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���a TOWN OF YARMOUTH BOARD OF HEALTH ���������
APPLICATION FOR LICENSE/PERMIT-2015
�"'` * Please complete form and attach all necessary documents by Decemb r 1 �tbi�.41U95
Failure to do so will result in the return of your applicahon pac t.
HEALTH
ESTABLISHMENT NAME: ` e TAX ID• -
LOCATION ADDRESS: dG Im TEL.#: $"�f G'O Z��J
MAILING ADDRESS: `I'S �.� �hf h �`
E-MAII.ADDRESS: A�ILI� �J1-P�'l�«Pecod�co� (7S�►-e�'u � �F�, MAGLbs�
OWNER NAME:
CORPORATION NAME (IF APPLICABLE):
MANAGER'S NAME:_�v1��n)i�F� TEL.#: OS'-Lf ZD— CJ LG 9
MAILINGADDRESS: So�wt Q A 5 m�0 0�/'Q
POOL CERTIFICATIONS:
The pool supervisor must be certitied as a Pool Operator,as required by State law. Please list the designated
Pool Operatar(s) and attach a copy of the certification to this form.
1. S e�'f/� i 4 7�� �C✓V► z. ��t✓2 S�2J �t� SG�1
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 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. S�r�11� �V\�Qr,II 2.��� �/Q �cvP✓� ��[/�
3. '' 4.
FOOD PROTECTION MANAGERS - CERTIFICATIONS:
All food service establishments aze 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. 2•
PERSON IN CHARGE:
Each food establishment must have at least one Person In Chazge (PIC) on site during hours of operation.
1. 2.
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 applica6on. The Health Department will not use past years' records. You must
provide new copies and maintain a file at your establishment.
1. Z•
HEIMLICH CERTIFICATIONS:
All food se.rvice establishments with 25 seats or more must have at least one employee h�ained in the Henniich
Maneuver on the premises at all times. Please list your employees trained in anti-chokmg procedures below and ',
attach copies of employee certifications to this form. The Health Department will not use past years' records. i
You must provide new copies and maintain a�le at your place of business.
1. 2. I
3. 4. I
RESTAURANT SEATING: TOTAL# �
OFFICE USE ONLY
LODGWG:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �.
B&B $55 CABIN $55 MOTEL $110 �
!NN $55 CAMP $55 SWIMMINGPOOL$ll0ea '
_LODGE $55 _TRAILERPARK $105 _WFIIRLPOOL $IlOea. I
FOOD SERVICE: '
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �
0-100 SEATS $125 _CONTINENTAL $35 NON-PROFIT $30 '�,
—>100 SEATS $200 _COMMON VIC. $60 WHOLESALE $80 '�,
— —RESID.KITCHEN $80 '�,
RETAIL SERVICE: �'�
L[CENSE REQUIRED FEE PERMIT# WCENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �
<50 sq.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 '��
=<25,000 sq.ft. $l50 _FROZEN DESSERT $40 _TOBACCO $110 '���.
NAME CHANGE: $l5 AMOUNT DUE _ � ��.
*'"•**PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*****
ADMINISTRATION I
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 Warker'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 Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID: �
YES N� I
i
MOTELS AND OTHER LODGING ESTABLISHMENTS
TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be �
limited to the temparary 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 inspection t6ree(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 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 i
required Temparary 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 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 wili result in the suspension or revocation of your Frozen �
Dessert Permit until the above terms have been met.
OUTSIDE CAF`ES:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must k�ave 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:Pernuts 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 I5, 2014.
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: �b— � l"1 SIGNATURE:
PRINTNAME& TITLE: ��� VV"�tf� I� �4-SST� ����y
Rev. 11/03/]4 '" "—"�/��
I � The Comnronwealth ofMassachusetts
� 7�' Department ojlndustria/Accldenrs
�'- 1 Congress SYreer,Sulte 100
Boston,MA OI114-z017
www.mass,gov/dia
I� Worken'Compeuaa[ion[asuranee Attidavip Generai gusfuesses.
