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Home My WebLink AboutApplication and WC .� TOWN OFTYARMOUTH BOARD OF HEALTH w�� °�^ � APPLICATION FOR LICENS . , -�Q14 NQ�I �8 20�3 * Please complete form and attach all nece�sa�y ` qt�� ee 2013. Failure to do so will result in the reti?iPh o t`zt �ic2'tf Pl: ESTABLISHMENT NAME: — � —/ / LOCATIONADDRESS: � , Q.fMO TEL.#: B— O-�.D(C7 . MAILING ADDRESS: � M 0 �MAIL ADDRESS: U LO i,J QDl• C�/Y) . _ OWNER NAME: CORPORATION NAME APP Afh ): C��'1 O� � G . MANAGER'SNAME: Q/Y)U2 I"� � TEL.#: �i —7 O�'a06� MAILINGADDRESS: ��19/Y)� $g �,� O�f/�C , 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. 1. 2. 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 all dmes. Please list the employees below and attach copies of their certifications to this form. The Health Department will uot use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one fixll-time employee who is certified as a Food ProtecUon 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 establishmen� �. ,�amuR- � `��.c� 2. �don� S` . Co� . PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. �. ��,� ��,I P� - 2. u oa� s . �o� . 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 file at your establishment. 1, 00 �- �0"�-' ' 2. HEIMLICH CER FICATIONS: All food service establishxnents 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-cholung procedures below and attach copies of employee certifications to this form. The Health Deparlment 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 REQUIRED FEE PERMIT# �B&B� $55 CABIN $55 MOTEL $55 INN $55 CAMP $55 SWIMMING POOL $SOea _LODGE $55 _7RAILER PARK $105 � _WHIRLPOOL $80ea FOOD SERVICE: � � LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �0-100 SEATS $85 �1�4-083 CONTiNENTAL $35 • NON-PROFIT S30 � _>100 SEATS $160 �COMMON VIC. S60 � WHOLESALE S80 � —RESID.KITCHEN S80 RETAIL SERVICE: LICENSE REQUIRED FEE � PERMIT# � LICENSE REQUIRED FEE PERMI'I'# LICENSE REQUIRED FEE PERMIT# GSO sq.ft. S50 >25,000sq ft $225 VENDING-FOOD $25 =<25,000 sq.ft. S80 �ROZEN DESSERT $40 TOBACCO $95 NAME CHANGE: $15 t1MOUNT DUE _ $ I�S..00 •*•*•PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*•*•' � � ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yannouth is now required to hold issuance or renewal of any license or pernut 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 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 sMall 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 sha11 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, sha11 generally be considered Transient. POOLS POOL OPEPiING:All swimming,wading and whirlpools which haue been closed for the season must be inspected by the Health Department pnior to opening. Contact the Health Department to schedule the inspection three (3) days prior to opening.PLEASE NOTE:People are NOT allowed to srt 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. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven (7) days of closing. . - -- - ---------_ --- ---- -- F�S��SERVIC�.-- - --- --- — __ _ _ _ _ _ —_ _ SEASONAL FOOD SERVICE OPEPiING: All food service establishments must be inspected by the Health Department prior to opening. Please contact the Health Departznent to schedule the inspection three (3) days prior to opening. CATERING POLICY: Anyone who caters within the Town of Yannouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. T'hese forms can be obtained at the Health Depariment, or from the Town's website at www.yannouth.