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' y � TOWN OF YARMOUTH BOARD OF HE �TH �i��'
��� APPLICATION FOR LICE /P � 014 CdU"� 1 `J Z013
* Please complete form and attaGh�ll�� ., �ume.n s by 20 3.
Failure to do so will result fn th�,retut7i,o�'yonr�p lic • '
:�
ESTABLISHMENT NAME•�>d O�N J T�+Yi��/' j��T TAX ID• �/—� '
LOCATION ADDRESS: ,� �oZ f'�iP�^�' �T- w T/�er��t} TEL.#: S'OP 7f%G�.�3 '
MAILING ADDRESS: SA-�v 1P �
E-MAIL ADDRESS: /9NN-e �" n-�O/NO � /�e L • lo Fl
OWNERNAME: ' ;
CORPORATION NAME (IF APPLICABLE): � �-!✓i.vd G �✓/�t� �w�� �G
MANAGER'S NAME: �d M Cr/�ii o�•iw J EL.#: S"'D�''l� 'lJ—D���
MAILING ADDRESS: �'�n,t'
POOL CERTIFICATIONS:
The pool supervisor must be certi6ed 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 basic water safety, standard First Aid and
Community Cardiopulmonary Resuscitation(CPR),having one certified employee on premises at a11 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 T►le 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._� M �i /9��/vil 2. �'� ���0 /n.�
PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
1. `T8 k (Yl1},��i��, 2. �� �1L,r,/Jrw�
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 Serviee 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. T n , 2n�N� �� �;.�.4i^r� ''
�
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 yow 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. � H �iP'/1 a�n.�� _2. �� �//R�j rta
3. J� 4.
RESTAURANT SEATING: TOTAL#
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE � PERMIT�t LICENSE REQUIRED FEE PERMIT#
B&B $55 CABIN $55 _MOTEL $55
�NN $55 _CAMP $55 _SWIMMINGPOOL $80ea .
LODGE $55 _TRAILERPARK $105 _WHIRLPOOL $80ea
FOOD SERVICE: �
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
0-100 SEATS $85� CONTINENTAL S35 NON-PROFIT $30
�>100 SEATS � $160 � ,��1JF �COMMON VIC. $60 ��-�—�'.i� =��D.KITCHEN $80
RETAIL SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMTT# LICENSE REQUIRED FEE PERMIT#
<50 sq ft. $50 >25,000 sq.ft. $225 VENDING-FOOD $25
� —<25,000 sq.ft. $80
=FROZENDESSERT $40 _TOBACCO $95
NAMECHANGE: $15 AMOUNTDUE _ $ 2ZC%�GG �
� *"**PLEASE TIJRN OVER AtVD COMPLETE OTHER SIDE OF FORM'***•
ADMINISTRATION �
Under Chapter 152, Section 25C, Subsection 6,the Town of Yasmouth 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 Yannouth 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 shaIITie –
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 ofnot more than tliirfy(30)days,and an aggregate of
not mare 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 coilection 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 OPEIVING: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 srt in the pool azea 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.
_-,—v ___-- _ _ _-->_.1�'OH�
SEASONAL FOOD SERVICE OPENING:
All food service establishments must be inspected by the Health Department prior to opening. Please contact the
Health Departrnent to schedule the inspection three (3) days prior to opening.
CATERING POLICY:
Anyone who caters within the Town of Yarmouth must notify the Yannouth Health Departrnent by filing the required
Temporary Food Service Application form 72 hours priar to the catered event. These forms can be obtained at the
Health Department, or from the Town's website at www.varmouth.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 CAFES:
Outside cafes (i.e., outdoor seating with waiter/waitress service), must have prior approval from the Boazd of Health.
OUTDOOR COOHING:
Outdoor cooking,prepazation, or display of any food product by a retail or food service establishment is prohibited.
NOTICE: Permits run annually from January 1 to December 31. TT IS YOUR RESPONSIBILITY TO RET[JRN
THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 13,2013.
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 REQUT A SITE PLAN.
DATE: /r,- S '/� SIGNATURE: C�i���z.'c��,��Lt�
PRINT Nt�ME&TITLE: FOw�rt o /� • �,AsLd�e
Rev. 10/08/13 �/�,.lJ/Ql� �
' i
�~ � � The Commonweadth ofMassaehasetts •
Department of Industrial Accidents �
' Office of Investigations j
' I Congress Street, Suite I(JO '
Bvstan,MA 02114-2017
www.mass.gov/dia '
Workers' Compensation Insurance Affidavit: General Businesses '
Apnlicant Information Please Print Leeiblv i
Business/Organization Name:�, ��e.Q i„>��� �ey� ��r�ji}��,�,�" €
Address: ���.,—, fh. N �T 2. ( , c��' '
CityJStatelZip:�t�T Ko k hi J�J . a°�'ry-3'hone#: �t?t�'� 7��`– (�.,�.��
Ar,e�y,�ou an emptoyer?Check the apgrogriate baa: Bnsiness Type(required}: !
1.L✓1 1 am a employer with employees{full andl 5. ❑ Retail
orpart-time).* 6. �"Restau:anLBar/EatingEstabii;lu-nent
2.❑ I am a sole proprietor or parmership and have no �, � Offrce and/or Sates(incl. real estate,auto,etc.)
employees working for me in any capacity. ,
[No workers' comp. insurance required) $• 0 Non-profit
3.❑ We are a oorparation and its o�cers have exercised 9. ❑Enterkainrnent
their right of exemption per e. 152, §1(4), and we have lp.[� Manufacturing '
no ernp3oyees. [No workers' comp. insurance required]* 11.0 Health Caze
4.❑ We aze a non-prafit organizatian,staffed by volunteers,
with no employees. [No workers' wmp. insurance req.] 12.� Other
*Any appticant that ehecks box#1 must atso fi13 oui the seetson below sfwwisrg their workers'eompen,alion po3iey information.
