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HomeMy WebLinkAboutApplications and WC �* scTOWN OF YARMOUTH BOARD OF HEALTH APPLICATION FOR LICENSE/PERMIT -2! JAN 15 2019 * Please complete form and attach all necessary d 1 i'' 'c ¢ 1 Failure to do so will result in the return of y . evco a ,* `' . DEPT NOTE:ALL BUSINESSES WITH LIQUOR LICENSES MUST ' RIV 4# '. _ ' MBER 154 ESTABLISHMENT NAME: A4;11 1-I;it Re r. r_e TAX ID: LOCATION ADDRESS: t(o4 MR a1 w• YA/,-o� 1-L, /1/1 0.0(Q13 TEL.#: - LC)o - S/ MAILING ADDRESS: 1 to\-t i \{ ax t�. 0,4-4 MA a a CQ 7.7 E-MAIL ADDRESS: Mak.t•N(1 C3) e 0 a S ) . Con-, D2 e rn. /.P,-•)0.d.r/. cap•-� OWNER NAME: — J �/ CORPORATION NAME (IF APPLICABLE): t-Iof(cwt, d ti1 Po-‘d LLC MANAGER'S NAME: To ar„n Lo\"‘e.P TEL.#: "77 _Y.?o Y MAILING ADDRESS: 1.(Q 1 MA ar, YA ov.1-. MA- o;L I17 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 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 yearsrecords. You must provide new copies and maintain a file at your place of business. 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 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. W-t(ii 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. 1. S� 2. C.Gr i 0-- A-ft 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 provide new copies and maintain a file at your establishment. 1. 2. We,-. rte. �l xo,•� HEIMLICH CERTIFICATIONS: 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. You must provide new copies and maintain a file at your place of business. 1. o,ei i-1- tie JJ' 2. (Pyle-- 3. P✓lG-3. be f-. ix o.- 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY (364, -(-1- (43(01 -03 LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED 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: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 1 0-100 SEATS $125 zo-6 eS CONTINENTAL $35 NON-PROFIT $30 >100 SEATS $200 I COMMON VIC. $60 'VD—0'61 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 DESSW44,0,-$4Q. - TOBACCO $110 I — C?O NAME CHANGE: $15 " " AMOUNT DUE _ $ ) a *****PLEASE TURN O ANDCO ETELMP 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 ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR CERT. OF INSURANCE ATTACHED K 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 X 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 REQUIRE A SITE PLAN. DATE: 1 S a o a o SIGNATURE: C1,- PRINT NAME&TITLE. 3o c Rev.10/15/19 TOWN OF YARMOUTH BOARD OF HEAL" x . y APPLICATION FOR LICENSE';,51'.\ IT 2 *42 T.�� JAN 15 2019 * Please complete form and attach all neces .�, I Ocum b )` 'mber 13 2019. Failure to do so will result in the re f yduttifplication p.c e . H DEET. NOTE:ALL BUSINESSES WITH LIOUOR LICENSES MUST RETURN FORMS B ' `I ' ' ' ESTABLISHMENT NAME: M \ 11 V Jn Cie_ TAX ID: LOCATION ADDRESS: \LP4 r\At d g AAA oa ter13 TEL.#: rri 41 0 -S-l`7 MAILING ADDRESS: ‘lo�{ MA a� �. Yc,r.+-,�.4L MAt oacorl3 E-MAIL ADDRESS: ,M \ 1; c; � ,r„�Ate cx�dfi , coy,., eyrt jlov-e�/..,17 ,-,-none,,.. �JI.c.� OWNER NAME: CORPORATION NAME(IF APPLICABLE): FAGI4,,-,v0. 11 N. Co nc LL C- MANAGER'S NAME: ;58 e,,"r, I o v> TEL.#: 114 - o -S/7 t( MAILING ADDRESS: 1(,4 m AAA pals).? 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 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 yearsrecords. You must provide new copies and maintain a file at your place of business. 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 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. S.,c.Lr; 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. -J W.R df 2. Sin G.vin on .�.IJ'62/ 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 provide new copies and maintain a file at your establishment. 1. 33 oNn i (").0;If 2. "j-e)-vi IACri -'.- HEIMLICH CERTIFICATIONS: 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. You must provide new copies and maintain a file at your place of business. 1. c.n; we, 2. (go:, t kt 01 3. C.O.r.i n);3l,. i J 0,1 4. RESTAURANT SEATING: TOTAL# 6 OFFICE USE ONLY 13044C---0-43(93-(5 LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED 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: LICENSE REQUIRED FEE PE IT_# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 1 0-100 SEATS $125 ( CONTINENTAL $35 _NON-PROFIT $30 >100 SEATS $200 COMMON VIC. $60 20-O60 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. $245 VENDING-FOOD $25 _<25,000 sq.ft. $150 4 1VE!'F „R7-$40 —TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE = $ 19 S *****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 ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR CERT. OF INSURANCE ATTACHED NV 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 K 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 REQUIRE A SITE PLAN. DATE: 1 \S a 0 ab SIGNATURE: PRINT NAME&TITL e)c-2c-'h,'e_ i c u✓ Rev.10/15/19 `—/' __ The Comixvnwealth n„f', assacleasatc I.