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TOWN OF YARMOUTH BOARD OF HEALTH
":! APPLICATION FOR I ICENSE/PERAITT-2019
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F T LI ION A CKENT S, ei;t ;
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 busoess if a person or company does not have a Certifies*of Worker's
Cotmptnsatioe Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR
CERT.OF INSURANCE ATTACHED
OR
WORKER'S COMP.AFFIDAVIT SIGNED AND ATTACHED
Town of Yannonth taxes and Dans mot be paid to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES NO
MOTELS AND OTHER LODGING ESTABLISHMENTS
TRANSIENT OCCUPANCY: For purposes ads;imitations of Mote or Hole!use,Transient occupancy shall be lIuliud to
the temporary and duet semi occupancy,ordinarily and customarily essacuted with motel and hold use. Transient occupants
mast stave and be able to demonalrate that they maintain a principal place of residence ebewrhete.Transient occupancy shall
gem rets to costbruous occupancy of not more than thirty(30)days.and as awe of aot 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 coaaidaud headiest.
Occupancy that is subject to the concedes of Room Occupancy Excise.as defined is ALG.L c.640 or 830 Chit 640,as
amsesded,shell ganaaily be considered Transient.
POOLS
POOL OPENING:All swimming,wading and whirlpools which have been doted for the memos must be impacted by the
Hosea Da eat prior to opening. Contact the Health Department to aiadale the three days
epeeist.P' Potpie aro NOT allowed to sit in die pool area until the pool has�isepeesed)nod opened. ~
POOL WATER TESTING:ING: The water must he tested for ,total coliform and*songbird prase count by a Stale
certified lab.and submitted to the Health Depart:neat ism )tor di,,prior ro opening.and Wanly*mallet
POOL CLOSING:Easy 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 impaled by the Health Department prier es Ming Please contact the Health
Department to schedule the inspection three(3)days prior to openew
CATERING POLICY:
Anyone who cars within the Town of Yennor h must notify the Yarmouth Health Department by filing the
Foodemporary Service APpd+ r loam 72 bouts prior a the catered event. These formas can be Maimed at the Health
Depalreaeue,or Sum the Town's wahine at wvnv.varrmout.ma.ra under Health Department,Downlosdabb Forms.
FROZEN DESSERTS:
Falcon desserts mast be sealed by a Stale certitkd lab prior to opening and monthly darealfar.with sample modes aubasired m
the H
eaa lth . Farhat to do so will result in tits ati�ion or revocation of your From Demon Permit until the
shove met
OUTSIDE CAFE
Outside cafes(i.e.,outdoor waft with wa l ws aaas service),must have prior approval from tie Board of Health.
OUTDOOR COOKING:
Outdoor cooking.preparation.or display of any food product by a retail or food service establishment is rabbeted.
TOBACCO PRODUCT PERMIT CAP
A tobacco permit bolder veto 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 die tobacco license cap is reduced,
NOTICE:Permits run annually front January I to December 31.rr IS YOUR RESPONSZBILY1Y 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 SIGNATURE: yf, ,,,a..�,• ��„ � � �_.�..,�—
PRINT NAME do TITLE r' r
Rfr.ca2uu
The Commonmeask ofMes huset s
. •= ==�,
Department of Industrial Acehiestts
Office ofIse g ons
® - I Congress Street,Smile 100
Boston,MA 02114-2017
wwwmaassigovidia
Wetter** Compensation Insurance Affidavit:General Businesses
Applicant Information 'fie Print Lesditly
Business/Organization Name: ( (.1 — N r{ ' `' -
Ate: c
City/State/Zip. �4 ;` phone Vit; `
Are ' ' an employer'Check the appropriate box: Ihniness Type( uked):
1.0 I am a employer with E. employees(full and, 5. D a1
or )* 6. aRestausantifiarlEating Establialmtent
2.0 lam a sole or partnership and have no 7. Q Office an3dlor Sales(incl.real estate,auto,etc.)
employees working for me in any capacity.