**[f the eqxporate officers have exempted ffiamselves,but t6e corporaYion has other employees,a workers'eompansalipn pdicy is required and such an
organization shaufd check bqx#I. � � �� � �
I am an emptoyer that is providi/n�g worpkers'compensatton insurance for my emptoyees. Betow is the poticy infornwtion.
Insurance Campany Name: �E.1 �' ! �e'/�G/
Insurer's Address: �� . [�d ,yL !C� � �
City/StatelZip: / /9'�ta iv 18 Ni /�i+�- � oZ'/ �� "" �19`�,
Policy#or Self-ins.Lic. # 4^s �, �}7� 3�°�"�.J – p� Expiration Date: [��a "B/--/�"
Attach a capy of the workers' compensatian policy declaration page{shawiag t6e policy number and espiratian date}.
PaElure to sec::re-�overage as requiredunu'�r 5e:.tion 25A af MGL c. t52 can Iead ta the#tn`pos"�ciT Sf�Yininal p�nalti�s��
fine up to $1,500.00 andlor one-yeaz imprisonrnent,as well as civil penalties in the form of a STOP WORK ORDGR and a fine
of up ta$250.00 a day against the vialator, Be advised zirat a copy of this statement may be farwarded to ihe Of2iee of
Investigations of the DIA for inswance coverage verification.
; I do hereby cerC under the pains a pen ties of perjury th he information provided above Ts true and co�rect.
Si ature: ate: �/.J �..�
Phane#: �L�4 " ! 7.l '�3.�...5�
Offteiat use onty. Do not wrtte in this area,to be eompteted by eity ar town affieial
City or Town: }jEk{LM4U'Tt{ Permit/License#
' Iss ' circie one):
Board of Health . Buildiug Department 3. CitylTown Clerk 4.Licensing Board S.Selectmen's Office
6.O
Contact Person: Phone#: SD6�-3�r f�-�-"z3� k�2y l
www.mass.govldia
- �
��Vorkers Compensation and Employers Liability ZURICH�
' Insurance Policy
NORTHERN INSURANCE COMPANY OF NEW YORK
Information Page
NCCI CO211p3IIy NO.: 13765 ACCO�N1'tiliMBER:M019W8308-001-0OOOI
Branch Policy Number Producer Code Previous Polticy Number �a7aweu,
CONNECTICUT OFFICE WC 04239283 03 �19722768 WC 04239283 02
SOrviCillg AddiCSS PO Box 2248 � Gra�Rapids,MI 49501-?24$,
ITEM 1. Name Insured and Mailing Address Producer Name and Se�viciug Address
GiARDINO'S TASTEE 7'OW ER 1NC DGP-MILES INSURANCE AGENCY,IYC. .
242 MAIN ST. PO BOX 1018
WF.ST YARMOUTH MA 02673 TAUN'I'ON MA 02780-0957 ��
(508)824-8961
This Infortnation Page,with policy provisio�s aad endoisements,if any,completes this policy.
Insured is: coxpo�u,TtoN
Risk LD.No: F.E.I.N.:
O[heT WO[kp18C8S NOt$hOwn AbOVB: SEE SCHEDULE OF INSUREDS A1VD I.00A170NS
TTEM 2. Policy Period: From:osrolrzot3 To:osrotrzota 12:01 a.m. Standazd Time at the Insured's Mailing Address
Tl'EM 3.
A. Workers Compeusation Insurance: Part One of t6e palicy applies to ihe Workers Compensation Law of the states iisted here
MA
B. Employers Liability Insurdnce: Part Two of the policy applies to work in each state listed in Item 3A. 'Ihe limits of our
liability under Part Two aze:
Bodily Inj�uy by Accident S 100,000 Each Accident
Bodily Injury by Disease $ 500.080 Policy Lunit
Bodily Injury by Disease $ 100,000 Each Emp(oyee
C. Other States Insurance: Part 77uee of the policy applies to the states,if any,listed l�re:
ALL STATES EXCEPT ND,OH,WA,WY AND THOSE LISTED IN 3A.
D. '11�is policy includes these endorsements and schedules: sEs FoaAis a[vn EwnousE�nrrs aeei,icnet,e i,ts2
1TEM 4.
The premium for this policy will be detevnined by our manuals of rules, classifications,retes and rating plans. All information
required on the following Classification Schedule(s)is subject to verification and change by audit.
SEP CLASSIFYCATTON SCHSDULE
Total Estimated Standard Pcemium $ 2,556.00 If indicated below,adjushnents of premium shall be made:
Premium Discount $ � ��ly
Expense Constant $ 338.00
Premium for Endo�ements $ 95.00 0 Semi-Annually
� Quarterly
Taxes and Surchazges $ 113.00 � Monthly
Total Estimated Annual Premium S 3,102.00
Miuitnutn Premium $ 470.00
Deposit Ptemiutn $ 3,102.00
Issue Date: ov�262at3 txSURED corY Countersigned By Authorized Representa6ve
WC00 60 01 B(Fd.04-02) E�PYnE�+6 t987 itiatiomi Couucil ort Eompensation Insumnce