= ° D a,fIndnstrktIAccidents w ,�- a., e'arf nee lis s Congress Stye Sri 100 `==*,`' Boston,Ml l2ll4-2©17. tvtaw. v/diat Workers' Compensation Insurance Affidavit: General Businesses Business/Oron Name. t ,'b Mill Mid F�esiclancp Address: 164 MA»28 City/St /Zip: W Yarmouth MA 02673 Phone# 508-827-1908 Are y, . an employer?Check the appropriate box Business (required): I.►: I am a employer with .....2._____ AIo3' Rtil and/ �• 0 Retail or parttune).* 2.Q I am a sole proprietor or 6. 0:Restaurant?Bar/Eating Establishment partnership and have no employees working forme in any capacity, 7. 0 Office and/or Sale(incl.real estate,auto, .) 3.0 [No workers'comp.insurance required] 8. 0 Non-profit We are a corporation and its officers have excised their right of exemption9. 0 Entertainmentl I52,§l( ).andwrehave 10.0 , no emPloyees,[No workers'comp.insurance requited]* 4.0 We are a non-profit arganiz ion,staffed11 Ieatrh(''.are 03!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 , +* e corporateofficers have eacaapted themselves,but the n ii tlon patiar, or .tanintioa should check box#1, corporation has odor gmgoi"eea,a xrocs' policy is and such an I am an employer that Is prang workers' Insu snce compensation rarnce far my employees. geiriw Is tine policy information: Company Name: The Memic Grou Insurer's Address: 180 GlastonburyBlvd#304 City/State Zip Glastonbu CT 06033 Policy#or Self-ins.Lic,.# 3102804908 Attach a copy of the workers'coni ation policy declaration gqn Date; 6/1/2020nexpiration Failure to secure coverage as ,� im8e{��g the policy number and date). required Section 25A of MOL c. 152 can lead to the` fine up to$1,500.00 and/or one-year`-'� ' , imposition of adminal penalties of a up o o 51,50 a maent,as well as civil penalties in the form ofa STOP WORK ORDER and a.fine day against the r. , Be advised that a copy of this Investigations of the DIA.for.. e :r .+1 be forwarded to the Office of Am/ 'vim verifrmtion. Ido hereby cent*,under th:,,r, #'�', , ,�:�✓° penal ofperjmy that the b(ir on provided above -true and corer .,,.:� -K . OA Official use only. Do not write iamb area,to be completed by city or town nifictaL City or Town: { AuthorityPermit/ii ,# , Issuing (circle erne): 11.Board of Health 2,$ � 6.Other g Department 3.CitytTowa Clerk 4.Licensing Board S.Selectmen's Office Contact Person: Phone#: www.mass.govidis ACORO® DATE(MM/DD/YYYY) CG CERTIFICATE OF LIABILITY INSURANCE 6n/2019 THIS 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 AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER CONTACT NAME: Commercial Lines Service Team M&T Insurance Agency, Inc. PHONE . FAX 285 Delaware Avenue, Ste 4000 tAlc,No.Esti:716-853-7960 (A/C.No):855-595-4605 Buffalo NY 14202 aoo&SS: CLServicing©mtb.com INSURER(S)AFFORDING COVERAGE NAIC S INSURER A:Great Northern Insurance Co. 20303 INSURED MAPLE-5 INSURER B:MEMIC Indemnity Co 11030 Maplewood Mill Pond LLC INSURER c:National Fire&Marine Ins Co 20079 do One Gorham Island Westport, CT 06880 INSURER D:Hallmark Specialty Ins Co 26808 INSURER E:TDC Specialty Ins Co 34487 INSURER F:StarStone Specialty Ins Co 44776 COVERAGES CERTIFICATE NUMBER:546590202 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION 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 CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSR WVD POLICY NUMBER IMM/DD/YYYY) (MM/DD/YYYYI D X COMMERCIAL GENERAL LIABILITY 75LTP000739 6/1/2019 6/1/2020 EACH OCCURRENCE $1,000,000 DAMAGE TO CLAIMS-MADE X OCCUR PREMISES(EaENTED occurrence) $50,000 MED EXP(Any one person) $ PERSONAL 8 ADV INJURY $1,000,000 _ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $3,000,000 POLICY JECT X LOC PRODUCTS-COMP/OP AGO $1,000,000 X OTHER: Shared Aggregate Policy Aggregate $10,000,000 A AUTOMOBILE LIABILITY 73594041 6/1/2019 6/1/2020 (Ea aBIRWINGLE LIMIT $1,000,000 X ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLYAUTOS _ HIRED T NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY _ AUTOS ONLY (Per accident) , $ UMBRELLALIAB X OCCUR 75LTX000740 6/1/2019 6/1/2020 EACH OCCURRENCE $19,000,000 C X EXCESS UAB FNSC100124 6/1/2019 6/1/2020 EF CLAIMS-MADE N86678190AHL 8/1/2019 6/1/2020 AGGREGATE $19,000,000 DED RETENTION$ LTX-00135-19-02 6/1/2019 6/1/2020 $ g WORKERS COMPENSATION 3102804908 6/1/2019 6/1/2020 X STATUTE ETH AND EMPLOYERS'LIABILITY Y/N ANYPROPRIETOR/PARTNER/EXECUTIVE ElN/A E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE•EA EMPLOYEE $1,000,000 If yyea describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 D Professional Liability 75LTP000739 6/1/2019 6/1/2020 P3,000,000 erIncident1,000,000 Occurrence Form Policy Shared Aggr 10,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of Yarmouth Board of Health 1146 Route 28 AUTH DREPRESENTATfVE South Yarmouth MA 02664 " `' I ®1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD