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TOWN OF YARMOUTH BOARD OF HEALTH }�{�R (1 2 Z013 �
' ��� APPLICATION FOR LICENSE/PERMIT-2013
* Please complete form and attach all necessary documents by De : ,,
� Failure to do so will result in the return of your applicaho e � ' '� �i�`
ESTABLISHMENT NAME: �-O�7Y1��S �Ct C'.REAM T�In•
LOCATIONADDRESS: q�8 ouiE 2P So,�/AamouTH �A 0,261��F TEL.#:
MAII.ING ADDRESS: � y �rORTVit"W (2� � , C Ff A?IihM f� Q 2(o S
OWNERNAME: AK �Y /� • ANA�y , oYr'Y'H F' ('AHA�y
CORPORATIONNAME IFAPPLICABLE): C�1YS Er� 1�=KP �Sk"� I-1-C
MANAGER'SNAME: �^'��'I1�- CAHA�y esr'Pti F CAHA�YTEL.#: SUS'r-tf32-87�s
MAILINGADDRESS: rIS ORrV�t�n/ Di SO. CNATHAM� MA fJ �(��5
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, standazd First Aid
and Community Cardiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of
employee certifications to this form. The Health Department will not use past years' records. You mast
provide new copies and maintain a file at your place of business.
L 2.
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 at[ach copies ofcertification 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.
i. (�I�r�ey /�. C�RHA�y 2. �asEPN � l�1NA�y
HEIMLICH CERTIFICATIONS:
All food service establishments with 25 seats or more must have at least one employee trained in the Heim:ich
Maneuver on the premises at a11 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. I
You must provide new copies and maintain a �le at your place of business.
1. 2.
3. 4. �
RESTAi1RANT SEATING: TOTAL#
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT# L[CENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �
�
_B&B $55 CABIN $55 MOTEL $55
_INN $55 _CAMP $55 _SWIMMING POOL $80ea.
_LODGE $55 _1RAILERPARK $105 _WH[RLPOOL $80ea
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# I
�0.�100 SEATS $85 �[j� _CONTINENTAL $35 _NON-PROFIT $30 i
>100 SEATS $160 �COMMON VIC. $60 .�l�I�� _WHOLESALE $80 I
RETAIL SERVICE: —RESID.KITCHEN $80 '
LICENSE REQUIRED FEE PERMIT H LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_<50 sq.ft. $50 >25,000 sq.ft. $225 _VENDING-FOOD $25 �
Q5,000 sq.ft. �80 _FROZEN DESSERT $40 _TOBACCO $95
NAME CHANGE: $15 AMOUNT DUE _ $ _�76, OO
*"***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 5TATE WORKER'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR
CERT. OF INSURANCE ATTACHED /
OR j
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED r
Town of Yarmouth taces and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK i�
APPROPRIATELY IF PAID: '
YES NO
MOTELS AND OTHER LODGING ESTABLISHMENTS
TRANSIENT OCCUPANCY: For purposes ofthe limitations of Motel or Hotel use,Transient occupancy shall be
limited to the temporary and short term occupancy,ardinarily 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 ofnot 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 ar
dwz:liug unit shatl nat be consic�ered transient. Occupai��y that is subject to fhe cullection of Ro�m 8c�upanoy
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 De�artment to schedule the inspection tlu�ee(3)days
pnor to opening.PLEASE NOTE: People aze NOT allowed to sit m 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
closing.
FOOD SERVICE
SEASONAL FOOD SERVICE OPEPTING:
All food service establishments must be inspected by the Health Department prior to opening. Please contact the
Health Departtnent 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
obtazned 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 Yermit 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 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 QUIRE A SITE PLAN.
