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Home My WebLink AboutApplication and WC� ' ' f-'o-:�, , . - � - � °" � TOWN OF YARMOUTH BOARD OF HEALTH /}�Q�A�� APPLICATION FOR LIC� �� ,(�;, � * Please complete form and attach all hecess y docume}at�s�b}�, ce ber 13��01�. Failure to do so will result in the�etu4�i of your applicati n p .�H p� ESTABLISHMENT NAME:' M9['� Y3Actaa��s rlSA — Ai'-,uCuo Sikt-'S Tt�X ID• LOCATION ADDRESS: � /�uyf1,UC�✓Du /tli'� 5' �`F1�Ihto�Y �dbEy TEL#• 3"l�3 �9 y a�si MAILING ADDRESS: SJHl6' E-MAIL ADDRESS: A� 2 L OWNER NAME: .�. CORPORATION NAME (IF PLICABLE): ��j �,y�,Es /.�59- AO-,�ocD �-� MANAGER'S NAME: A/vlls';f: �tl TEL.#: .S7Jb'-p'a/-07�- MAILING ADDRESS:_�,�ll,.,�2J,�� „Fii/,s �' Y.rf.s�ytdt✓l!� OZ�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. 1. N/A 2, Pool operators must list a minimum of two employees cunently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation(CPR),having one certified employee on premises at ali 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. 1. NfA' 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments aze required to haue at least one full-6me 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. �� 2. PERSON IN CHARGE: ' Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1.��9 2, ALLERGEN CERTIFICATIONS: All food service establishments aze required to have at least one fixll-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. N�/� 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-cholang 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. 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 —SWIMMINGPOOL $SOea. _LODGE $55 =TRAILER PARK $105 _WHIRLPOOL $80ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-I00 SEATS $85 _CONTINENTAL $35 NON-PROFIT $30 � _>100 SEATS $160 _COMMON VIC. $60 �WHOLESALE $80 RETAIL SERVICE: —RESID.KITCHEN $80 LICENSE REQUTRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 5q.ft. $50 >25,000 sq.ft. $225 VENDING-FOOD $25 _<25,000 sq.ft. $80 �ROZEN DESSERT $40 =TOBACCO $95 NAME CHANGE: $15 AMOUNT DiTE _ $ SO.00 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM'**** F ' t 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 Compensarion Insurance. THE ATTACHED 5TATE WORK�R'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 pernuts. 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 shall generally refer to continuous occupancy of not more than thiriy(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. a 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 aze 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 standard 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 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.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 have prior approval from the Board of Health. OUTDOOR COOHING: Outdoor cooking,prepazation, or display of any food product by a retail or food service establishxnent 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 APPROVE Y THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SI AN. DATE:�'�)�/j SIGNATURE: - PR1NT NAME&TITLE: />�gy T [��rsuicC� , 1J�!'oT/h4..f�4��{� Rev. ]0/08/13 . . ^ ' '`�� CERTIFICATE OF LIABILITY INSURANCEZ,,,Zo,4 opl/30/2013� THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLV AND CONPERS NO RIGHTS UPON THE CERTIFICATE XOLDER.THIS GERTIPICATE DOES NOT AFFIRMATIVELV OR NEGATIVELV AMEND,E%TEND OR ALTER THE GOVERAGE AFFORDED BV T7E POLIGIES BELOW. TXIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BE7WEEN THE ISSUING INSURER�S),AUTHORIZED � REPRESENTATNE OR PRODUCER,AND THE CERTIFICATE HOIDER. IMPORTANT:Ii the cer6fi<rte holtle�is an ADDITIONAL INSURED,[�e policy(les)muat be entlorsetl. tt SUBROGAT70N IS WAIVED,subject to tlie terms antl contlitions of Ne policy,certain policiea may require an endoBement A atatement an Nla certHkate dces not confer rig�b to Ne certificate holtler in lieu of such entlonemenys�. PROWCER LOCKTON COMPANIES LLC-N DALLAS �� 717 N.HARWOOD,LBtF�� PlJCNNo E.e: � xo: DALLAS TX 75201 E-MAIL 214-969-6700 i ir+5ur�o gBU,Inc.on behalf of itself and irvSu�R e: Indemnit Insurance Co ofNorth Amenca 359436 U.S.subsidiaries including (see attached addendum) a c: 225 Business Center Dr. Horsham PA 19044 v THIS IS TO CERTIFV THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICV PERIOD INDICATED.NOTNITHSTANDING ANV REQUIREMENT,TERM OR CONDITION OF ANV CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAV 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 MHV HAVE BEEN REDUCED BY PAID CL41MS. � TVPEOFINSURIINCE DL BR pp�H,yNUMeER �V�ffF LICYEXP LIMRS p GENErsnLLualulv N N HpOGZ7OI5177 2/1/2OI3 2/1/2O14 I OOOOOO X COMMERCIALGENERALLIABILITV /� ET RENTED jOOOOOO - CtAIMS1MOE X❑occua 5 000 ERSONALBADVINJURV I OOOOOO 2�� 'LAGGR TELIMIT SPER'. PROOUCTS-COMP/OPAGGS2OO0000 PR s p FUTOMOBILELIABRITY ]�J N ISAH08713236 2/�/20�3 2/�/20�4 �BINEOSINGLELIMIT 5000000 X ANV AUTO OILY INJURY(Per person) S }{J{�'}{}{ '�' qULO`SMJED SqCU7OE5ULED DILVINJURV(Peraaitleni5 }[ TO HIREDAUTOS q�OSWNED ROPERTV�AMAGE g 5{�'�'XXXX E }{}Q{}{}{}{�' UMBRELLALIAB OCCUR CHOCCURRENCE E �'](]{}{}{}�}[ EXCESSIJAB CIAIMSMNDE NOI�APPLICABLE GGREGATE S }�')(){}{X}�}[ DED REtENTION$ 3 WORKERSCOMPENSATION TAT - iH- A ANDEMVLOYERS'LIABILITY N WLRC47128213(CA&MA) 2/1/2013 2/1/2014 X B nrvraaoaRiE.owrna.HeRrexecurrve ��N WLRC47128225(AOS) 2/1/2013 2/I/2014 A oFFicewMemeeaoecwoeoz N� N�p SCFC47128237(WI) 2/12013 2/1/2014 ��eHnccmen�r �M.