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 subttutted 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. IT IS YOUR RESPONSIBILITY TO RETURN 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 AP ROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUI ITE PLAN. DAT$: I I 3 � � SIGNATLJRE: ' ' , PRtNT NAME&TTI'LE: 9�n Sf. �-O+�.� P�$ Rev. 10/OS/13 ' • � The Commonwealth ofMassachuseits • Department ojlndustrial Accidents Office ofinvestigations ' 1 Congress Street, Suite 200 � Boston,MA 02114-2017 www.mass.gov/dia l Workers' Compensation Insurance Affidavit: General Businesses Apalicant Information Please Print Leablv Business/Organization Name: l�a� — vl - �d�-�—. Address: �� 19 � �-� z� , � ,�o��cx� O�� , VV�� 6 �-- City/State/Zip: Phone #: ��8 - 7�� `—�0 b fl Are you an employer? Check the appropriate box: Business Type(required): 1.❑ I am a employer with employees(full and/ 5. ❑ Retail or part-time).* b. � Restaurant/BazBating Establishment 2.❑ I am a sole proprietor or paztnership and have no �, � Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers' comp.insurance required� $• ❑ Non-profit 3.❑ We aze a corporation and its o�cers 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]* I 1.� Health Care 4.❑ We aze a non-profit organization,staffed by volunteers, with no employees. [No workeis' comp.insurance req.] 12.� Other *Any appGcant that checks box#1 must also Sll out tlte sec[ion below showing their workers'compensation policy infortnalion. *•If[he colpotate officecs have exempted tltemselves,but the corporation has other employees,a workexs'compensation policy is required and such mm ocganization should check box#1. � -��-- : �� -� � I am an employer that is providin workers'co ensation insurance fo-rI my employees Be[ow rs the po[icy information. Insurance Company Name: �U( � rn 4G �b�`' �((,�{'l(f1 Insurer's Address: �fl � YY�'.�.G �t.L p ��(/Ci CiTy/State/2ip: �U�f1 Q l��' ��j32 , Policy#or Self-ins.Lic.# Gl�� - 0 Q 7lj Z ��/ Z —�(}��on Date: � 3 �� Attach a copy of the workers' compensarion poGcy declaration page(showing the policy number and eapiration date). Failure to secute coverage as reqtsired'under Seetian 25A-of h4GL c. 152 can lead to the imposition of criminat penalties�f 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 wpy of this statement may be forwazded to the Office of InvesGgations of the DIA for insurance coverage verifica6on. I do hereby certify,un er the pains and penalties ofperjury that the injormation provided ab ve is true and correc4. Si ature: � Date: �� I � Phone#: S � 6 0 ^a�6 (7 Official use only, o not write in this area,to be completed by city or town offuiaL City or Town: yAd21�.�trirn� Permitll.icense# ircle one): Board of Health .Building Department 3. City/Town Clerk 4.Licensing Board 5. Selectmen's Office 6. Ot Contact Person: Phone#:�UB-3S. =Z'�l k�Z�{( wwwmass.gov/aia . ja0�N R�� +�' CERTIFICATE OF LIABILITY INSURANCE °"„ro`�'o,°"g' THIS CERTIFICA7E IS ISSUED AS A NIATTER OF INFORMA710N ONLY AND CONFERS NO RIGHTS UPON iHE CERTIFICAiE HOLDER. THIS� ' CERi1FICATE DOES NOT AFFIRMA7IVELY OR NEGAiNELY AMEND, EXTEND, OR ALTER THE COVERA6E AFFORDED BY iHE POLICIES �� BELOW.