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Home My WebLink AboutApplication and WC _ , � , �--_ -� • Y_a� Bc�nc��M�o N� a TOWN OF YARMOUTH BOARD OF HEALT � � APPLICATION FOR LICENS '�1�°` ,� � �+��`� � 6 P�75. ��.��.. � �� ' * Please complete form and attach all nece�d � e��'p e{ ber-IS 3Q1 . Failure to do so will result in the ret�i+n o ' appl' ation pael�eE:--- � n� i 20.� ESTABLISHMENT NAME: ' TAX ID: - " LOCATION ADDRESS: TEL.#: -2� MAILING ADDRESS: E-MAIL ADDRESS: �\\�tc��i�z.. ��S O WNER NAME:�lJ�l�am 0.nne .� CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: �TPct�. �l`ct.�vs - �S �\rr�� n TEL.#: ,50$-d•30- ']loDd MAILING ADDRESS: '( C n-c iaa��T S �JTo n � � d �[1 S 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. ---- /�f ' � ^�- n - Q n--- -__ -- --2.-t _ _�ti�D�—V� �� Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cazdiopulmonary Resuscitation (CPR), having one certified employee on premises at a11 times. Please list the employees below and attach copies oftheir cer[ifications to this form.The Health Department will not use past years' records. You must provide new copies and maintain a �le at your place of business. 1.�Tac�c �CaT vS-��, rr`d t� 2. �t G i�� y�1 0. 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. 1-�� 'A 2. PERSON IN CHARGE: 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 aze 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 Heatth Deparhnent will not use past years' records. You must provide new copies and maintain a file at your establishment. 1. �1 'p1 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 a11 times. Please list your 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 tle at your place of business. 1. t�1 � 2. 3. 4• RESTAURANT SEATING: TOTAL# - _ _ _ OFFICE USE ONLY _ � LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE P�RMIT# S B&B $55 CABIN $55 I MOTEL $I10 [NN $55 CAMP $55 �SWIMMINGPOOL$IlOea. — 7 .. 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 >I00 SEATS $200 WMMON VIC. $60 WHOLESALE $80 � — — —RESID.KITCHEN $SO �� RETAIL SERVICE: �. � WCENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq.ft. $50 >25,000 sq ft. $285 VENDING-FOOD $25 '—<25,OOOsq.ft. $I50 —FROZENDESSERT $40 _TOBACCO $1l0 NAME CHANGE: $15 AMOUNT DUE _ $ 220 .a O *****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_J� Town of Yarxnouth 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 'I'RANSIENT OCCUPANCY: For purposes of the limitat;ons of hlotel or Hotel use,Transient occupancy shall be limited to the temporary and short term occupancy,ordinazily 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 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 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 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. __ _ -- - - ___ - - Ft30II SERVIC� - 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.yannouthma.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 Board of Health. OUTDOOR COOKING: 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 3 L 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, MOTE OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROV E BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A S E DATE: �i-�i-ly_SIGNATURE: ; PR1NT NAME & TITLE: ti Rev. 11/03/14 . i ' � � The Commonwealth ofMassachusetts Depart»tent of Industrial Accidents O�ce oflnvestigations ' 1 Congress Street, Suite I00 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Auulicant Information Please Print Legiblv Business/Organization Name:��p� ��nc�n (.��p�� M a�,P l_ Address: 1�•lO� .,Y� �.$ City/Staxe/Zip: , o� Phone #: `�p$-39 Fc-a.3 L� Ar�e yo an employer? Check the appropriate box: Business Type(required): 1.IJd I am a employer with L�. _employees(full and/ 5. ❑ Retail or part-time).* 6. ❑ RestauranUBaz/Eating Establishment am a so e propne or or p ers tp an nave no — `" - " ' • 7. ❑ Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers' comp.insurance required] g• ❑ Non-profit 3.❑ We aze a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. I 52, §1(4), and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]* 4.