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TOWN OF YARMOUTH BOARD OF HE L I NOV Z 2 2019
(E APPLICATION FOR LICENSE/P -2 ; ,,
<; G�„' HEALT .
* Please complete form and attach all necess �.< doe II s Dece 1 • , 1 ,SEPT.
Failure to do so will result in the return our'application packet.
NOTE:ALL BUSINESSES WITH LIQUOR LICENSES MUS TURN FORMS BY NOVEMBER 15th.
ESTABLISHMENT NAME: C'f�,n aSS -cA o Se: TAX ID: -\�) (
LOCATION ADDRESS: a��-' -k,e Loo TEL.#:5043-3C,a_' 3LIS"
MAILING ADDRESS: (SIAYAC
E-MAIL ADDRESS: Y1A9ac)C2pt P Qom scZs Pcu Qe cc.mom
OWNER NAME: Pkis e .ek \- -...-....1/4\ 13
CORPORATION NAME(IF APPLICABLE):, Qc>rnfr.),40.--?0, p.& 1. ,
MANAGER'S NAME: Y�fhP Cl a TEL.#:
MAILING ADDRESS:
POOL ERTIFICATIONS:
The po supervisor must be certified a a Pool Operator,as require, by State law. Please list the designated
- oo p _ator(s)and attach-a copy of the rtification toitliisTorm.
1. 2. .
Pool operato s must list a minimum of two em loyees currently certified in •tandard First Aid and Community
Cardiopulmo Resuscitation (CPR), having o e certified employee on pre ises at all times. Please list the
employees belo and attach copies of their certific 'ons to this form.The Heal 1 Department will not use past
yearsrecords. ou must provide new copies an aintain a file at your p1. e of business.
1. 2.
3. 4.
FOOD PROTEC ION MANAGERS - CERTIFICATIONS:
All food service a blishments are required to have at least one full-time employee who is certified as a Food
Protection Manager, defined in the State Sanitary Code for Food Service stablishments, 105 CMR 590.000.
Please attach copies of ification to this application. The Health Departme I will not use past years'records.
You must provide new c ies and maintain a file at your establishment.
1. 2.
PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation.
1. A �(Z`(� \ °''t v,v N 2.
ALLERGEN CERTIFICATIONS:
All food se ice establishments are required to have at least one full-time employee ho has Allergen certification,
as defined i the State Sanitary Code for Food Servic- stablishments, 105 CMR 5'1.009(G)(3)(a). Please attach
copies of cert cation to this application. The Health ►epartment will not use pa years' records. You must
provide new c 1 1 ies and maintain a file at your estabh 1 ment.
1. 2.
HEIMLICH CERTIFI ' TIONS:
All food service establis . ents with 25 seats or more must have .t least one employee ..ned in the Heimlich
Maneuver on the premises ,t all times. Please list your employees ,ained in anti-choking . ocedures below and
attach copies of employee ce i ifications to this form. The Health De rtment will not use .,st years' records.
You must provide new copie and maintain a file at your place of b siness.
1. 2.
3. 4.
RESTAURANT SEATING: TOTAL # 0.0 L-1-7-4?6 7-013
5ON-F-17--ce780-03 -
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_B&B $55 CABIN $55 MOTEL $110
I INN $55 ZO.-Or} _
1 CAMP $55 SWIMMING POOL$110ea.
LODGE $55 TRAILER PARK $105 WHIRLPOOL $110ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT LICENSE REQUIRED FEE PERMIT#
_0-100 SEATS $125 -L CONTINENTAL $35 2b-03 _NON-PROFIT $30
>100 SEATS $200 COMMON VIC. $60 WHOLESALE $80
—RESID.KITCHEN $80
RETAIL SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_<50 sq.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25
<25,000 sq.ft. $150 -FROZEN DESSERT $40 _TOBACCO $110
NAME CHANGE: $15 AMOUNT DUE = $ 90 .00
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*****
C
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
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
APPROPRIATELY IF PAID:
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 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 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 CAFÉS:
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 13, 2019.
