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Home My WebLink AboutApplication and WC . �.-= ?�r�,�b , �e� TOWN OF YARMOUTH BOARD OF HEALTH ` - � , APPLICATION FOR LICENSE/PERMIT - DEC 1 3 ZO1Z � * Please complete form and attach all necessdry;dcSc en �� ' b p7 Failure to do so will result in the rehun of yourapp�ic�H . ESTABLISHMENT NAME: G/dne L�� 's,ri--nc-�'v� LL� TAX ID: �� LOCATION ADDRESS: � c � TEL.#: - cr) MAILING ADDRESS: �r �. � � OWNERNAME: �� +�.9-v;? CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: TEL.#: MAILING ADDRESS: POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Poe? Operator(sl and attach a copy of the certification te this form. _ . 1. 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cazdiopulmonary 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 must provide new copies and maintain a file at your 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. ��/� �/�-viS 2. �P�Ct C fM ��-r�t.�G�� I'ERSaP IN�HAt2GE: ----- --- - - —_ — _ - Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. ��i9-�^S 2. �U-. �Uv��ti/ 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' 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 LODG[NG: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERM[T# _B&B $55 � _CABIN $55 _MOTEL $55 _INN $55 _CAMP $55 _SWIMMING POOL $80ea ' _LODGE $55 _TRAILER PARK $105 WHIRLPOOL $80ea FOOD SERVICE: LICENSE REQUIRED FEE PF.RMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 10-100 SEATS $85 �J � 7 _CONTINENTAL $35 _NON-PROFIT $30 >I00 SEATS $160 _ I COMMON VIC. $60 �O� _WHOLESALE $80 RETAIL SERVICE: —RESID.KITCHEN $80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# [,ICENSE REQUiRED FEE PERMIT# _<50 sq.ft. $50 � >25,000 sq.ft. $225 _VENDING-FOOD $25 <25,000 sq.ft. $80 L FROZEN DESSERT $40 kl"►.3�00� _TOBACCO $95 — � NAMECHANGE: $15 AMOUNTDUE _ $ 185.00 *****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 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 • NO ' MOTEL6 AND OT�IER LODGING ESTABI;ISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be , limited to the temporary and short term occupancy,ordinazily 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 j elsewhere.Transient occupancy shall generally refer to continuous occupancy ofnot 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 OPEPIING: All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department priar to opening. Contact the Health Department to schedule the inspection three(3)days prior to opening.PLEASE NOTE: People are NOT allowed to srt 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 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: ' Ail 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 ', requued 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 revocahon of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: ' Qutside cafes(i.e.,outdoor-seating-iarith�aiYerlvuaitress-seruice),must have prior apprav�l from L�$oard o€HealEh. 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 RESPONSIBILIT'1'TO RETURN II 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: j�'i',�i l'a— SIGNATURE: �jL,� �,� ��,,,,r PR1NT NAME & TITLE:�/�/}� rii • 6 �S ' �L.in er Rev.10/09/12 , . . � The Commonwealth ofMassachusetts Department of Industrial Accidents Off:ce of Investigations 1 Congress Street, Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Leeiblv Business/Organization Name:��e �o,•L �r�-,�,�n*�"y, , Address: ,� �J,�e �ti�e✓��.r. IL�• City/State/Zip: _ ,t., �, �+'/c� 0 Phone#: S'� 9 - 3� �'�f�0� Are you an employer?Check ffie apprapriate box: - �- . -Basiness-Ty{�e(required): � - 1.❑ I am a employer with employees(full and/ 5. ❑ Retail or part-time).* 6. ❑ RestaurantBaz/Eating Establishment 2.❑ I am a sole proprietor or parinership 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 corporarion 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 aze 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[he section below showing the¢workers'compensation policy informa[ion. '*If[he corporn[e officers have exempted[hemselves,but the coryoration has other employees,a workers'compensation policy is required and such an organi¢a[ion should check box Nl. . I am an employer that is providing workers'compensaKon insurance for my employees. Below is the policy informaHon. Insurance Company Name: Insurer's Address: City/State/Zip: _ Folioy#or�effins.Lic.