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Home My WebLink AboutApplication and WC ��""_ il n ....rj; �� ` a � TOWN OF YARMOUTH BOARD OF HEALTH ' �� APPLICATION FOR LICEN�%PE IT-201 CEC O ) O1Z �z �� ., t ��a-13!� � 2 * Please complete form and attach all nec�giary e�ments�iy De em 012. Failure to do so will result in the return of your applicatio " T• ESTABLISHMENT NAME: �uuc I�SG.ATf� ��r7K'/ �TD�.t2 TAX ID: � LOCATION ADDRESS: ,S�& �ucx /.fl�r,va � Wt�!' Y'�2Mcu�!* mat TEL#• Sa��90 �aY� � MAILING ADDRESS: OWNER NAME: �--cTh� K CORPORATION NAME (IF APPLICABLE): y�/� ,1/JA�2T CsRO- /NC - MANAGER'S NAME: G-�Tpr� Kd1� TEL.#: Sd�3Yd ��-`t� MAILING ADDRESS: Sst-�n� AS �L POOL CERTIFICATIONS: The pool supervisor must be certified as a Poot Operator,as required by State law. Please list the designated Pool Operator{s) and attach a copy of the certificati�n to this form. _ 1. 2. Pool operators must list a minimum of two employees urrently certified in basic water safety, standard First Aid and Community Cazdiopulmonary Resuscitation ( PR). Please list these employees below and attach copies of employee certifications to this form. The Heal�epartment will not use past years' records. You must provide new copies and maintain a file at you 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 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. I��2. rEK�D�Viiv �'rlA�fi�___ - - - - - - - Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. 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-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' rewrds. You must provide new copies and maintain a Fle 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 TRAILERPARK $105 WHIRLPOOL $SOea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQU[RED FEE PERMIT# L[CENSE REQUIRED FEE PERMIT# _0-100 SEATS $85 _CONTINENTAL $35 NON-PROFIT $30 _>100 SEATS $160 COMMON VIC. $60 WHOLESALE $80 RETAIL SERVICE: —RESID.KITCHEN $80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT N LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $50 >25,000 sq.8. $225 _VENDING-FOOD $25 I <25,000 sq.ft. $80 �1"J�-O��J _FROZEN DESSERT $40 I TOBACCO $95 �f -[17'] NAMECHANGE: $IS AMOUNTDUE _ $ I�S.Op *****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 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 Yarmouth taaces and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES ✓ NO NIf)TEf.S'AND OTHER LODGYNG ESTABF.ISF �1x1TS 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 hotei 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 tl�irty(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 ar 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 Heaith 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 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 ciosing. 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 priar 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 obtamed 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.;eutdeer-seating�ith uraiter/waitress servicel,must have prior approval from theBoazd of Health____ OUTDOOR COOHING: Outdoor cooking,preparation,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, 2012. 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: /d-�0 3�/Z SIGNATURE: ��a� ,��a=��T �z��rE�L PR1NT NAME& TITLE: �Ci?YL K _� Rev. 10/09l12 ' � The Commonwealth ofMassachusetts Department of Industrial Accidents Office of Investigations 1 Congress Street,Suite I00 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Aanlicant Information Please Print Leeiblv Business/Organization Name: /�uGK /SC-sYnl� Ca-u,u7ry Jia�.& Address: -5�-8 .C�st(CK /S�fi�`�-� 'a`� . ; City/State/Zip: f't� �in a�w7i ai6 Phone #: S�� ' �'�� Are you an employer?Cheele�the.appre@riate.bo� _.�._ ,s> . Busi s&�T'ype-(requ,ir�¢� ,_,r._. - � . . _ I.❑ I am a employer with employees(full and/ 5. [�Retail or part-time).* 6. ❑Restaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or parhzership 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-prafit 3. We aze a corporation and its officers have exercised 9. ❑Entertainment their right of exemption per c. 152, §1(4),and we have �0.