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 '4"QU ' / S ' A ►
/ "
DATE: �01 01.016 SIGNATURE: - ...go./
i ®/
PRINT NAME&TITLE: Ow r n e r �h o/d jh.127I/T7)
Rev.10/15/19
s
The Commonwealth of Massachusetts
Department of Industrial Accidents
_` _tet Office of Investigations
V
r. ='��=_4 1 Congress Street, Suite 100�=
Boston,MA 02114-2017
l'--,,,,,--..,34-- www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name: 0 ,f s s /S-e
Address: W? 7 41,1e ‘ /4
�j a et/( D(-i c.v
/
City/State/Zip: �Yrn flL�,f 6l Y� Phone #: /7�5 5 s 7 5-Df-.3601-P Y eP
Are yo p an employee? Check the appropriate box: Business Type(required):
1.IJ"/I am a employer with employees(full and/ 5. 0 Retail
__-or-Part-time)_* 6. RestaurantBaz/
�a�g Establishment - -
-
2.❑ I am a sole proprietor or partnership and have no 7. 0 Office and/or Sales(incl.real estate,auto,etc.)
employees working for me in any capacity.
[No workers' comp.insurance required] 8• ❑ Non-profit
3.❑ We are a corporation and its officers have exercised 9. 0 Entertainment
their right of exemption per c. 152, §1(4), and we have 10.❑ Manufacturing
no employees. [No workers' comp.insurance required]** 11.0 Health Care
4.❑ We are a non-profit organization,staffed by volunteers,
with no employees. [No workers' comp. insurance req.] 12.0 Other
*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#1.
I am an employer that is providi g workers' mpe sation prance for my emplo ees Below is the policy information.
Insurance Company Name: Ar /� G �%/4 yy� k �"I Ye Tn s' eV
Insurer's Address: „,Z2,2a2 A i .a S �7L .
City/State/Zip: cb iC.a.n2 /l11 - Q�, a C
Policy#or Self-ins.Lic. # 1. F7-7x7 / 1 Expiration Date: 7 i.
Attach a copy of the workers' compensation policy declaration page(showing the policy number and e iration 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 ce • , nder the 'ins a ,p i • , 'es of perjury that the information provided above is true and correct.
Signature: ., dor i / Date: / 2Q-//,*
Phone#: .7”/ V 37S-7 0T7`I Ce LOP" 34,7—7-7
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
WORKERS COMPENSATION AND EMPLOYERS'LIABILTY
INSURANCE POLICY--INFORMATION PAGE
INSURER: POLICY NO: WE1$7249A
NORFOLK & DEDHAM MUTUAL FIRE INSURANCE COMPANY
222 AMES STREET ENDORSEMENT EFF 07/01/20:
DEDHAM, MA 02026 NCCI Company No: 21059
Account No:
•
FEIN:
I •
ITEM 1. NAMED INSURED AND MAILING ADDRESS: AGENT NAME AND ADDRESS:
COMPASS ROSE HOSPITALITY INC NUMBER ONE INS AGCY', INC
277 MAIN ST RT 6A C/O THE FAIR INS AGCY
YARMOUTHPORT, MA 02675 INC/RAIS
619 MAIN STREET, SUITE 1.
CENTERVILLE, MA 02632
AGENT NO.: 20001FA2
LEGAL ENTITY: CORPORATION
OTHER WORKPLACES NOT SHOWN ABOVE: • (See Workers Compensation Classification Schedule)
ITEM 2. POLICY PERIOD; From: 07/01/2019 To: 07/01/2020
Effective 12:01 A.M.Standard Time at the Insured's mailing address.
ITEM 3. COVERAGE:
A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the
states listed here:
MA
B. Employers'Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits
of liability under Part Two are:
Bodily Injury by Accident: $ 500,000 each accident
Bodily Injury by Disease: $ 500,000 policy limit
Bodily Injury by Disease: $ 500,000 each employee
C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here:
SEE ENDORSEMENT WC 20 03 06 B
D. This Policy includes these Endorsements and Schedules:
See Schedule of Forms and Endorsements.
ITEM 4. PREMIUM:The premium for this Policy will be determined by our Manuals of Rules,Classifications, Rates and.
Rating Plans. All information required on the Workers Compensation Classification Schedule is subject to
verification and change by audit.
Total Estimated
Minimum Premiurji: ,$ 231 Annual Premium: $ 492
Audit Period:QUA, Additional/Return Premium:
Comments : CORRECT DIA ASSESSMENT FACTOR
Issued At
Date:07/09/2019 Countersigned by
WC 00 00 01 A Copyright 1987 National Council on Compensation Insurance
INSURED COPY