The URL can be used to link to this page

Home My WebLink AboutApplication and WC ��D van�cEflvro��s RECENED Towiv oF YnxMouTx sonun o HE�� . � � � � �/ 7 APPLICATION FOR LICENSE/PE I1UtP,T1�3j 2014 `tO3� ,�i ��Y � / v" * P�aas�e complete forxn and attach all necessary d c � TAX ACCOUNTI��'e to do so will result in the return of ' cke : � ESTABLISHMENTNAME: va�ct k�h � T D• -�� ' LOCATION ADDRESS: 1 a�ov�, TEL.#: Sag- 258- l030 MAILINGADDRESS: /o � /.} ov � E-MAIL ADDRESS: OWNER NAME: CORPORATION NAME (IF APPLICABLE): A�oP.vttYtc,i_ S�dtCJ ��wir�.h- 1�-�- MANAGER'SNAME: 31'EL.#: S D-3�2- 9« MAILING ADDRESS: POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated `_ _ r^5ot�p�'at6r(sj urd��lr�eopyb€theeert'xfieaEion to ihisfor�.- 1. 2. Pool operators must list a minimuxn 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 f►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 �le at your establishment. 1. Z• _ _ t�r,R�HN i�i Cii?iRv�:-_-- - - _— __ __ _ -- -- _ - Each food establishment must have at least one Person In Charge (PIC) on site during hours 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 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 Sle 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-choking procedures below and attach copies of employee certifications to this form. The Health Deparhnent 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 ' LODGINC: �� LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# � B&B $55 CAB1N $55 � M07'EL $ll0 INN $55 CAMP $55 SWIMMINGPOOL$110ea LODGE $55 1RAILER 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-PROF[T $30 � >100 SEATS $200 COMMON VIC. $60 WHOLESALE $80 �� —RESID.KITCHEN $80 �� RETAIL SERVICE: � LICENSE REQUIRED FEE P�'��0 3.3 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# I l <50 sq.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 �' QS,OOOsq:ft. $I50 =FROZENDESSERT $40 _TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE _ $ �-.� ***'*PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** ��. � Ani�iNrs�rRaTTarr Under Chapter]52, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal � o£any license or per�nit ta operate'a business if a person or cornpany does not have a Certificate of Worker's Compensation Insurance. THE AT"TACHEI? S'CATE W412KER'S COMPENSAI'ION INSUItAN'CE AFFIDAVIT MUST BE COMPLETED AND SIGNEll, OR CERT. 4F INSC7RANCE ATTACHED OR WdR.KER'S COMP. AFFIDAVIT SIGNED AND ATTACHIsD Taum of Yannouth taxes and liens must be paid prior to renewal or issuance of your parmits. PLEASE CHECK APPROPRIA'CEI,Y IF PAID: YES NO MOTELS AND OTHER LODGING F.STABLISHMENTS '1'RANSIENI'OCCIIPANCY: For purposes ofthe limitations of Motel or Hotel use,Transicnt occupancy shall be limited to the temporary and shart term occupancy,ordinarily and customariTy associated with motel and hotel use. Transient accupants must have and be able to demanstrate that they maintain a principal piace af residence elsewhere.Transient occupancy shall generally refer to continuous occupancy of not rnore than thiriy(30)days,and an aggregate af not more than ninety(90)days within any six(6)manth 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 Raam Occupancy Excise,as defined in M.G.L. c. 64G or$30 CMR 64G, as arnended,shall generally be eansidered Transient. POOLS PdOL OPENING:Atl swimming,wading and whiripoois which have been closed for the season must be inspected by the Health Department prior to opening. Contact the Health DepartmenY to schedule the inspection three(3) days prior ta op�ning. PLEASE NOTE: Feople are NOT aIlowcd to sit in the pool area until the paol has been inspected and opened. POOL WATER TESTING: The water must be tested for pseudamonas,total coliforrn and standard