DATE: !'f'I� (�'J SIGNATURE:� Q L,�-�^1'c-cv �0'�6d^ � la,��
PRINT NAME & TITLE: 1��ncy � C^NA�.� �ose�N (= CA N A Ly
Rev.10/09/12 Q W ���i2 S -f� (ti1AMA 6 ET2 S
_ �—�
Apr. 1. 2U13 2: 21PM Nu. 5111 P. 2
� � The Commonwealth oJMassachusetts - . ���
Department ojlndustrial Accidents
� O�ce ojlnvestigations �PR Q 1 2013 €�
' 1 Congress Street, Suite I00
Boston,MA 02114-20U - _ �_
r _ _
_, _
www.mass.govldda
Workers' Compensafion Insurance Affidavit: General Businesses
A�plicantInformation C�f�NT�/�/°R,C(E.f LLG PleasePrintLeeiblv
Business/Organization N�A I�Lori'� i E', _c t l..(�r A/�'I
Addtess: f 2� �ourt o2� S s . yrq2Mou; la, 1 ' �� 02�b �f
City/State/Zip: Phone#:
Are you an employerl CLeck the appropriate box: Business Type(required):
1.[l�I am a�mployer with �3-� employees(full and/ 5. ❑Retail
r part-bm�.• 6. �estaurantBar/Eating Establishmen[
2.❑ I am a sole proprietor or parhiership and have no 7, �Office and/ar Sales(incl.real estate,auto,etc.)
employees working for me in any capaciry.
[No wockers'comp. insurance required] $• ❑Non-pm6t
3.❑ We aze a corporntion and its officers have exercised 9. ❑Entertainment
their right of exempiion per c. 152, §i(4),and we have I0.❑Manufacturing
, no employees. [No workers'comp.insurance required]�
4.❑ We aze a non-profit organization,staffed by volunteers, 11.❑Health Care
with no employees. [No workecs' comp.msurance req:] 12.0 Other
*My applicant that chccks box M I mustal5a fill out ihe sectian helowshowing[heu wo[kers'compensetian policy iofmmalion.
"IE�he corparate officers have a�empMA thcroselvcc,hut�he coryoration has otheremployees,a.wrkers'compensation policy is required and such an
organiiatioo should check boa#I.
I am an emp(oyer that is providrng workers'compensation rnsurnncejar my em�layees. Be(ow is the po7icy inja�maHon.
]nsuranceCompanyName: 7�Al�ELER,T IN.d�i�h�virj �'o�i9�.vy oF�4ihE.e•CA
Insurer's Address:�O 'l�'�j�D ���6� Di2L,I'1N�0. �L ,,,���O.2
CitylStatelZip: � � / r
Policy#or Self-ins.Lic.# l'�O .�E /.,�.1 vf� E�riration Date:7 � .� '��/
Attach a copy of the workers'compensation policy declaration page(showing the policy uumber and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposiHon of criminal penalues 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�d a 6ne
ofup to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwazded to the Office of
Investigatioos of the DIA for iosurance covenge verification.
I do he certrfy,under fhfepoins�nnd a/Nes ojpe ju rhat th¢injo�ma[ian provided abov¢is true and correcl.
