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Home My WebLink AboutApplication and WC _ � Cri-hiPGK�E�NOJGI} 1 a TOWN OF YARMOUTH BOARD OF HEALTH (��s ��s p�� k� � APPLICATION FOR LICEI�S�lR �II'I'=2�, r ,� �"°' * Please complete form and attach a11 necessa��"s by� e mber Y5�2�0��4 Failure to do so will result in the r�turn�ef�wr a}iplication �e�LTH DEPI, ESTABLISHMENT NAME: TA ID: - - LOCATIONADDRESS: ��7 ine S-� Y mo r�, Porl MA ,�a/�.5� TEL.#: so&.i�a-_3vaR MAILINGADDRESS:_aZl� ln/,►Iou� 5� y�cr„vo�n .�r-�— M,4 oaG.7i E-MAILADDRESS: zalnn OWNERNAME: �' � r � .T3��5 (' T � e�a! 5�r>� Mtri�ct� CORPORATION N (IF APPLICABLE): �..��a as o�oov2 MANAGER'S NAME: Mwlna.e,l fZ'i�eY TEL.#: _sDF-3Ga-�/3da MAILINGADDRESS: c'1N7 1,�il�ow 5� �nCmn �l$+ �nr� I`�/{ odlo'1�' 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. �. N 1� 2. Pool operators must list a minunum of two employees currently certified in basic water safety, standard First Aid and Community Cazdiopulmonary 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 witl not use past years' records. You must provide new copies and maintain a fi(e 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 certificatiomto this application. The Health Department will not use past years'records. You must provide new copies and maintain a file at your establishment. 1. /"I m� Za�r,✓� 2. —� PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. l. /1mV Z.v.�n� _ 2. ALLERGEN CERTIFICATIONS: All food service establishments aze required to haue 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 Deparhnent will not use past years' records. You must provide new copies and maintain a file at your establishment. l. /�Im L�a�Y\ 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 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# -- ----- - -- _ .__ --- -- i7FFIC'E IJSE DI�Ti� ___ LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&.B $55 CABIN $55 MOTEL $I10 —INN $55 �CAMP $55 1 -00 _SWIMMINGPOOL$110ea LODGE $55 _TRAILER PARK $l05 _WHIRLPOOL $ll0ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100SEATS $125 _CONTINENTAL $35 �NON-PROF[T $30 �/S/ZS >100 SEATS $200 COMMON VIC. $60 WHOLESALE $80 — — —RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERM[T# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq.ft. $50 >25,000 sq.ft. $285 VEND[NG-FOOD $25 <25,000 sq.ft. $150 —FROZEN DESSERT $40 _TOBACCO $110 NAME CHANGE: $15 � AMOUNT DUE _ $ S S•�O *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** r 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: � f YES N � 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 sha11 generally refer to continuous occupancy of not more than thirry(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 whiripools 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 azea 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. 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 Yannouth Health Deparhnent 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.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 haue prior approval from the Boazd of Health. OUTDOOR COOHING: Outdoar 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. 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 BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: 11 �a l I 1� SIGNATURE: '1� PRINT NAME & TITLE: �rriy ayne Z.ce�n11 " �l�S�'nLr �l)1 fet-Tfl1� Rev. ll/03/14 � � t� The Commonwealth ofMassachusetts Department of Industrial Accidents Office oflnvestdgations ' 1 Congress Street, Suite I00 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Annlicant Information Please Print Legiblv Cape Cod & Islands Council� lnC.� BUSI110SS��Pgc1ri1Z3hOri N31riC: Boy Scouts Of America 247 Willow St. E�d(ITBSS: Yarmouth Port, MA 02675 � City/State/Zip: Phone#: Si1,F -3(�0� —�13,2,� Are yyu an employer? Check the appropriate box: Business Type(required): 1.� I am a employer with -�3 employees (ful]and/ 5. ❑ Retail orpart-time)." �ut� k�wyt z� YFm�''1��'^'^+z3g 6. ❑ RestauranUBaz/EatingEstablishment 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 corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §I(4), and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required)* 4.❑ We aze a non-profit organization,staffed by volunteers, I 1.