plate count by a State certified lab, and snbmitted to the Health Dapartrnent three (3} days ptior to opening, and quarterly thereafter. PQOL CL(}SING:Every outdoor in ground swimming pooi must be drained or covered wi#hin seven{7)days of closing. FQOA SERVICE SEASONAL FOQD SERVICE OPENING: All food service establishments must be 3nspected by the Health Deparfinent prior to opening. Please cantact 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 Xannouth Health Department by filing the requared Temparary Foad Service Application farm 72 haurs prior to the catered event. These forms can be obtained at tha Health I7epartment,or from the Town's website at www_yarrnoixth.ma.us under Health Deparhnent, Dawnlaadable Forms. k'RO'LEN DESSERTS: I'rozen desserts must be tested by a State certified lab prior to opening and monthly thereafter,with sarnple results submitted to the Health Department. Failure to do sa will result in the suspension or revocation of your Frazen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must haue prior approval frorn th�:Board af Health. ' -- — ---- -- __— - . . __ _ ._._ _ --- - -- _ ------ .---- QUTDOOR COOKING: Outdoar cooking,preparatipn,trr display of any food product by a retail or food servioe establishment is prohibifed. 1VOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETI7IZN THE COMPLETED REN�WAL APPLICATION(S}ANI}REQUIRF�D FEE(S} BY DECEMBER 15,2014. ALL RENOVATIONS T4 ANY FOOD ESTI�BLISHMENT, MOTEL dR POOL (i.e., Pt1IN'T'ING, NEW EQUIPMEN'1",E1'C.), MUST BE REPORTEI3 TO AND APPROVEI7 BY THE BQARD OF HEAI.TH PRIQR TO COMMENCEMENT. RENOVATIONS MAY RE UIRE A SITE PLAN. DA7'E� /� " �' �`� STGNATURE: ! FRINT NAME& TITLE: �o�i - ' Kev.]i143t14 '� � t� The Commonwealth ofMassachusetts Department of Industrial Accidents Office oflnvestigations I Congress Street, Suite l00 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Annlicant Information Please Print Leeiblv Business/Organization Name: ��!�n�',� �� / /"J Address: � '1 ? S�i, �km. ��-� Ciry/State/Zip: Phone#: Are you an employer? Check the appropriate box: Business Type(required): :.�---Iasla��mplBXerwit�_- - - emplo�e�slfull,and/ 5. ❑ Retail ___ or part-rime).* 6. ❑ Restaurant/Baz/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7, � 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 aze a corporarion and its officers have exercised 9. ❑ Entertainment their right of exempflon per c. 152, §1(4), and we have �0.❑ Manufacturing no empioyees. [No workers' comp. insurance required]* 4.❑ We aze a non-profit organization, staffed by volunteers, 11.❑ Health Care with no employees. [No workers' comp. insurance req.] 12.❑ Other *Any applicant that checks box#1 must also fill out the section below showuig their workers'compensation policy infocmation. **If the coiporate officecs have exempted themselves,but the corporation has other employees,a worke:s'compensation policy is required and such an oganization should check box#1. I am an employer that isproviding wor�k/ers'compensation insurance for my employees. Be[ow is thepolicy information. Insurance Company Name: ��f< /7�G�� Insurer's Address: City/State/Zip: _ Policy#or SeCf-Tns.Lic:# _ -- __ . - - __ _ ___ixpaatian Date:------ __ _ _- ---_ _ Attach a copy of the workers' compensation policy declaration page(showing the poGcy nnmber and espiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposiAon of criminal penalries of a fine up to $1,500.00 and/or one-yeaz imprisonment,as well as civil penalties in the form of a STOP VJORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwazded to the Office of Invesrigations of the DIA for insurance coverage verifica6on. I do hereby certi der ihe pains d penaltfes of perjury that