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Home My WebLink AboutApplication and WC : . rrtSr.�. CRr��r� , a TOWN OF YARMOUTH BOARD OF HEALTH � �� APPLICATION FOR LICENSE/PERMI� 1S 3,c> � _ � `'" * Please complete form and attach ali necessary document by Dece er S 2014. - Failure to do so will result in the return of your application pa ESTABLISHMENT NAME: A-nl �e e- G D,�2.r ID: LOCATION ADDRESS: �� itI u /1')q,.c�, �S'�L. I.y�v+ein.o«-n°��iaTEL.#: ��- -�-55�-�cS'70� MAILING ADDRESS: `�P �Un . h�a.c7. S'�t.. �Sv . �.�..c.�.�...e-�,. +� /�a__ o�Lc v E-MAIL ADDRESS: — � OWNER NAME: �h.��--6� C_� c�c� a✓�'//e, CORPORATION NAME (IF APPLICABLE • /��C.ee CeA-��'x-C MANAGER'SNAME: /�- cr�cJ�s �%/� T�- 'rEL.#�8-3ys�--�s--i�' MAILING ADDRESS: � iUd. "vSrYc� d • d,-�-',' POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(sl and attach a copy of the certification to this form. - 1. 2. Pool operators must list a minnnum of two employees currently certified in basic water safety, 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 years' records. You must provide new copies and maintain a tile 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 certifica6on 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• - PERSON iN C��RGE: — - _ __ _ __ _ _ _ Each food establishment must have at least one Person In Chazge (PIC) on site during hoars 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 far 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• 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-chokmg 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. 2• 3. 4• RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQU[RED FEE PERMIT# B&B $55 CABIN $55 MOTEL $ll0 —INN $55 CAMP $55 SWIMMING POOL$]l0ea. 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 _CONTINENTAL $35 NON-PROFIT $30 >100 SEATS $200 COMMON VIC. $60 WHOLESALE $80 . — — —RESID.KITCHEN $80 � RETAIL SERVICE: �L CENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# � <SOsq ft. $50 �O�Z >25,OOOsq.ft. $285 _VENDING-FOOD $25 _<ZS,OOOsq.ft. $l50 —FROZENDESSERT $40 _TOBACCO $ll0 NAME CHANGE: $15 AMOUNT DUE _ $ 50•00 . **•**PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** , ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now requized 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 I CERT. OF INSURANCE ATTACHED ' OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taa�es and liens must be paid priar 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,ardinarily and customazily 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 aze 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 standazd plate count by a State certified lab, and submitted to the Health Department three (3) days prior to opening, and quarterly ' thereafter, i - 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 Heaith Departrnent 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 reqwred Temporary Food Service Application form 72 kours prior to the catered event. These forms can be ; obtained at the Heaith 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 priar 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 Boazd of Health. -- _ - - ___ _ _ _ ____ _ UTDOOR COOHING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. NOTICE:Pernuts 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, 2014. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST$E REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SIT L . DATE: �� SIGNATURE: � � PRINT NAME& TITLE: ` � � p ✓ Rer. 11/03A4 , � � TheCommonwealthofMassachusetts Department of Industrial Accidents Office oflnvestigations ' 1 Congress Street, Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Leeiblv Business/Organization Name: �io-i�s.��- �,c.r'�—�'_ � Address: 4�P �Ql fY�Q-n-+ �d�-�-u"— City/Staxe/Zip: �� .+-aµ-� 1�'1�', o Phone #: �J"��'- .�.5� ��s"'za� Are you an empbyer?Check the appropriate boz: Bus ness Type(required): I.� I am a employer with Z employees(fiill and/ 5. � Retail or part-time).* 6. ❑ RestaurantJBaz/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no �. � pffice 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 corporarion and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4), and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]* 11.❑ Health Caze 4.❑ We are a non-profit organization,staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12•� Other *Any applicant tl�st checks box#I must also fill out the section below showuig the'v workexs'compensation policy information. � 'xIf The colpomte officers have exempted themselves,but the corporation has otha employees,a workers'compensation policy is required md such au organization should check box#1. I am an emp[oyer thai isproviding workers'compensation insurance for my employees. Below is thepolicy information. � Insurance Company Name: ��-�c t-+-��,�x'� �7tJ i7� C� 'T4 i�.