HomeMy WebLinkAboutApp-License-Certifications a.-.-_� TOWN OF YARMOUTH BOARD OF HEALTH
� '►` `'
' APPLICATION FOR LICENSE/PERMIT-2022
* Please complete form and attach all necessary documents by December 18, 2021.
Failure to do so will result in the return of your application packet.
ESTABLISHMENT NAME: /--/4,=4y a.// . /14(./ /fM
,�jn � TAX ID: (
LOCATION ADDRESS: 7 7 /2,71,1- 64 ybM-n1►vu�5 / / TEL.#: ,6biS--, ,/. 3F7C
MAILING ADDRESS: j.6rrlc
E-MAIL ADDRESS: Z-4.3&4-7%Ai 61 cis Cod, 4,-1—
OWNER NAME: -J,4,' /- /t/ Tit -r Tit,/ /r Sii 4otif ,
CORPORATION NAME (IF APPLICABLE): 1.j4sf-y i-4// ,i L,Gfi
MANAGER'S NAME: T4,✓ j</ 4- TEL.#: S,dolie
MAILING ADDRESS: J� h
POOL CERTIFICATIONS:
The pool supervisor must be ce titled as a Pool Operator,as required by State law. Please list the designated
Pool Operator(s) and attach a co% 4 f the certification to this form.
1. A /r/ 2.
Pool operators must list : i mum of two employees currently certified in standard First Aid and Community
Cardiopulmonary Resuscitat',n (CPR), having one certified employee on premises at all times. Please list the
employees below and attach opies of their certifications to this form. The Health Department will not use past
years' records. You must s rovide 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. T 4y itgit 2.______7/2/ /c j1'
PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
1. 'v.J // K4-2' 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)(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. c— 2.
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 ll times. Please list your employees trained in anti-choking procedures below and
attach copies of employee ce lfications to this form. The Health Department will not use past years' records.
You must provide new cop' s and maintain a file at your place of business.
1. 2.
3.. kie 4.
RESTAURANT SEATI G: TOTAL#
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
B&B
$55 _CABIN $55 _MOTEL $110
NN CAMP $55 SWIMMING POOL$110ea.
LODGE $55 _TRAILER PARK $105 _WHIRLPOOL $I 10ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
0-100 0 SEATS $200 CONTINENTAL $35 _NON-PROFIT $30
— /OMMON VIC. $60 _WHOLESALE $80
RETAIL SERVICE: —RESID.KITCHEN $80
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 = $ 071-.{.-0
*****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
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 .7- 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 whohas-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 18, 2020.
ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT, ETC.),MUST BE REPORTED TO AND APP'OVED BY THE BOARD OF HEALTH PRIOR
TO COMMEN E ENT. RENOVATIONS MAY REQUI' SITE PL- l►
DATE: , , SIGNATURE:
l,,
PRINT NAME &TITLE: OWA/liU
Rev. 10/15/19
The Commonwealth of Massachusetts Fee
Town of Yarmouth $55.00
Lodging License
Number: BOHL-15-1898-07 Issue Date: 1/1/2022
Mailing Address: Location Address:
LIBERTY HILL INN LLP 77 ROUTE 6A
LIBERTY HILL INN YARMOUTH PORT, MA 02675
77 ROUTE 6A
YARMOUTHPORT, MA 02675
IS HEREBY GRANTED A 2022 LICENSE
TO OPERATE:
Lodging House
This license is granted in conformity with the statutes and ordinances relating thereto,
and expires December 31, 2022 unless sooner suspended or revoked and is not
transferable.
Conditions
INN: 1st Floor- 1 bedroom;
2nd Floor-3 bedrooms; 1 owner bedroom;
3rd Floor- 2 bedr000ms.
BARN: 1st Floor- 2 bedrooms;
2nd Floor-2 bedrooms.
Board Hillard Boskey,M.D.,Chairman
Mary Craig, Vice Chairman
of Charles T. Holway,Clerk
Debra Bruinooge
Health Eric Weston
Bruce G.Murph ,MP, ,R.S.,CHO
Healt Director
The Commonwealth of Massachusetts Fee
Town of Yarmouth $185.00
Food Establishment License
Number: BOHF-15-1899-07 Issue Date: 1/1/2022
Mailing Address: Location Address:
LIBERTY HILL INN LLP 77 ROUTE 6A
LIBERTY HILL INN YARMOUTH PORT, MA 02675
77 ROUTE 6A
YARMOUTHPORT, MA 02675
IS HEREBY GRANTED A 2022 LICENSE
TO OPERATE:
Food Service; Common Victualler
This license is granted in conformity with the statutes and ordinances relating thereto,
and expires December 31, 2022 unless sooner suspended or revoked and is not
transferable.
Conditions
SEATING: 10
*RESTRICTION: Guests only.
Board Hillard Boskey, M.D., Chairman
Mary Craig, Vice Chairman
of Charles T.Holway,Clerk
Debra Bruinooge
Health Eric Weston /
n
Bruce G.Murphy, PH, ".' ., CHO
.... ,
Health Director
, The Commonwealth of Massachusetts
Department of Industrial Accidents
,it � K; Office of Investigations
=r l..... 1 Congress Street, Suite 100
* ='� �� Boston, MA 02114-2017
Y
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name: /�./A `y /1/ /1
—,—
j 1-
Address: 7 7 C- ,h
0-67s—
City/State/Zip:
-675City/State/Zip: �d2,rvd i Ail 1 Phone #: D S --34-,2 - 9 7C
Are yon employer? Check the appropriate box: Business Type(required):
1. I am a employer with , employees(full and/ 5. 0 Retail
or part-time).* 6. 0 Restaurant/Bar/Eating 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. 8. Non-profit
[No workers' comp. insurance required] P
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 10.0 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.] I2.�ther // J'IS
*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 providing work'ompensatioginsu fence for my employees. Below is the policy information.
Insurance Company Name: p/�J//Q�, J #- '
Insurer's Address: (W. /✓-/N E,5 I . �t2 ffG
City/State/Zip: f eI / og,U
Policy#or Self-ins. Lic. # UV g d3'3 c 4 A Expiration Date:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration 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 certify,un/it
� he pains an enalties of perjury that the information provided above is rue and correct.
Signature: 1 Date: A/ 3 "�
Phone#• �r _ ` ��• - .
'r.
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:
& DEDH M : UTIRE- E NSURANCE COMPAW`a
\,,,„/4 2 A S STREET
DED4AM, MA 0202.6 NCCI Company No:
Account No:
FEIN:
ITEM 1. NAMED INSURED AND MAILING ADDRESS: AGENT NAME AND ADDRESS:
77 ROUTE 6A
YARMOUTHPORT . MA 02 67'
AGENT NO.:
LEGAL ENTITY:
OTHER WORKPLACES NOT SHOWN ABOVE: (See Workers Compensation Classification Schedule)
ITEM 2. POLICY PERIOD: From: To: 09/23/202z
Effective 12:01 A.M. Standard Time at the insureds 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:
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: $ each accident
Bodily injury by Disease: $ policy limit
Bodily Injury by Disease: $ each employee
C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here:
SEE ENDORSEMENT WC 2 0 0 3 06 Zi
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 Premium: $ Annual Premium:
Audit Period: Additional/Return Premium:
Comments :
Issued At:
Date: Countersigned by
WC 00 00 01 A Copyright 1987 National Council on Compensation Insurance
INSURED COPY
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