� THIS CERTPICATE OF INSURANCE DOES NOT CONSi1TU'fE A CONTRACT BETWEEN THE ISSUIN6 INSURER�S), AUTHORIZED ' REPRESENTATIVE OR PRODUCER,AND 7HE CERTiFICATE HOLDER. '�. IMPORTANT: If the eertificate holder is an ADDI710NAL INSURED,the policy�ies)must be endoroed. If SUBROGA710N IS WANED,subject to �I the tertns and�condttions of the policy,certaln policies may requlre an endorsement A statement on ihis certifieate does not con(er righb to the certificate holder in lieu of such entlorsemenqa). � PRODUCER 02�11 -001 �yQ��T Murroy&MaeDonald Insuranee ��o, ; (608)640-2400 �.N,,: (608)288-4777 s�m MA02 3I2d aCC�C�b@D �bEN��: �, �,�.a�% � . A.I.M.MutuallnsurenceCompany 33758 � INSURED I SURERB: �I Bwndon Ino y��.'.��' i ��GI1L 1318 Roub 28 South Yarmouth,MA 02664 I E: I COVERAGES CERTIFICATE NUMBER: �� REVISION NUMBER: THIS IS TO CERTFY THAT THE POLIqES OF INSURANCE LISTED BELOW HAVE BEEN 133UED TO hiE INSURED NAMED ABOVE FOR THE POLICV PERIOD I INOICATED. NOTMTHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT 1MTH RESPECT TO NMICH THIS ' CERTIFICA7E MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDFA BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL hiE TERMS, EXCLUSION3 AND CONDITIONS OF SUCN POLICIES.LIMITS SHOVM!MAY HAVE BEEN REDUCED BY PAID CLAIMS. �� TYPE OF INSURANCE � POLICY NUNBER N ��7g � OENERIILLI/�BILITY EACHOCCURRENCE S COMMFRCIALGENQtALLIABILITY �� y PREMIS ,irtence CWMS-MADE �OCCUR . MED IXP V�Y one Penon) S PERsowLLBADVINJURY S � GENERALAGBREGATE b EMLAGGRE6ATELIMITAPPLIESPER: PRODVCTS-CAMP/OPAGG $ UCV � OC AU70M0&LELIABILI7V . NGLELI S Ea accid n ��T� BODILV INJURY(Per persnn) E ALLOVrNFD SCHEDULED AUf0.S AUf05 BO�ILY INJURV(Poraccitlenq E HIREDAUTOS NONdNNED p�yTy AUTOS Peracciden $ S UNBRELLA LI118 OCCUR EACH OCCURRENCE S E%GESSLIAB CLNMSMADE AGGREGATE $ DED REfENfION S g _ .__ __ . _ �L47�83'�I�BILITl.. .. .- Y/ __---' _ . . ._ —. —�. X TORVLIMI�3 ER � n a��`��'�"'�[d�3`EO1�"�� r„a AWC-400-7026372-2013A zra�zo�a ?13/2014 E.L.EACHACCIDENT s �ao.000.00 (MenEeOoryInNN) E.L.DISEASE-EAEMPLOYEE S ��Opp.00 IS��`C��i�'b�YSaErtnnoNsceww E.L.DISFASE-POLICVIIMR s 500,000.00 OESCRIPTIWI OF OPERp7pN3/LOCA710NS I VEHICLES(Al�pCORD 707,ptlEilbnel Renarin SCMtlule,H morv�pep b�aqu0ed� CER7IFICATE HOLDER CANCELLAiION �II Town of Yartnouth AftentlOn:Boa1'd of Heeltll Dept SHOULD ANY OF TXE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 7748RoUte28 hIE EXPIRATION DATE TFIEREOF, N0710E WILL BE DELNERED IN SoUtll Yelllloutll,MA 02864 ACCORDANCE WITN TXE POLICY PRONSIONS. IIUTXORIZm REPRESENTA7IVE . ._. . . _ _ . _. _ __ ._._. _.. . ..._ - . .- .. ... ... .. _z--+�-'G-�— �1868-2010 ACORD CORPORA710N.All rights reserved. � ACORD 26(2010/06) The ACORD name and logo are registered marks of ACORD �', i Sharen Rabesa MurrayandMacDonald (z/2) 11/06/2013 11 :43:27 AM -0500 .n�c�� CERTIFICATE OF LIABILITY INSURANCE °"„�05�2"�"' , TNIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ON�Y AND CONFERS NO RIGHTS UPON TNE CERTIPICATE HOLDER. lH1S ' GERTIFICATE DOES NOT AFPIRMATIVELY OR NEGATIYELY AMEND, EXTEND, OR ALTER THE C04ERAGE AFFORDEO BY THE POLICIES � BELOW. THIS CERTiFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S�, AUTHORIZED � . REPRESEIiTATIVE OR PRODUCER,AND TNE CERTiFICATE XOLDER. . IMPORTANT: N the certificate holder is an ADDIl10NAL INSURED, the policy(ies)must be endorsed. If SUBROGAl10N IS WAIVED,su6ject W ' [he tem�s and conditions of the pdicy,certain polities may require an endorsement. A statement on[his certificate does not confer rights to the . certifica[e holder in lieu of suoh eMorsement(s)_ q�q ', PRODUCER OZ]�� -�� NSME:�T �.. Murtay 6 MacDonald Insurance '��-�-,.�- P�p�o.gt: (608�640-2/00 �.no.: (608�288-9171 ..