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Home My WebLink AboutApplication and WC � � ;� R�CEIVED TOWN OF YARMOUTH BOARD OF HEALTH � � APPLICATION FOR LIC�� '��y�' � NOV � 1 ��3 � �,� 3 � � • �- � � �"' * Please complete form and attach all�ne 0s �tts� ecember 13�2013. TAX ACCOUNTINGFailure to do so will result in the�re e�y6u't applica ' ESTABLISHMENTNAME: a�« �r " I � TAXID• LOCATION ADDRESS:_ N'�7 S I'a�ro� /�vt TEL.#: '�'D X- 25`S- l0'�� MAILING ADDRESS: 0 ro �x-�kP ✓A 2 au f E-MAIL ADDRESS: i�ov�S P �/.t_ i�i'i�;gp�+.� OWNER NAME: � CORPORATION NAME (IF APPLICABLE): ✓clince {a�CS COM/�<�� /v� MANAGER'SNAME: � TEL.#: S�f�-362- 5'/I MAILING ADDRESS: 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 ropy ef the certification to this fo*rn:. L 2. Pool operatbrs 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 all 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 file at your place of business. l. 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 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 51e at your establishment. 1. 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Chazge (PIC) on site during hours of operation. L 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 Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment. L 2. HEIMLICH CERTIFICATIONS: 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-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. l. 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 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 $SS _CONTtNENTAL $35 NON-PROEIT $30 >I00 SEATS $160 _COMMON VIC. � $60 WHOLESALE $80 . —RESID.KITCHEN $80 RETAIL SERVICE: � LICENSE REQUIRED FEE - PERM T# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 1 <50 sq.ft. $50 ��-(( >25,000 sq ft. $225 VENDING-FO 5 _<25,000 sq.ft. $SO =�ROZEN DESSERT $40 —TOBACCO $9 xnn�E cHwNCE: ��s AMOUNT DUE _ $ 50 �fJ •**:•pLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** ' f ADMINISTRATION � , Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permi�to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. TAE 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 pkior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES / NO __ MQTE_LS AIVD OTHER LODGI_NG 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 shall 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 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 inspecfion three (3) days , prior to opening.PLEASE NOTE:People are NOT allowed to sit 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. . _ FOOD SERVICE SEASONAL FOOD SERVICE OPENING: All food service establishments must be inspected by the Health Departrnent 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.yarmouth.ma.us under Heakh 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 COOHING: Outdoor cooking,preparation, or display of any food product by a retail or food service establishment isprohibited. NOTICE: Permits run annually from January 1 to December 3 L IT IS YOUR RESPONSIBILITY TO RETLJRN 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 RE A SITE PLAN. DATE: I� ' 13 " �� SIGNATURE: � PRINT NAME& TITLE: CI n�"� �"�S - Rev. 10/OS/13 � The Commonwealth ofMassachusetts Department of Industrial Accidents • Office oflnvestigations ' 1 Congress Street, Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses A�plicant Information Please Print Leeiblv Business/Organization Name: /��1��C� �.�'J �y/h Address: �� '� 5��1�c� �✓t City/State/Zip: �q/�r�te�,�� /t1J`�" L'Z��v'�C Phone#: Are you an employer? Check the appropriate box: Business Type(required): 1.u I am a employer with employees(futl and/ 5• �eTail or part-time).* 6. ❑ RestauranUBaz/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no �, � 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 iu officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4), and we have 10.� Manufacturing no employees. [No workers' comp. insurance required]* 11.� Health Care 4.❑ We aze a non-profit organizadon,staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.� Other *Any applican[that checks box#1 must also fill out the section below showu�g their workers'compensation policy information. **If the co�porate officers have exempted themselves,but the wrporatlon has other employees,a workers'compensation policy is reqnired and such an organization should check box#1. . � : � � - � - I am an emp[oyer that is providing workers'compensation insurance for my emp[oyees. Below is the policy injormation. Insurance Company Name: ��C e �� Insurer's Address: CitylState/Zip: Policy#or Self-ins. Lic.