77-A/ - '7ifII-nowis; /n/I- U2.f,75"
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 m O 2
Cardiopulmonary Resuscitation(CPR),having one certified employee on premises at all times. PIease list the D .c El
employees below and attach copies of their certifications to this form.The Health Department will not use past r
years'records. You must provide new copies and maintain a file at your place of business. i
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1. 2. R]
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 Food9 'il
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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.
1. 2. C'`
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 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)(3Xa). 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. '11
k
HEIMLICH CERI'Ir'ICATIONS: 1
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. p
You must provide new copies and maintain a file at your place of business. N
I. 2. O
3. 4.
RESTAURANT SEATING: TOTAL#
OFFICE USE ONLY
. LODGING:
LICENSE REQUIRED FEE PERMIT S LICENSE REQUIRED FEE PERMIT S LICENSE REQUIRED Fhb PERMIT S
B&B $55 CABIN $55 MOTEL $110
—INN $55 —CAMP $55 _SWIMMING POOL$110ea.
LODGE $55 TRAILER PARK $105 _WHIRLPOOL $110e,,.
FOOD SERVICE:
LICENSE REQUIRED FEE MN S LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT Il
1_0-100 SEATS $125 CONTINENTAL $35 NON-PROFIT $30
>100 SEATS $200 JCOMMON VIC. $60 itOpWHOLESALE $80
_RESID.KITCHEN$80
RETAIL SERVICE:
LICENSE REQUIRED FEE PERMIT 8 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT it
<50 ..ft. $50 >25,000 sq ft. $285 VENDING-FOOD $25
—<25,0 i I sq.ft. $150 =FROZEN DESSERT$40 =TOBACCO $110
NAME CHANGE $15 AMOUNT DUE = S 185.Of)
PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM
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 ATTACHLD STATE WORKER'S COMPENSATION INSURANCE
Al'r(IDAVIT MUST BE COMPLETED AND SIGNED,OR /
CERT.OF INSURANCE ATTACHED 1/
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
APPROPRIATELY IF PAID: p�
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 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 foronas,total coliform and standard plate count by a State
certified lab,and submitted to the Health Department three(3)daysaprior 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 required
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.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.
TOBACCO PRODUCT PERMIT CAP
A tobacco permit holder who has failed to renew his or her permit within thirty(30)days of the previous year's
permit expiration date is considered an expired license,and the tobacco license cap is reduced.
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 15,2018.
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: i(-1 Ip �( SIGNATURE:
PRINT NAME&TITLE: (�1 , (r P� E tat
Rev.10/23/18
Worker's Compensation and Employer's Liability Policy
Berkshire Hathaway AmGUARD Insurance Company-A StockCo.
Policy Number RYWC861112
GLIARD Insurance Renewal of RYWC729668,
Companies NCCI No. [21873]
Policy Information Page
[i Named Insured and Nailing Address Agency
Ryan Family Amusements Inc TPA INSURANCE AGENCY INC.
116 Waterhouse Road 10 NEW ENGLAND SUS CTR
Bourne,MA 02532-3867 SUITE 303
Andover,MA 01810
Agency Code: MATPAAIO
Federal Employer's ID Insured is Corporation;
Risk ID Number 917565287
Locations on Policy -See Extension of Information Page- Schedule of Locations
[2) Policy Period
From December 31, 2017 to December 31, 2018, 12:01 AM, standard time at the insureds mailing
address.
[3] Coverage
A. Workers'Compensation Insurance - Part One of this policy applies to the Workers'Compensation
Law of the following states: Massachusetts, Rhode Island
S. Employer's Liability Insurance- Part Two of this policy applies to work in each of the states listed
in item (3)A. The limits of our liability under Part Two are:
Bodily Injury by Accident- each accident- $500,000
Bodily Injury by Disease - each employee $500,000
Bodily Injury by Disease,- policy limit $500,000
C. Other States Insurance-Part Three of this policy applies to all states, except any state listed in
item [3IA.and the states of North Dakota,Ohio, Washington, and Wyoming.
D. This policy includes these endorsements and schedules:
See Extension of Information Page-Schedule of Forms
(43
_ . Premium m .
The Premium Basis and therefore,the premium will be determined by our Manual of Rules,
Classifications,Rates,and' hating Funs, All required information is subject to verification and change by
audit. (Continued on another page)
Total Estimated Policy Premium $ 24,419
Total Surcharges/Assessrnerrts $ 1,018.00
Total Estimated Cost $ 25,437.00
] 1 , Page-1 trfsarcnation Page
MGA :RYWC861112 WC 000001A
Date : 11/26/2017
MAN0TE,
Issuing Office:P.O.Box A-14,16 S.River Street,Wilkes-Barre,PA 18703-0020•www.guard.c om
over#s Compensation and Employer's Liability Por cy
An UAR�►Insurance Company-A Stock Co.
' reri shtr�', Hathaway PolicyNumber 1
Insurance R C8+6 i1
GLIAR,D Companies Renewal f RY1NC729668
NCCI No. (21573]
Policy Information Page
Extension of information Page
Schedule of Locations
(L2) 200 Main Street,Buzzards Bay, MA 02532(12/31/2017- 12/31/2018)
(L3) 441 Main Street, Hyannis,MA 02601 (12/31/2017 - 12/31/2018)
(L4) 1067 Rte 28 ,South Yarmouth, MA 02664(12/31/2017 - 12/31/2018)
(LS) 115 New State Hwy,Raynham, MA 02767(12/31/2017 - 12/31/2018)
(16) 1170 Main Street,Millis, MA 02054(12/31/2017 - 12/31/2018)
(L8) 23 Town Hall Sq., Falmouth, MA 02540(12/31/2017 - 12/31/2018)
(L9) 19 Circuit Ave, Oak Bluffs, MA 02557(12/31/2017- 12/31/2018)
(L10) 268 Thames St, Newport, RI 02840(12/31/2017 - 12/31/2018)
(L11) 769 Lyannough Road , Hyannis, MA 02601 (12/31/2017- 12/31/2018)
(L12) Cape Cod Inflatable Park,512 Route 28,Yarmouth, MA 02664(12/31/2017 - 12/31/2018)
(L13) Cape Codder Resort, 1225 Iyannough Road, Hyannis, MA 02601 (12/31/2017- 12/31/2018)
Ira Na ISE__ Pie-2- inforrtsatttsn Page
mqA :ftvwc8sutz WC 000001A
Date : 11/26/2017
MANOTE
Issuing Office:P.O.Box A-t,26 S.River Strom Wilk -Barre,.PA 18703.0020•www.guard.cem