� 550 MacARhur Blvd � Bourne,MA 02532 �� u� ��, NOV 06 [U13 � G !' iNsueERA: A.I•M.MuWallnsunnceCompany 337b8 INSURED . '� BlLOdOp IIIO IXSUtER B: . MEALTH DEPT, i 1318 Raub 28 � South Yarmouth,MA 02884 �"s ', INSORERE: �'�. COVERAGES CERTIFICATE NUNBER: REVISION NUMBER: '. THIS IS TO CERTFY TIiAT THE POLICIES OF INSURANCE L15iED BELOW HAVE BEEN ISSUED TO 7F�INSURED NAME�ABOVE FOR THE POLICY PERIOD IfmICATE�. NO7LMTHSTANDING ANV REOUIREMENl, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT VNTN RESPECT TO IMIICH THIS GERTRCA7E MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY ThiE POLIGES DESCRIBED HEREIN IS SU&IEGT TO ALL THE TERMS. �� EXCLUSIONS AND COPIDITIONS OF SUCH POLICIES.LINRS SHOIhN MAY IiAVE BEEN REDUCED BY PAID CWMS '��. ��R ttPEOFINSVRANCE �� POLICYNU�6ER 1��.�Fn '��' ��y�75 � GENERALLIA9ILIN - EACXOCLUNRENGE g II COMNFRdAL GENERAL LIABILITV ��5� �� rt�� y �I., CLAIMSMApC ❑OCCl1R N[DaP(Myonepenon) g � PERSONAL6ADVINJURY S I GENERAL/G6REGATE $ I GEN'LAGGliEGATELIMIThPPtIEuPER: PROOUGTS-COMWOPAGG 3 li POLICV PRO- OC �'�,. AUTOMOBLELU181LITY COM&NEOSINGLELIMIT s �. µYwT� 60DILYINJURY(Porpemm� 7 . ALL ONNFD SGHEIXILED _AUTQS qU7pS BODILV INJUFY(Poraecitlenp 9 i HIREOAlIT05 n�Nd�� PROPHtTYDqM1MGE � _ AlJr05 'Perac' ent g i 3 UMHRELLpL1AB OCCUR EACHOCCUftRENCE g EXLESSLIAB CWMSMl�E AGGREGATE 9 DE� REfEHrION 5 y � RNDEMPLOYERS'LII�BILITY x TORV LA�ITS . OFFIL ��ECLITNEY/N ELEALHACCI�FM S 'IOO,OOD.00 A �� N x�A AWCd00-7a25372-2D13A vuzo�a varzo�a (ManOelorylnNM� — E�.DI9EASE-EABr1PLOYEE 3 ��.�Q DESGRI�iONO oPERAT10NSwlwv E.L.DISFASE�PoLICVLIMR 9 500,�0�.�0 DESCRIPIION OF OPERATION51 LOCql10N5/VEHICL6(AttacM1 ACORU 10t.AC�fional R�mafks SchMUPo,if moR apece fs rcqulreG� CER7IFICATE HOLDER CAqCELLA710N Town of Yarmouth Attentim:Boafd of Healtll Dept SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 7746Route28 � 7lIE EIfP6tATION DATE THEREOF, N0710E WILL BE DELIVERED IN $OUfll Y2flHOOih�MA 026W AGGORDANCC WITX TXG►OLICY►ROV131ON3, AUTXORQ�REPRESENTATIVE `y �.�`�\ �J�-�Sc'JL �1988-201D ACORD COR ORATION.All rights reserved. ACORD 25(2010(O5) The ACORD name and logo are registered marks of ACORD � � NOTICE _ � � NOTICE TO � TO w � x EMPLOYEES A � EMPLOYEES �,�t �•� The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS ' 600 Washington Street, Boston, Massachusetts 02111 617-727-4900 � i As required by Massachusetts General Law, Chapter 152, Secdons 21, 22, & 30, this will give ou � nouce that I(we) have provided payment to our injured employees under the above mentioned � chapter by insuring with: ' A.I.M. Mutual Insurance Company � NAME OF INSURANCE COMPANY ' I P.O. Box 4070 Burlington, MA 0 1 80 3-09 70 ' ADDRESS OF INSURANCE COMPANY AWC-400-7025372-2013A 02/03/2013-02l03/2014 � POLICY NUMBER EFF'ECTIVE DATES � 550 MacArthur Blvd Murray 8 MacDonald Insurance Boume, MA 02532 (508)540-2400 NAME OF INSURANCE AGENT ADDRESS PIIONE ' Brandon Inc 1319 Route 28 South Yarmouth, MA 02664 ' EMPLOYER ADDRESS 01/1 M2013 DATE MEDICAL TREATMENT The above named insurer is required in cases of personai injuries arising out of and in tLe course of employment to furnish adequate and reasonable hospital and medical services in accordance wikh the provisions of the Workers Compensation Ack. A copy of the First Report of Injury must be given to the iqjured employee. The employee may select his or her own physician. The reasonable 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 work related injury. In cases requiring hospital attention, employees are i hereby notified that the insurer has arranged for such attention at the NEAREST AND BEST MEDICAL FACILITY EMPLOYER ADDRESS � , TO BE POSTED BY EMPLOYER '