#- - - -- - -- ------ —-- —��ion tSate: — - _ _ -- - __ Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secwe coverage as required under Secrion 25A of MGL c. 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 statemern may be forwazded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cer[ify under the pains and penalties of perjury that the injormaBon provided above is true and conect. Si�nature: /�� 2� �GI.�� Date• l/' S ' �! '�_ Phone#: S� �! ' 7 �tU ' S�O� OJficial use on[y. Do not write in this area,to be completed by city or town oJJ"aciaL City or Towa: �A{C/YLOy`r� Permit/License# I circle one): Board of Hea .Building Department 3. CiTy/Town Clerk 4.Licensing Board 5. Selectmen's Office 6.Other Contact Persan: Phone#: �08-��8-o"Za'-3� k�Z�� - ' � � www.mass.gOv/dia - � � ' • Gient#:46785 CCCRE ACORD,� CERTIFICATE OF LIABILITY INSURANCE DATE�MMIDDM'YY) 11/02@012 � THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATIQN ONLY AND CONFERS NO RIGHTS UPON TME CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATNELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURRNCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED . REPRESENTATIVE OR PRODUCER,ANp THE CERTIFICATE HOLDER. �� IMPORTANT:If the certifiwte holder is an ADDI710NAL INSURED,the policy(ies)must be endo�sed.If SUBROGATION IS W/UVED,subject to the terms and eondkions of the Dolicy,certain pollcies may require an endorsement.A statemenl on fhis certificate dces not confer rights to the certfFlwte holder in lieu of sueh endorsement(s). � rnooucEa N E, Patricia Tome � Rogers&Gray Ins. Kingston PXONE ac No�c:508-7463311 ac.No: 877$162156 63 Smiths Lane E-R�Ess: Ptome�rogersgray.com Kingston,MA 02364�3700 INSURER�S�AFFORDINGCpVERAGE NAICY 508 746-0055 ir+sunean:CNA/Continental Casualty Compan � msuaeo � iNs�RERe:National Fire Insurance Co.of Cape Cod Creamery,LLC �NSURER�: 5 Theater Colony Way INSURERD: South Yarmouth,MA 02664 � � INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICV PERIUD INDICATED. NON/1THSTANDING ANY'REQUIP.EMENT, iERM OR CONDITIONOF ANV CONTR4CTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS � CERTIFICATE MAV QE ISSUED OR MAV PERTAIN, THE INSURANGE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT Tp ALl THE TERMS, EXCLUSIONS AND CONOITIONS OF SUCH POLICIES. LIMITS SHOWN MAV HAVE BEEN REDUCED BV PAID CLAIMS. µR TYPE OF INSURANCE D BR POLICY Fi LICY E IN POLIGY NUMBER MMIDU/YYYY MMIDD/riYY LINITS A GENERALLIABaRY BZO�I�'I�3H22 S/O�IZO��L O$IO�IZO� EACHOCGURRENCE $'I OOOOOO X COMMER�IALGENERALlIA81lRY DAMAGET RENTED PREMISES Ea occ rtenm $3OO OOO CLAIM$-MqOE �OCCUR MEDE%P(Myoneperson) $�OOOO PERSqW1L8A0VINJURV $�,000,000 GENERALAGGREGATE $Z�OOO�OOO IGEN'LAG�REGATELIMITAPPLIESPER: PftODUCTS-COMP/OPAtiG $Y�OOO�OGO POLICV PEa lOC $ $ �AUTONO&LELIABILITY 2095490286 �0��'j0�'10�0��'j0� COMBINEDSINGLELIMIT � Eea�aeML 1,000,060 ANVAUTO BODIIVINJURY(Perparson) $ ' ALLOWNED SCNEDU�ED � AUTOS X AUTOS � I BODILVINJURY(Pareccitlenl) $ X HIREDAUTpS X NON-0WNEO PROPERTVDAMAGE $ AUTOS Per acddent $ B °"�"�"^'�� occuR B2097307367 5/01/2012 OS/01/201 EACHOCCURRENCE a10 0000 IXCESSLIAB p�qIMS-MADE AGGREGATE $� OOOOOO � DED X RETENTI N$�OOOO $ A WORKERSGOMPENSATION � WC277773879 Q§/0�/QQ�Q Q�Q��QQ� X WCSTATLL �'��' . AND EMPLOYERS'LIABILttY ANV PROPRIETORIPARTNER/EXECUTNE y�N E.L EAf.H ACpDENT $SOO OOO OFFICERIMEMBEREXCLUDED4 � N/A IfyestlEes�'nbe�nder I E.L.DISEASE-EAEMP�OYEE $SOOOOO DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICV LIMIT ,$SOO�OOO DESCRIPTION OF OPERAiiONS/LOGATIONS/VEXICLES(AMaeh ACORD 101,Atltli4onal RamarFs$chedula,H mae epaea is roquinE) CcRTIFI ATE HOLDER - CANCElLAT70N Town of Yarmouth,Health Dept ;iMOULD ANV OF THE ABOVE OESCRIBED POLICIES BE CANCELLED BEFORE THE E7(PIRATION DATE THEREOF, NOTICE WILL BE DELNEREO IN ' 1146 Main Street�ROUtC 28 ACCORDANCE WRH THE POIICY PRO��SIONS. South Yarmouth,MA 02664 AUTHpRREDREPRESENTATIVE �198 •2070 ACORD CORPORATION.All rights reserved. ACORD 25(2010105) � pf� The ACORD name and logo are registered marks of ACORD � #S89668/M80631 SJP -