�ama,y��xp �.oisense-easrnv�ovee 1000000 � o�"scaiariox oF oPERn.iorvs e.iow 1 000 000 DESCRIPTION OF OPERATIONS I LOCATIONSI VEHICLES ryPttac�ALORD 101,AEdXlonal Remarks ScliMule,H more space is requiretl) CERTIFICATE HOLDER CANCELLA710N See Attaclvnent SHOUL�RNY OF THE ABOVE OESCRIBEU POLICIES BE LANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE NALL BE OELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 72760299 /UTHOR¢E�ftEPRESENTATIVE For Information Only - .�r � ACORD 25(2010/OS) �1988-2070 ACORD CORPORATION.All rights reserved The ACORD name and logo are registered marks of ACORD INSURED BBU,Inc.on behalf of itself antl U.S.subsitliaries including(see attached addendum) 255 8usiness Center Drive Horsham,PA 19044 USA The following are Named Insufetls uMer�he GL antl Auto policies: Advantafirst Capital Financial Services.Inc Allen Foods Inc Amold Foods Company,Inc. Amold Products,Inc Arnold Sales Company Inc BHL Transport, Inc Bimbo Bakeries USA, Inc Bimbo Bakeries DisVibution Management,LLC Bimbo Bakeries Distribution Company,Ltd Bimbo Foods Bakeries DisVibWon,Inc Bimbo Foods,Inc . Bimbo Foods,LLC Butter Krust Baking Company Inc. Carlisle Foods Inc Earthgreins Vemoq LLC � Earingreins Baking Companies,Inc. Earthg2ins Bakery Group,Inc. Earthgrains Distribution,LLC EGR Califomia Region Support Services,Inc. Entenmann's ProducGS,Inc Entenmann's Sales Company,Inc Freihofer Products,Inc Freihofer Sales Company,Inc Maspeth Holdings,LLC Mid-Gulf Bakery,LLC Orograin Bakeries Manufactunng,Inc Orogrein Bakeries ProduGs,Inc Orogrein Bakeries Sales,Inc Potomac Foods,LLC SB NY Inc SVcehmann Bakeries P.A.LLC SVcehmann Bakeries,Inc. Strcehmann Bakeries,L.P. Strcehmann Line-Haul,L.P. Strcehmann Sales LLC 7ia Rosa Bakery of Ohio,Inc � , Westfield Foods LLC The following are Named Insureds under the WC policy: Allen Foods Inc Amoltl Products,Inc Arnoltl Sales Co Inc Bimbo Bakeries USA,Inc Bimbo Foods Bakeries Distnbution,Inc Earthgreins Baking Companies,Inc. Orogrein Bakeries Manufacluring,Inc Orogrein Bakenes Sales,Inc Orogrein Bakenes Protlucts, Inc Mid-Gulf Bakery,LLC Stroehmann Line-Haul,LP. Standazd Attachmen[:BIMBAKUSNI Master ID: 1359436,Certificate ID: 12160299 ' .� The Commonwealth ofMassachusetts • Department oflndustrial Accidents O�ce oflnvestigalions ' 1 Congress Street, Suite I00 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Annlicant Information Please Print Leaiblv Business/Organization Name: `��j `�}�G,er� f/5� Address: 3'1 f{�fc,'�'7,U�;�v,U r¢t/E Oz��y City/State/Zip: � yi9x'it�Ipr.�E� Phone#: 3'p� 3S� 077'"y'/ Are you an employer? Check the appropriate box: Business Type(required): I.[� I am a employer with �, employees(full and/ 5. ❑ Retail or paR-time).* 6. ❑ RestauranUBaz/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 corporation and its 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�* 11.0 Health Caze 4.❑ We aze a non-profit organization, staffed by volunteers, � with no employees. [No workers' comp.insurance req.] 12.�'Other�� C,ry2S Gc�tFi��Y � *Any applicant that checks box#1 must also fill out the sectioa below showing Ihe'v workers'compensation policy iaformation. � **If the corporete officecs have exempted themselves,but the corporafion has other employees,a workers'compensation policy is required and such an � organization should check box#1. - � � I am an employer that is providing workers'compensation insurance fot my employees. Below is the policy information. Insurance Company Name: Insurer's Address: City/State/Zip: Folicy#or Self-ins.Lic. # Expiration Date: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL a 152 can lead to the imposition of criminal penalUes of a fine up to $1,500.00 and/or one-yeaz imprisonment,as well as civil penalUes 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 forwazded to the OfFice of Investigations of the DIA for insurance coverage verification. I do hereby certijy, n er the ' and pena[t:es ofperjury that the injormation provided above is true and correct Si ature: � Date: l% 3� �� i Phone#: 57115 ��7S<. ()7�.� Official use only. Do not write in this area,to be completed by city or town officiaL City or Town: yAQMo U77t Permit/License# I g u ' cle one): Board of Health Building Department 3. City/Town Clerk 4.Licensing Board 5. Selectmen's Office 6. ContactPerson: Phone#: sb8—,3Qg��/ .Y/Zy/ www.mass.gov/dia