# Expiration Date: Attach a copy of tbe workers' compensakon policy declarafion page fshowing the policy number and eapiration date� Failure to secure coverage as required under Section 25A of MGL a 152 can lead to the imposition 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 ORDER 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 Invesfigations of the DIA for insurance coverage verification. I do hereby ce ' ,under the pains and penalties of perjury that the information provided above is true and correct. Si ature: L Date: 'I3��3 Phone#: S ��'�- 6�G( Official use only. Do not write in this area,to be comp[eted by city or town officiaL City or Town: ��p�-M Permit/License# Is u circle one): Board of Health Building Department 3. City/Town Clerk 4.Licensing Board 5. Selectmen's Office 6. O e ContactPerson: Phone#: 5D8-39B-,�3� X ��/� www.mass.gov/dia � � �`�� CERTIFICATE OF LIABILITY INSURANCE °oso�no�3°�"'"' THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE FiOLDER. 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 BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTAN7: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policfes may require an endorsement. A statement on this-certificate tloes not confer rights to the certificate holder in lieu of such entlorsement(s). - � � � PRODUCER CONTACT � . � M2lS�USA InC. NHME: � Thf2EJ3m25CB��E� PHONE- � �� ppX 1051 Easl Cary Stree�,Suile 900 E,MAa ---"-------- �ac.Na: RiChmOnQ VA 23218�1137 ADDRE55:____ ___.___ T RiChmOntl C2tlRequ251@mdlSh COm ...._ �NSURERIS(AFFORDMG COVERAGE I NAIC p _ -__ __ _ J32008 GAWC13�14 INSURERA ACEAmencanlnsuranceCompany 22667 _..._ _..._ ._.. .—__.. __..._—___ __- ._- . __ INSURED INSURER 6 Indemnily Ins Co Of Nodh Amenca 43575 Ativance Sto2s Company Inc ---- -- -_-- .—__ __. SOOB AiryOn ROdd INSURER C: Roanoke,VA 24012 �- '�""--- INSURER 0: .__--_...___—____—"__ INSURERE: �� _ ._-- INSURER F:. .'" '� —__-_"___.__ - __-__ COVERAGES CERTIFICATE NUMBER: CLE�W3421374-29 REVISION NUMBER: THIS IS-TO CER7IFY 7HATTHE POLIGES OF INSURANC� LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. N07WITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT IMTH RESPECT TO IMiICH 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 POLIGES.LIMITS SHOWN MAV HAVE BEEN REDUCE�BY PAID CLAIMS. INSR-�� -�� -� �� qDDLSUB� PpLICYEFF POl1CYEXP � LTR I TYPE OF INSURANCE POLICV NUMBER MMIDDIYYYY MM/DD/YYYY LIMIT$ A GENEaaulABlutt ', %SLG27020306 O6N1R013 06I01I2014 EACHOCCURRENCE 5 1,500,000 �, x� I COMMERCIALGENERALLIABILITY I PRMMI ET a �u n. E ��500,000 r �_ _ i.��I . .�I CLAiMS-MADE I xJ OGCUR MED EXP An orre erson 5 5,000 � I _-_ �_. .. _ .._. _ . ... _. _.._ I PERSONALSADVINJURY E . 1,SOO,OOO ___ ��,-. � .__- . ._..__ __ I � � . GENERAL AGGREGATE S 10,000,000 ___ _..__ __....___' IGENIAGGREGATELIMITAPPLIESGER� PRODUCTS�COMP/OPAGG S 3,500,000 j x �I POLICY�.�.. � PRO- �-� LOC 5 - A AUTOMOBILEINeILITY ISAHOB719743 - O6/01/2013 O61Y172014 COMBINEDSINGLELIMIT 5,�0,� -i . Ea eccMenl �_X I ANY AUTO , _._ � � � BODILY INJURV(Per parson) S _____ �-" �.ALL ONMED SCHE�ULED . BODILV INJURY ' AUTOS I_ _�AUTOS j (PerecciEenq E I_x HIRED AUTOS I X�NON-ONMEU 'I PROPERTY DAMAGE r._._ AUTOS Peracu ent $ __ I S EXLES LLA LIAB ppCUR � EACH OCCURRENCE E IF... __ ...__ S LIAB I CLAIMS-MADE i Y-- � .._"_r. 1._l._____-- I AG6REGATE 5 � � DEU �. I RETENTION$ $ g I,WORNERSCOMPENSATION WLRC47318993(A05) O6IO11201J OBN112014 X N.CSTATLL OTH- I ANO EMPLOYERS'LIABILITY A aN�PROPRIETORIPqRTNERIE%ECUTIVE y�N I � SCFC4731J01H(WI) �I01/2073 OENi/Z014 E.LEACHACCIDENT E ��O,OOO A '�OFFICER/MEMBEREXCLUDED4 � NIFi ._-_ i� �ManCatoryinNH) I I WLR�473190�6��A,MA) osroinoi3 Of)/�l/$�14 E.L.DISEASE-EAEMPLOYE S ��,� A � u yes tlescnoe untler I WCUC47318981(OH)SIR:500,000 O6N1/2013 �6N1/2014 i,000,OW ��, �ESCRIPTION OF OPERATIONS belax E.L.DISEASE�POLICV LIMIT 5 A iGENERALLIABILITY XSLG27020306 � A6I01R0?3 W�OV2C14 GLLIMi1S EXCESS jCLARIFICAT10NOPlIMITS I� OVER$500,OOOSIR DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Fttac�ACORp 101,Atltlilional Rama�ks ScheJule,if more apace Is requiratl) CERTIFICATE HOLDER CANCELLATION EviOence ol Covarage SHOULD ANV OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICV PROVISIONS. AUTHORREDREPRESENTAT7VE of Marsh USA Inc. � Susan e.Vignone ��, � �� OO 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(20'IO/O5) The ACORD name and logo are registered marks of ACORD