(No workers'comp.insurame required) 8. ❑14:at-profit
3.0 We are a corporation and its officers have exercised 9. 0 Entertainment
their right of exemption per c. 152,§1(4),and we#
no [No workers'comp.` s 1Kent3ft taring
4.0 We are a Bunn-profit staffed by volunteers, 11 1iea Care
with no employees.s.[1 o workenti comp,.' req.] 12.0 Other
*Any app&eet that theca box#1 must neo 50 out the section below Amities their wake,'omapmeadoe policy Mutation.
"If the corporate official bwe extunmed thennalvek but the annotation tion m[otter a teachers*sonmenashea
thitanizatioa should check box#1. poky it and as
1 am en employer that Is proW&ag markers'conyeasmion bustreacefor m employees. env Is the peaty is n.
Insurance Company Name. i, •
Insuer's r vt- $ .,-Y `. T
Policy a or Self-ins.Lic. 's '' '�" _ '
Attacha of the �+oaa � Expiation Chats:
compensating l�declaration page(Akowing the policy number and expiration date).
Failure to secure coverage as reduced under Section 25A of MGI.c. 152 can lead to the invosition
a
fine�to 51.5{!4 t#l?and/or+tee- ram imprisonment, ofe' stal penalties of a
y prisoru „as well as civil in the form ofa STOP WORK ORDER and a fine
of up to$250.00 a day against the violater. Be advised that a copy of this staannent may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I aka hereby caet;lotfy,under the pens andpenakks of perfrtry oat the'Myrmidon provided above is true acrd owed.
S .. Daae: '
Phone g: ' " '
aflcialuse only. Donot mit ithlb area,to be amplesed
by dry der town official
City or Town: PeraaWL.eerie d
Issuing Authority(dm,.one):
L Board of Health 2.Bundbag Department 3.City/Town Clerk 4. *
6.OtherBoard s Office
Contact Penes:
Plmaae#:
woommate.joefthe
CERTIFICATE OF LIABILITY INSURANCE °"' '
IA
11/13/2018
TIRS 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/,EXTEND OR ALTER THE COVERAGE AFFORD BY THE POLICIES
` BELOW. THIS CERTIFICATE OF MSE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING ESSUMERM,AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT If the certirmite holder is an At/DITIONAI.ENSURED,the policyllesi must have ADDITIONAL INSURED provision*or be endomsed.
If SUBROGATION IS WAIVED,subject to the terms and cortions of the policy,certain policies may recants an endorsement. A stent on
this certificate does not confer risgits to the certificate holder in tied of such endore ment(s).
PRODUCER =ACTCarol Creentnen
Lawrence Caren Insurance Agency
234 Jones Roast i .EASE {S4H}344 7104 I ,RAE
(548)5404426.Ns
t'Axnssss
cerotelawnencacaran corn
Fa4makah MA 02540 *sunk A ArbeI1a Ca
f*rraec19krNEURERM AFFORDING commasi 41NAIC 360
EGRARED
QAS Corp;DEA Tugboats
M s
Mass Remi Menirants/Coee Risk
srrait c
224 Scranton Ave.
F MRE;
MA 02540 MSR F
COVERAGES CERTIFICATE NUNMEtx: CL181301225 REVISION NUMBER:
THS-IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW RAVE!LEEN ISSUED TO THE INSURED NAMEDABOVE FOR THE POLICY PE
RICO
HOICATED. NOTIWTHSTANENNO ANY REQUIREMENT.TERM OR COMYTIOAI 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 COF40ITIONS OF SUCH POLICES UMITS SHOWN MAY NAVE BEEN REDUCED BY PAID CLAIMS.
LugPOR! Plkity REF FOUCY Ent
TYPE Of otsgt ►Cum*a anew tom
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EACH OCCURRENCE $ 1,400.400
CLAdM3 ht+I3E I F ttr.c 144 000
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Aal 8500032964 01/03/2018 41143/2419 pfteiosAt s Apv NouRY f 1.000.000
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CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF TME ABOVE D5SCR ED POW.**BE CANCELLED BEFORE
THE EXPIRATION RATS TNEREOF NOTICE WILL BE DELIVERED IN
Town of Yarmouth ACCORDANCE MTh THE POLICY
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