� TO BF FILED N'!T8 THE AER'�1ITTING AUTHORITY,
A licant Iaf rmatioo
Pleas P int e ibl
Busincss/Organization Name: �Jw�� LS lcav�p�. U� ��q � -- �
�'^��,�� ti J ru
Address: �{ 5f l ��,ti� �'j�Av�O�. �CC,q�
CirylStak/Zip: 25�- �p�r ,n,�oL.�� �N`� 0•���7 3 —
Phonc#: 50�- - y � � _ p�c�9
Are you�n employer?Check t6e appropriate boz; Buct¢ess Type(roqulredj: �
I� 1 am a:;mployer u�ich � emplo�roa(fu11 andi 5� ❑Retail �
or pan-�ime).+ 6. �Rcstaurant/Baz/£ating Hstablishmmt �
2.❑ 1 am a sole propnetor or partnership and have no �
employces working(or me in any capacity. �� Q Offiee and/or Seles(incl,rea! es�atq euto,ete.) '
[No workers' comp,insurance required) 8. Q Non•profit
��0 We erc a corporatioa and its o�cers have ezerciscd 9. �Emenainmem
iheir nght of exemption per c. 152,§l(4),and we havc '
na employees. [No workers' cvmp. insuranee requiredj• ��'p Manufacturing '
4-❑ W e are a non-profit wganization,stafftd by voluntars, ���0 Health Care I � /�
with no employees.[No workers'comp,insuranee req.j 12.�Other �P 7 i pG�n'�c�..a� C.0�
'�^Y�VA�����Nar chocks bva M�mvrt Wa fill pyt ip�socuao babw�hvwiag�pcu worktN�omDmn400 policy id'orautioo.
••If�h<corponm oRicart W ve rsemqed[6emwlva�,bm th<corponuon hu o�Lv employ�ec,�worken'compe��Uaa yolicy u mq�wed wE sucb Yn
oresnu.a4oe spouttl check boa M�.
1 am an employcr thot(s prnvldtng workers'comprnsadon lnsu.ancr Jn�my employees Below is the policy inJormadoa
Insurana Company Name� N Cc i"..n�K y. ���� -
�- '''n ]�_—'�+^�4�� i,�.5 wr av��z, / -_—
lncurer's Address:_�c�oZ �y�,��5 S`�-e L^f
Ciry:SiaidZip� IJ��e-�n0.Vv� I/Vl I� 0� C.,� 4 �' _ -----.—._
Policy a or SclFins. Lic.N w� I4 5U 37✓� I�- � - � S�
Aa■ch�copy of t6e worken' eompeus�tloo polky decl�ntlon pa¢e(showtnQ the polte aumber aod expindoa dace).
Fai�ure ro sewre coverage as required under Sectioo 25A of MGL c. 152 can lead to the impositioo of criminal penaltics o(a
fine up to SI�,SOO,Op anyor one•year imprisonment,as well as civG ponalties in the forto of a ST'Op WpgK ORDER and a fine
of up eo 5250.00 a day against the violator. Be edvised tha[a copy of this statement may be fonvazded to the Oftice of
lm•estigaiions,6lthe D1A for insurq�ce covua�t ycrification.