❑Manufacturing no employees. [No workers' comp. insurance required]* 11.❑ Health Caze 4.❑ We are a non-profit organization,staffed by volunteers, with no employees. [No workers' comp.insurance req.] 12.❑ Other *My applicant that checks box#1 must also fill out the section below showing the'v workers'compensation policy info�mation. •*If the corporete officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organi�ation should check box#1. I am an employer that is providing workers'compensation insurance for my employees. Below is the po[icy information. Insurance Company Name: Insurer's Address: City/State/Zip: -- --- -�oYicy#at`S�ifins:i,ic. rt -- - — - ._ __ -- --�xpuariuirHate: - - _ Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiraHon date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year 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 forwazded to the Office of Investigations of the DIA for insurance coverage verification. I do he�eby certify,under the pain�and pena[ties of perjury that the informarion provided a6ove is due and correct. Si ature: -�-_��-�" \\� Date• l�a3 l �Z� Phone#: SD� �� o�/S� Official use ox[y. Do not write in this area,to be completed by city or town officiaL City or Town:_ /A�Q,�►�,p�'�- Permit/License# g ut or (cir one): 1.Board of Health 2 ilding Department 3. City/Town Clerk 4.Licensing Board 5.Selectmen's Office Coutact Person: Phone#: ��Q-3 Q�Q-aa�( X lZy � . . . . . . . . www.ina;s.govidia � � �� v. � YOP DATE�MM/DD/YYYYI CERTIFICATE OF LIABILITY INSURANCE R045 lz-o4-zo�z THIS CERTIFICATEIS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOTAFFIRMATIVELYOR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATEOF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER�SI,AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate hokler is an ppDIT10NALINSU(�D,tt�e policy(ies)mus[he eriAorsed, If SUBROGATIONIS WAIVED,subject to the terms and corkidws of the policy,certain pdicies may reaire��rsert�rt. p yya[¢men�on Urs certificate dces not confer rights to the certficate Iqlder in lieu of sud�endorsefnent�sl. EP.STERN INSURANCE GROUP LLC/PHS � c,� 087059 P: (866) 467-8730 F: (800) 308-5459 E_w� ' �866)467-8730 u�,c,n,r (800)309-545 301 WOODS PARK DRIVE AO°'� CLINTON NY 13323 �NSURERIS�AFFOR�INGCOVEBAGE NAICF INSUflEP A: Z'WSII Clt Fire ZIIS CO �� INSURER B: WE MART CORP INC. DBA BUCK ISLAND INSUqHtC: COUNTRY STORE 528 BUCK IS�D � INSUflEflD: WEST YARMOiTTH MA OZE)73 INSURERE: INSURER F: COVERAGES � CERTFICATE NUMBER: HEVISION NUMBER: THIS IS TO CEflTIFV THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTAACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SU&IECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BV PAID CLAIMS. � TYPE OF/NSURAAC£ �'y� �� [lF Mq POLCY M/MBER p�[.y�q�ry►r� p�{ypry�y�� LNerS GEI�RAL L/AN!/)Y FACH OCCIMBICE S COMMEFQAL GENERAL LIABILITV � ��-�� $ CLAIMS-MADE ❑OCCUH MED IXP(Any o�perwn) S .❑ � PERSONALflAOVIWUPV 5 GENERAL AGGREGATE S C�ll AGGREGATE LIMIT ArPP�IES PEfl: PRO�UCTS-COMP/OP AGG 5 PoLICY �P� I �LOC 8 AUT�'MOBI[E�wB[?Y COMBINED SINGLE IIMIT IEa accidentl S ANV AUTO BODILV INJUflV IPer person) 3 ALL OWNED SCHEOULED .❑ � BODILV INJURV rybr�dvq 5 AUTOS AUTOS PftOPEPTY DAMAGE HIRED AUTOS NON-0WNED '� �.�.) g AUTOS S UNBREL[A [/AB pCCUR EACM OCCURRQJCE 3 EXCESSL/AB ❑ ❑ AGGREGATE 5 REfENTION 5 S WOR/fERSCO�NAEFSATpN � MICSTATIF OM ANDEMIKOYERS'l/ABN/!Y V/N X Tq1YLMffS 9i ANY PIiOPflIEfOFVPAPTNER/EXECUTIV .E.L EACH ACCIDENT 3 IOO OOO A OFFICERrtdEMeEHEXCWDEO? � N/a � OB WHC NK2265 OS/OS/201 O1/OS/2013 �'Nandaoryi"°�� ELDISEASE-EA s 100 000 If Yes,tlescribe u�Mer DESCRIPTION OF OPEflAT10N5 below EL.DISFASE-POLICV LIMIT 5 S O O� n O O � � OFSCPoPI/ONOFOY£Iti)1H1NS/LOLATpNS/VE/pC[ES/Axxh ACOqD f01.AdMioiulRsm�ka SCAstlup.Anipe ywce y ieqv�rq Those usual to the Insured' s Operations. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE TOWSl Of Yarmouth DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 1146 ROUTE 28 ��MA� SOUTH YARMOUTH, MA 02664 ��. "'lQ�/_, � LO��/ � 1988-2010 ACORO CORPORATION. All rights reserved. ACORD 25 (2010/051 The ACORD name and logo are registered marks of ACORD