❑ We aze a non-profit organization, staffed by volunteers, 11.❑��H th Caze with no employees. [No workers' comp. insurance req.] 12.�]d'Other�n�te.I *Any applicant thaz checks box#I must also fill out the section below showing the'v workers'compensatio¢policy infoimatioa. ••If the cotpomte officers have exempted themselves,but the cotporation has other employees,a workess'compensation policy is requirecl and such an orgauization shovld check box#L � . � . � � I am an employer that is providing workers'compensa8on insura�n^ce for my employees. Be[ow is the policy information. Insurance Company Name: `A 1Sg�p Sn.wfn n c.e., l_B . Insurer'sAddress�lt �c�cgy.��tS�O - �T�`a �$��'tL.�'+� �� A 0 �� City/State/Zip: Policy#or Self-ins.Lic. # Expiration Date: Q- (n - ao t�' Attach a copy of the workers' compensation policy declaration page(showing the policy nnmber and espiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalries of a _ .� . . 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 i ce coverage verification. I do hereby certify,unde e p s nd pena[ties of perjury that the information provided above is true and correct. Si ature: Date: Phone#: ' - Officia[use only. Do noi 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 � �1 s '4��' CERTIFICATE OF LIABILITY INSURANCE Zi24iZ�' TFilS CERTIPICATE IS ISSUED AS A MATTER OF INFORMAiION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THI3 CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATNELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLtCIE3 BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. : IMPORTANT: N the ceRlficate holder is an AODITIONAL INSURED,the policy(iec)musf be endorsed. M SUBROGATION IS WAIVED,subject to tlie terms antl corMitlons of the pollcy,certain policies may requlre an endorsemeM. A atatement on Mis cerdflcate does not eoMer rights to the certiHwte holder in Ileu of such endorseme s. PRODUCER JUdl MALC}I . WIME: Risk $tS8t,6J1B3 �.'OIDPSI1y P�NE , (781)961-0325 F� . ('Iel)336-10Y0 � � 15 Pacella Park Drive 'M � .jmarch@riak-stsategiea.c� suite 2ao ,ruune S APFORdNGCOYERpGE w�c. Randolph MA 02368 IN8URERA:W68C0 Ina. Co. ixsurtEo INSURER B: Yarmouth Hesch n'Towne Motel LLC INSVRERC: dba Beach n' Torme Motel INSIIRERD: 1261 Route 28 INSUREIIE: 3outh Yarmouth MA 0266d iN �aF: CpVERAGES CERTIFICATE NUMBER:�L14112186071 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE IISTED BELOW HAVE BEENISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NONNTHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTMER DOCUMENT 1MTH RESPECT TO WHICH THIS CERTFlCATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HERElN�IS SU&IECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPEOFINSVRANCE PO YNUMBER MOLI�FFF POLICVOli LIMIfS GENERALWIBILRY EACMOCCURRENCE S COATAERCIAL GENERAL LUIBILIT' PREMISES a oacurtanc� S CWMS{AADE ❑OCCUR MED EXP orreperson) S PERSONALdADVINJURV 5 GENERALAGGREGATE $ GENIAGGREGATELIMRAPPLIESPER: PRODUCTS-COMPIOPAGG 5 VOLICY PRO- L� S AUTOMOBILELIq&LITY BIN D LJM e ANYAUfO � BODILYINJURV(Perparean) S ALLONNED SCHEOULEO � AUTOS A�Tp$ BODILVINdURY(PbacdEwK) S HIkEDAUTOS AUT S�ED PR PER f Per f UNBRELIA Wl9 p�CUR EACH OCCURRENCE S IXCE88LI�8 ��p�S��E ACaGREGATE S DED RETENTION f t WORKERECOYPEN$qTION TATU- OTH- 1WDEMPtpVER8•WBILITY ANYPROPRIEtORIPARTNEWFJ(ECUI7VE Y�N 3098040 8/06/201C 8/O6/2015 ELEA�HACCIOENr S 10� 000 A OFFlCERMEMBEREXCLUDED? � N1A E� (Wndarory7nNX) E.LDISEASE-EAEMMOVE S SOO 000 M yes,douNEs unEer �ESCRIPTION OF OPERATIONS Eebw E.L.DISEA3E-POLICY LIMIT 3 SOO OOO DESCRIPTqN Of OVERpipNg/lOCA710NS/VEMICLES IAttaen ACORD 10f,AUqqon�l WmN�$eMtlW�.M mon spap i6IeqWRC) Re: 1261 Routa 28, South Yarmouth,Ma 02664 CERTIFICATE HOLDER CANCELLATION SXOUID ANY OF THE ABOVE DE3CRIBED POLICIES BE CANCELLEO BEFORE THE EXPIRATION DATE 7HEREOF, NOTICE WILL BE OELNERED IN To whom it may conc6rn ACCORDANCE wI7H THE GOLICY PRONSION3. AUTNORpEO�pREBlN7ATNE Harnie Gitlin/JOM ".-.L--�----� —�r""= - ACORD 25(2010105) 01988•2010 ACORD CORPORATION. All righffi resarved. INS025�mioos�.m The ACpRD oame and logo are registered marks of AGORD