!do hereby cR+'� , under thrpafn�oryd p na 'e}.o e�jury�hat fAe info.mnbon provlded obnve!s nu and corserc
XSienaturc ' .:� , .��� � � :.�� j f
50�� z v . o z 9 � De«�C � �� z/�5
OjJictW use onfy. Do no1 wrUe trt thts area,10 be completed by clry or�own offic(ol
Ciry or Towo: Permit/[,lceose q
Issuing Aut6oriry(cirele one):
1.Soord ot Healtb 2.Bullding Departmenl },Ctty/1'own Cle�k 4,Giceoslog Soard S.Seleetmen's Offfce
6.Other
Cootpct Penon:
Phoue#;
v^rw.m+q.eovlaii
1
WORKERS COMPENSATION AND EMPLOYERS'LIABILTY
INSURANCE POLICY•-••INFORMATION PAGE
INSURER: POLICY N0: WE145637A
NORFOliK & DEDHAM M[JTUAL FIRE INSURANCE COMPANY
222 AMES STREET NEW BU3INESS
DEDHAM, MP. 02026 NCCI Company No: 21059
Account No:
FEIN:
ITFM 1. NAMED INSURED AND MAILING ADDRESS: AGENT NAME AND AqpRESS:
BUCK :CSLANA VILI,AGE CONDOMINIUM MILLER %CCARTIN, INC. DBA
1046 MAIN STREET SUITE 11 C 0 DOWLING & 0'NEIL INS. AGCY
FIRST PROPERTY AfANA6EMENT PO BOX 1990
OSTERVILLE MA 02655 HYANNIS, MA 02601
AGENT NO.: 20762
LE(3Al ENTITY; REALTY TRUST
OTHER WORKPLACES NOT SHOWN ABOVE: (See Workers Compensation Classification Schedule)
I
ITEM 2. POLICY PERIOD: From: 11/08/2014 To: 11/08/2015
Effective 12:01 A.M. Standard Time at the Insured's mailing address.
I7EM 3. COVERAGE:
A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the
states listed here:
MA
B. Employers' Liability Insurance: Part Two of the policy applies to work In each state listed in Item 3.A. The limits
of liabiliry under Part Two are:
Bodily InJury byAccident: $ 500, 000 each accident
Bodily Injury by Disease: $ 500, 000 Po��cy limit
Bodily Injury by Disease: $ 500, 000 each employee
C. Othar States Insurance: Part Three of the policy applies to the states, if any, listed here:
SEE ENDORSEMENT WC 20 03 06 B
D. This Policy includes these Endorsements and Schedules:
See Schedule of Forms and Endorsements.
ITE:M 4. PREMIUM: The premium for this Policy will be determined by our Manuals of Rules, Classifications, Rates and
Rating Plans. All information required on the Workers Compensation Classification Schedule is subject to '
verifcaiion and change by audit. '
Total Estimated
Minimum Premium: $ 284 Annual Premium: $ 343
Audit Period: p��AL Additional/Return Premium:
Comments :
Issued At:
Date: 11/11/2014 Countersigned by
W(: 00 UO 01 A Copyrlght 1987 Natlonal Council on Compensatlon Insurance
INSURED COPY
Policy Number WE145637A
NORFOLR & DEDHAM MZ7TUAL FIRE INSURANCE COMPANY
WORKERS COMPENSATION CLASSIFICATION SCHEDULE
State of: MpSSACHUSETT3
Namad Insured gUCK 23LAND VILLAGE CONDOMINIIIM Effective Date: 11/08/2014
i12:01 A.M., Eastem Standard Time
I AgentNama MILLER MCCARTIN, INC. DBA DOWLING & AgentNo. 20762
�
Classification of Operatlon Code Mnual per$100 0� Deviation Eslimated
No. Remuneration Factor �nnual
__ emune�etion Premium
LOC �1 !
� SUCK I3LAND VILLAGE
. CONDOMINIUM
PEIN #
PIRST PROPERTY MANAG&MENT
OSTERVILLE MA 02655
HUILDINGS - OPERATION SY OWNfiR OR 9015 $ IF ANy 2.99 ,9g S 0 ,00
LESSEE NOC (9015)
! CLERZCAL OFPICE EMPLOYE85 NOC (8810) 6810 $ 25,000 .Od .98 S 20.00
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W C 89 0415
INSURED COPY
!