the information provided above is true and correct. Si ature: Date: Z '" ��7 Phone#: 5%3— ��"�/4 / Ojficial use on[y. Do not write in this area,to be comp[eted by ciry or town officiaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2. Building Department 3.City/Town Clerk 4.Licensiug Board 5. Selectmen's Office 6.Other Contact Person: Phone#: www.mass.gov/dia �., • S A�� CERTIFICATE OF LIABILITY INSURANCE DNIE�MMIDWYYYY) 0&,1/20,4 ' THIS CERTIFICATE IS ISSUED AS A MATiER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS �� CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BE7WEEN THE ISSUING INSURER�S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERi1FICATE HOLDER. IMPORTAN7: It the certificate holder Is an ADDITONAL INSURED,the policy�ies)must be endorsetl. If SUBROGATON IS WAIVED,subject to the terms antl conditlons of the policy,certain policies may require an endorsement. A statement on this certiflcate tloes not confer rights to the certificate holder in lieu of such entloisemenqs. PRODUCER CONTACT M3f$h USA IIIC. NAME: ThreeJamesCen�er PH�E NC No: 1051 East Cary Sireel,Suite 900 E-�� RichmoiM,VA 23218-1137 anors�53: Richmontl.CerlRequest�marsh.com INSURER 5 AFFORDING COVERAGE NAIC# J3200&-GAWUSi415 iNSURER a:ACE Amencan Insurance Company 22667 INSURED Indemnity Company of Norih America Advance Auto PaM1s,Ir�c. iNsunert e: 5008 AiipoA Road i�+sunee c:ACE Property And Casuaity Ins Co 20699 ROdrwke,VA 24012 INSURER D: INSURER E: � INSURER F: COVERAGES � � CERTIFICATE NUMBER: �CLE-00342137446 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIE$OF INSURANCE LSTED BELOW HAVE BEENI$SITEDTO THE MSQFtED AAFAED ABOVE FOR THE P6LICY PEFtIOD INDICATED. NOTMTHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT VNTH 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 ANO CONDI710NS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. �N1R TYPEOF INSURANCE ADUL UBR pp��CY NUMBER MM�IDDY/YYYY MM�U EXP 4MIT5 A GENERALLIFBNTY xSLG27$34076 Osro112i114 O6Al/2015 EACHOCCURRENCE E �� x COMMERpALGENERALLIABiLITY DAMAGETOREPIrED 1,500,000 PREMI E a E CLAIMS-MADE �OCCUR MEDEXPM aneperson) E 5,000 PERSONALBADVINJURY q ��O,OOO CaENERALAGGREGATE $ 70,000,000 GEN'LAGGREGATELIMITAPPLIESPER: PRODUCTS-COMPIOPAGG $ 3,W0,000 x POLICY PR� LOC S A AUTOMOBILELIABILITY ISAH�$Q20892 06�1I2�14 ��1/�15 COMBINEDSINGLELIMR 5�� Ea accitlerrt � X ANV AUTO BODILY INJURY(Per person) E ALLOWNED. $CHEDULEO BODILYINJURY�Perecdtlent) E AUTOS AUTOS NON-0WNED PROPERTV DAMAGE x HIREDAUTOS x q�TpS Peraccitlent E E C X UMBRELv.Lwe X p�CUR XOOG27427994 06101/2014 O6/01/2015 �,CHocCURRENCE g 10,000,000 EXCESSLIAB CLAIMS-MADE AGGREGATE � y 10,000,000 �E� RETENTIONE Y g WORKERSCOMGENSATON WLRCA7AAHSAY(AOSJ OFiNI/2014 OBNi/2015 % V�CSTATU- OTH- nr+o eMr�orerss�wa�uir A ANVPROGRIETORIPARTNERIEXECUTIVE Y'N SCPC47A�S��WI) O6/�l/�lb Oslbi/2015 1,�0,� A OFFICEWMEMBEREXCLUDED? � N�A WLRCA7HBA55A CA,MA O6N712014 pg�p��p15 ELEACHACCIDENT 5 '�O� (Me�WatoryinNH) ( ) E.L.DISEASE-EAEMPLOYE E A Ryeaaescrioeunder WCUC47886530(OH)SIR:500,000 O6lOt/2014 06/Ot/2015 1,000,000 DESCRIPTION OF OPERATIONS Eelaw E.L.DISEASE�POLICY LIMIT f A GENERAL LIABILITI' � �� - XSLG2733A@7G --� � OSN1/2U14 .-f!6�7/2015' -GL LUAITS EXCESS .� CLARIFICATION OF LIMITS OVER$500,OW SIR DESCRIPTIONOFOPERA710NSILOCATIONSIVEHIC�ES (AMachACORD101,AtltlltlonalRemarkaSCMduk,ifmorespaceinrequireE) CERTIFICATE HOLDER CANCELLATION ENdenca Of Coverage SHOULD ANY OF THE ABOVE OESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITN THE POLICY PROVISIONS. AUIHORIZED REPRESENTATVE of Mareh lISA Inc. Susan e.Vignone ��,.,� /g, �9,K,,-,u„ OO 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/OS) The ACORD name and logo are registered marks of ACORD