❑ Health Care with no employees. [No workers' comp. insurance req.] 12.0 Other *Any applicant that checks box#1 must also fill out the section below showing[heir workers'comprnsation policy information. **If the coiporate officers have exempted themselves,but the corporation has other employees,a workers'compensatioa policy is required and such an organ'vation should check box#1. I am an employer that is providing workers'compensation insurance for my em loyees. Below is the policy information. \ \ Insurance Company Name: ^ - � ? � / Insurer's Address: ,S�L� '��'/,�(Q� � I��r��Ctd J��LD� _ cityistateiziP: j� l �L�1�� "11� 2/�D_�— /�>�J�) Policy#or Self-ins.Lic. #�f Ul(; /()[I ' �(d��li�/�/� Expiration Date: 3 /3 i 1�/5 Attach a copy of the workers' compensation policy declaration page(showing the policy nnmber and ezpiration date). Failure to secwe coverage as required under Sec6on 25A of MGL c. 152 can lead to the imposirion 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 OKI3ER 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 verificarion. I do hereby certify,under the pains and penalties ofperjury that the information provided above is true and correct. Signature:��vGc/��i'+�_ Date: f a�/l//� / Phone#: ,5'/�� - .7i Le� - ��d � Official use only. Do not write in this area,to be completed by city or town offaciaL City or Town: PermitlLicense# 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 Ac R� CERTIFICATE OF LIABILITY INSURANCE osiosizo a�"' THIS CERTIFICATE IS ISSUED AS A MATTER OP INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATNELY 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 be endorsed. If SUBROGATION IS WAIVED,subJect to the terms and contlitions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certiFlcate holtler in lieu of such endorsement(s). I PROOUCER NAME: MHBT IfIC. PHONE FA% 8144 Walnut Hill Lane, 16th FI - - � "°. - - E�.1AIL Dallas TX 75231 ADDRESS: INSURE S AFFORDINGCOVERAGE NAIC# INSURER A: INSURED BOY SC011tS O£ America, National C011RCll dRCl INSURERB: All of its affiliates and subsidiaries including: INSURER C: . Cape Cod&Islands Council Inc,Boy Scouts of America iNsuaeao: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:g3157827 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 INDICA7ED. NOTWI7HSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT NATH RESPECT TO NhiICH 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 AODL UBR POLICYEFF POLICYEXP i �� TYPEOFINSURANCE INSR WVD POLICYNUMBER MMIDDIYYYY MMiDD/YYYY LIMITS A GENERnLUABIUTV MWZY301262 3/1/2014 3/1/2015 EACHOCCURRENCE $1,00O,OOU X COMMERCIALGENERALLIABILITY T REfJrED PREMISES Ea occurtence 3 CLAIMS-MADE �OCCUR MEDEXP An one on $ PERSONAL&ADVINJURY $ GENERALAGGREGATE $ GEN'LAGGREGATELIMITAPPLIESPER: PRODUCTS-CAMP/OPA6G $ X POLICV PRO- LOC $ AUTOMOBIIE LIABILITY Ea acciEent ANYAUTO BODILVINJURY(Perpenan) $ ALLOWNEO SCHEDOLED BODILVINJURY(Perersitlent) $ AUTOS AUT0.5 NON-0VvNE� PROPERTV DAMAGE $ HIREOAUTOS AUTOS Pe�eccitlen� , 8 I pMBRELLALIAB OCCUR EACHOCCURRENCE $ ' E%CESSLIAB CWMS-MADE AGGREGATE $ DED RETENTIONS 5 WORKERSCOMPENSATION `hCSTATU- OTH- ANDEMPLOYERS'LWBILITV ,.�N ANV PROPRIETORiPARTNER/EXECUTNE❑ N�p EL EACH ACCIOENT $ OFFICERANEMBER EXCLUDED"1 (MantletoryinNH) E.L.OISEASE-EAEMPLOYE S If yes,tlescnbe untler DESCRIPTIONOFOPERATIONSbelow E.L.OISEASE-POLICVLIMIT $ � DESCRIPTIONOFOPERATIONS/LOCATIONS/VEHICLES(AMaeM1AWRU101,AtltlilionelRemerks5chetlule,Hmorespacelsrequlred) � THIS CERTIFICATE IS INTENDED TO BE USED AS PROOF OF INSURANCE ONLY Useage during Cape Cod Festival of Magic August 26,27,28 , , CERTIFICATE HOLDER CANCELLATION � Dennis Yarmouth Regional School Distrid SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELIED BEfORE 296 Station Avenue THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN South Yarmouth, MA 02664 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTNl1VE �...�� ---� . OO 7988-2010 ACORD CORPORATION. All rights reserved. � ACORD 25(2010/OS) The ACORD name and logo a�e registered marks of ACORD � NOTICE � � NOTICE TO � TO � EMPLOYEES ` �,ag � �o� EMPLOYEES The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston, Massachusetts 02111 617-727-4900 As required by Massachusetts General Law,Chapter 152,Sections 21,22, &30,ttris will give you notice that I(we)have provided payment to our injured employees under the above mentioned chapter by insuz3ng with: A.I.M. Mutuai Insurance Company NAME OF INSURAIVCE COMPANY P.O.Box 4070 Burlington,MA 01803-0970 ADDRESS OF INSL7RANCE COMPANY VWC-100-6014316-2014A 03/31/2014-03/31/2015 POLTCY NLJMBER EFFECTIVE DATES 973 lyannough Road Miller McCartin dba Dowling&O'Neil Hyannis,MA 02601 (508)775-1620 NAME OF IIVSURANC�AGENT ADARESS PHONE Cape Cod &Islands Council Inc Boy 247 Willow St Yarmouthport,MA 02675 EMPLOYER ADDRESS - 02/27/2014 DATE MEDICAL TREATMENT The above named insurer is required in cases of personal ii{jnries arising out of and in khe coume of employment to farnish adequate and reasonable hospital and medical services in accordance with the provisions oP the Workers Compensation Act. A copy oF the First Report of In,jury must be given to the injured employee. The employee may select Ius or her own physician.The reasonaUle cost of the services provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably connected to the wort� related i�jury. In cases requiring hospital attention, employees are hereby no 'tEf'ied that the insurer has arranged for sach attention at the NEAREST AND BEST MEDICAL FACILITY EMPLO YER ADDRESS TO BE POSTED SY EMPLOYER