�
Policy Number WE145637A
NOkFOLK & DEDHAM MUTUAL FIRE INSURANCE COMPANY
WORKERS COMPENSATION CLASSIFICATION SCHEDULE
State of: DIpgSACHUSETTS
i Named Insured gUCK ISLAND VILLAGE CONDOMINIUM Effactive Date: 11/08f207.4
� 12:01 A.M., eastem Slantlard T me
� AgentName MILLER MCCARTIN, TNC. D8A DOWLING & AgentNo. 20762
�
Cotle Rates Devlalion Es�imated
1 Classifcalion of Operation Mnual per$100 ot
� No. Remuneration Factor Annual
Remunaretion Premium
MA - STATE SUHIDSARy
t
i
i
� �
i
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TOTAL CLA93 PREMIUM
EMPL, MINIMIIM DIFFERENCE ggqg S 20.00
TOTAL 6UHJECT PREMIUM S 5Q.00
. MER7:T RATIN4 PLAN .950 9885 $ 70.00
TOTAL MODIFIED PRBMIUM S - 4.00
LOSS CON9TANT 0032 $ 66.OU
STANDARD TOTAL S 20.00
EXPF;NSE CONSTANT 0900 $ 66.00
TERRORlSM RISIC INSVRANCS .030 9740 $ 159 .00
EXTE�N3ION ACT $ 8.00
PREMIUM SUBTOTT�L
POLI:CY MINIMUM DIFFERSNCE . �yyp S 392.00
MA L�IA ASSSSSMENT .058 9751 $ 39. 00
PINAL TOTAL S 1,00 �
$ 393.00
POL]',CY TOTAL EBTIMATBD C08T �
S 343 .00
WC ft9 04 15
INSUHEO COPY
(
Policy Number WE145637A
NOXFOLK & DEDHAM MATUAL FIRE INSURANCE COMPANY
' SCHEDULE OfFORMS AND ENDORSEMENTS
� Named Insured BUCK I9LAND VILLA6E CONDOMINTUM Effective Date: 11/08/2014
12:01 A.M., Eas�em Standard Tirnc
AgentName MILLER MCCARTIN, ZNC. DHA DOWLING & AgentNo. 20762
� '
WORKSRS COMPENSATION FORMS AND $NDpRSEMENTS
LOC SCHED SCHEDULE OF LOCATIONS
WC 00 00 00 B INSURANCE POL2CY
WC 00 00 O1 A � WC INFORMATION PAGE
WC 00 04 14 NOTZFICATION OF CHANGE IN OWNERSHIP ENDT
WC 20 O1 O1 TERRORISM RISK IN3 EXT ACT ENDT
WC 20 O1 02 TERRORISM RISK INS EXT ACT 2014 ENDT
WC 20 03 O1 MA LIMITS OF LIABILITY ENDT
; WC 20 03 02 A MA ASSESSMENT CHARGE
WC 20 03 03 D MA NOTICE TO POLICYHOLDER ENDT
' WC 20 03 06 B MA LIMITED OTAER STATES INSURANCE
WC 20 04 OS MA PREMIUM DUE DATE ENDT
WC 20 06 01 A MA CANCELLATION ENDT
WC 20 06 04 MA POLICY DEFINITSON ENDT
WC 88 20 O1 C MA DEPARTMENT OF INDUSTRIAL ACCIDENTS
WC 69 04 15 WC CLASSIFICATION SCHEDULE
WC 89 06 14 SCHEDULE OF FORMS AND ENDTS
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WC 739 06 14 INSVREDCOGV
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Policy Number wE145637a
NORFOLK & DEDHAM MLTTUAL FIRE INSURANCE COMPANY
NAME AND LOCATION SCHEDULE
I Named Insured BUCK ISLAND VILLAGE CONDOMINIUM Effective Date: 11/08/2014
� 12:01 A.M., Eastern Standard Time
AgentName MILLER MCCARTIN, INC. DBA DOWLING & AgentNo. 20762
O'NEIL INB. AQCY
State: MASSACHUSETTS
, BUCK ISLAND VILLAGE CONDOMINIUM
FIRST PROPERTY MANA�EMENT
OSTERVILLE MA 02655
FEIN :
SIC Code : 0111
# EMP : 1
PHON$ # : 508-420-0299
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INSVREO COPY