Si anv�✓lit,�k-�-Gf.i/�� �L4�4, Date �'I� ��3 �
Phone#:
OJficral use only. Do no��v�iie in lhis a�ea,to be comple�ed by ciry ar toivn o�cirtl
City or Town: YkfiQ/Yl6t}� Permit/License#
m u ' (cirde one):
1.Board of Hea 2. Building Department 3. City(I'own Clerk 4.Licensiog Saard 5.Selectmen's Oftice
Contac[Person: Phone H: �8-;3q,f1—��3/X/Zy�
www.maes.gov/dia
�o r. 1. 2013 2: 21 PM No. 5111 P. 3
' NOTICE OF ASSIGNMENT
EMPLOYER: COMBOI.O. STATUSOFEMPLOYER
CNJ ENTBRPRISHS LLC 000974�67 Limited Liability Com
75 PORT VIEW RD
S CHATHAM, MA 02659 COVERAGEGROUP
1026894
Coverage under this assignment
The Waiver of Our Right to applies to Massachusetts
Recover Prom Others Sndorsement operations only. Por coverage
is available on Pool policies. outside of Massachusetts, contact
Contact your agent Eor details. the appropriate Pool or Plan for �
that state. �
INSURANCECOMPANY:
AGENT AOGERS & GRAY INSURANCS AGENCY INC TRAVELERS INDEMNITY CO OF AMERICA
OR DAVID RUST Jona[han Scharnberg
i PRODUCER: RTE 134 � p p BOX 3556
I SOUTH DENNIS, MA 02660 ORLANDO, FL 32802-3556
(800) 443-4409
AGENCY FEIN:
CLASSIFICATZON OF OPERATION CLA55 ESTIMATSD RATS ESTIMATED
CODE TOTAL ANNUAL PREMIUM
� REMUNERATION
'_______'____________________________'___'__ ____' """"_"'_' "_"""' ______'___
RESTAURANT NOC 9079 $15,000 1.07 $161
EMPLOYERS LIABILITY 500/500/SOD � 9807 $50
STANDARD PREMIUM $211
LOSS CONSTANT 0032 $20
EXPENSE CONSTANT 0900 $250
TERRORISM CHARGE 9740 $5
TOTAL POLICY MINIMUM PRSMIUM $266
TOTAL ESTIMATED PREMI[R� $486
DIA ASSESS. 4.20 $7
TOTAL EST. PREMIUM PLUS ASSESSMENT $493 '�.
INSTALLMENTBASIS: Annual oEPO517PREMIUM: $493 �.
T HIS IS NOT A BILL �
COMMENTS
Coverage effective 12:01 AM on 04/02/13.
DATEOFNO7ICE: 04/Ol/13 PREPAREDBY: � Evelyn Cobb � � �
EXT 522
• i SBRVZCINa CARRISR ASSI6NDSBNT • + �
LETTERIO: 3997331 -
The Workers'Compensation Rating and Inspaction Bureau of Massachusetts
101 Arch Streel•Boston, MA 02110
(617)439-9030 •FAX(617)439-6055 •www.wcribma.org
Apr. L 2U13 2: 21PM No, 5111 P. 1
�° ROGERS a: GRAY
� I N S U R A N C E
David D. Rust
Client Manager, Business Insurance
434 Route 1�
South Dennis, MA 02660
506-760-4608 - Direct Phone
877-816-2156 -Fax
800-553-1801 - Office Phone
drust@rogersgray.com
I Date: 4/i/13
To: Town of Yarmouth
Health Dept.
FAX#: 506-760-3472
RE: Workers' Comp Affidavit
Number of pages including the rnver sheet: 3
-------------------------------------------------------------------------------------------
Please find the a�davit and evidence of insurance with this cover sheet.
THLS IvIGSSAGL IS QJTfwYDGD ONLY FOR iHL•USE OF iHE WDIVIDUAL OR ENT15Y TO WHICfi!T IS ADDRESSGD AND MAY
CON7'AIN INFORMATiON 77L\T IS PRIVILEGED,CONFIUENTIAI.OR EXEMP7'FROM llISCLOSURE UNDER e1PpL[CABLE Le1W.
IF T}IE ltEADER OF 7HIS MESSAGE I$NO'C T}IE INiENDED RECIPIEM,OR iHE ENIPLOYEE OR AGEMT RESPONSIBLE FOR
. DELIVERING TF� MESSAGE TO THE AlTEND&D RECIPIENT, YOU ARE E3EREBY NOTIPIED TFW'f ANY D]SSEh1INA710N, - �
�DISTRiBUTION OR COPYING OF THIS COMIvIDNICA770N IS STRIC7T,Y PROH�TTED. � YOU HAVE RECEIVED THIS �
WARv1UiVICA710NQJERROR,PLEe1SENOi1FYU51MA4EDLITELYBYTELEPHONE,.WDDESTROYTHI$DOCUMENT. THANK
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