�.C� �S�.e.ttJe-6 Q�� Insurer'sAddress: / +�ef.��/'"�—o�e-� dpL.+9'�-/'� City/State/Zip: ��o,e�i � �i�.. 0 � /S"�T�' --�licy#orSetf-its.�,�c:#- �-�✓�+�•�'�--�-b� �-------Exgiratien-Hate: --�'�- lr..s� ' 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-yeaz 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 forwazded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby ce ' ,under the pains and pena[tfes of perjury that the information provided above is true and correct. c Si ature: Date: �Z- 1 7 — Phone#: ��J 4�— a Official use only. Do not write in this area,to be comp[eted by city or town officiaL City or Town: Permit/License# Issuing Authority(ciecle one): 1.Board of HealtL 2. Building Department 3.City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone#: www.mass.gov/dia �.. A``p/tp� PFB uarnim�viw:r.,tti7 CERTIFICATE OF LIABILITY INSURANCE R.��« -�1�1�izo�4 THIS CERTIFICATEIS ISSUED AS A MATTER OF INF012MA710N ONIY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGA7IVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOE5 NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING MSURER(S),AUTHORI2ED REPRESENTATNE OR PRODUCER,ANO THE CERTIFICATE HOLDER. IMPORTANT:If the certiflcate holder is an ADDITIONAL INSURED,the policy(ies�must be endorsed. If SUBROGA710NI5 WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsemen[. A statement an this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PFOWCER �;pry7y;7 NPME: PAYCHEX ��'NSURAD'iCE AGEN:Y :NC '.i°no.e,:;: i.vc.H�r (556) 9'+"_�-5'� 12 210��5 OpO: F: {.��8) 443-51i2 noa�=ss ?O EVX JJO�.S IN�URERiS-AFFCRp:NGCGVERirv6E Yq;Cri SR_;d ANTOV_O TX �CZo� msuaea,�: T�:�i:� ti'sv F:ire Ins �o ' ��j� �'�2'Dp wsunea INSJR^RB: ]' INSVRER L�. 4 YANKEE CRAFTERS IPd�.^_. insu�x��o-. ?0 BvX ?_96 irvsu:�eae�. pEP1; SOUTH YAR.N_OUTA D?� 0206� wsu�a:�. COVERAGES CERTIFiCATE tJUMBER: REVISION NUMBER: TH7S IS TO CERT!FY THAT THE POLIGES OP INSURANCE tiSTED BEL06N kAVE BEEN ISSUED TO TNE WSUR€D NAMEO A@DVE.F�R ZH€ POLICY PERIOD IN�ICATED. NOTWITHSTANDWG ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMEN7 NIITH RESPECT TO WHICH THIS CERTIFlCATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BV THE POLICIES DESCRIBED HEREIN IS SUBJECT TQ ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN ktAY HAVE BEEN REDUCED BY PAI�CLAIMS. ('�:SF 1pDL 5'l;HN POfICF£FF MIIICYLYY TYPFOfIM1TORINfH A]p6N2M8FR �ry�M/OL/Vi'Yli U'N(�' LOMMERCIALGENERALLIABIUTY EFCM CC!IURRErvCE CLAIMS-MADE❑OCCUR DAMAGE TO REMe� FRFMiSES IFa uvcuvencel MEC EXF i,Nr,cne persoa) PERSCNAL 8 ACV iNJURY GEN'l AGG3EGATE LIMIT APPI.IES PER�. GEhERnL AGGR£GPTE POLCY PR� LOC PRO�VCTS-COMFiOPAGG �JECT � OTHER: AUTOMOBILE LJAHILITV �CMBN=_O SING:E LIMIT . - ^svtle�t) ANYAlJTO SppY,Y M!J9Y;Par pasw7 ALLCWYED SCHeDULED AUTOS AUT0. BODII.VINJLRY(Pe�u:qtlanlj HIkEDAJTOS NON-OWNED vROFERTY04MNGE AUTOS ;Par acciCer.!) UMBftELLALIAB OCCUR EACH OCCURqeNCE E%CESS LIA9 Ci�.i!US-UADE A66REGATE �Eo R=reunou� ryOB.2F5CQNPF,W:91[ON PER OLH� .INDPMPLOPE85'PAIDLf]Y '� 3iAilii£ E2 ANY PROPRIETJRIPANTivcR'EXECUTiYE Y;N E L EACH ACCIOF..NT '1'�� O C O OPFlCERMiENBER EXCWCED9 a (AtaMa[orylnNM ❑ �� ,e Ci�(i 4]'._noi ii5i0F/?.C19 CSiOti<'Ol,� E.L.OISEAScEAEPiPLOYEE '1�� 0(1� N y�s,tleecnbeunder DESCRIPTiON OP CPERATIONS�elav El.GISFASfi-PoCCti LIMIi �'�9��i� �V.�J OESCRIPTlONOF OPERATIONS/LOCATIONSi VEHlCLES(ACORD IDi,Adtl#ional Remarts$cbetlule,may Ee atlxbed if more apace is requirad) Thos2 usual to :.he -nsured's vpera�ions. CERTIFICATE HOLDER CANGELLATION � SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED Tow�; 0` Y3rmOu�h Hedith DEDnr�'men�` gEFORETHEEXPIRATIQNDATETHEREOF,NOTfCEWILLBE ' - '- ` DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Ex'ian M. l:e3slip FSst. He3ith P.gent nurHoerzeuxevaes�rarrve 1�96 kOIITE 28 "7�_ "^�Q��,�, SC�.UTI-i YA�+IOu^r1, MA ��c'a4 / � <O 1988-2014 ACORD CORPORATION.Ail rights reserved. ACORD 25(2014lOt) The ACORD name and logo are registered marks of ACORD AGENGY CUSTOMER ID: LOC#: A�W ADDITIONAL REMARKS SCHEDULE Page of AGENCV NAMEDINSURED cAYCH�X I`]SURA:QCE AGEidCY iNC POLICYNVMBER YANRE'� CRriFTERS I:dC S-�E A��!)RC• 25 p�� BGX 296 CARRIER NqICCODE GOUTH �ARMOU`TtI MA OGF)r09 S�_F, ACORL ZS EFFECTIVEDATE: SEG riCO�D ZJ AODITIONAL REMARKS THIS ADDITIQNAL REPAARKS PORM IS A SCHEDULE T6 ACORD PORM PORMNUMBER: i:C:0RD. 2� PORPRTI7LE: i:ER'I'IFICAT� CF LIABILI.Y INSI;'t2tiPJCE Brian M. Heaslip Rss�. Health Aaent _ .._. .. . . . .. _. ACORD 101 (2014f01) O 2Qt4 ACORD CORPORATIQN.All rights reserved. The ACORD name and logo are registered marks of ACORD