HomeMy WebLinkAboutApplication and WC . • CAP� Cep S�PC-2 �;,'FF�'(
a � TOWN OF YARMOUTH BOARD OF HEALTH
�� APPLICATION FOR LICENSE/PERMIT-20 4_
` * Please complete form and attach all neces�ai'� �6 ece�'f�e�r� 2��. .
Failure to do so will result in the retiirrF y ` .�pplic ' n packet.
� - HEALTH D�P7
ESTABLISHMENT NAME:
LOCATION ADDRESS: {�D � TEL.#: 0 � — //D
MAILING ADDRESS:
E-MAIL ADDRESS: E�e o�r1�.Con'�
OWNER NAME:
CORPORATION NAME (IF APPLICABLE): S P�' I�I //1 C
MANAGER'SNAME: ' EL.#: � —�7 � z �o
MAILING ADDRESS: n !�1-
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 certifcation to this form.
1. 2.
Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and
Community Cardiopulmonary Resuscitation(CPR),having one certified employee on premises at all dmes. Please list
the employees below and attach copies of their certifications to this form. The Health Deparhnent will not use past
years' records. You must provide new copies and maintain a fde at your place of business.
1. 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 attach
copies of certification to this application. The Health Department will not use past years' rewrds. You must
provide new copies and maintain a tile 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 opera6on.
1. 2.
ALLERGEN CERTIFICATIONS:
All food service establishments aze 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 applicaUon. The Health Department will not use past years' records. You must provide new
copies and maintain a file at your establishment.
l. 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 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. You must
provide new copies and maintain a £ile 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 $80ea
LODGE $55 TRAILER PARK $105 WHIRLPOOL $80ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
0-100 SEATS $85 _CONTINENTAL $35 NON-PROF[T $30
L>100 SEATS $t60 � 1 COMMON VIC. $60 - �}._p_.L, WHOLESALE $80
—RESID.KITCHEN $80
RETAIL SERVICE:
LICENSE REQUIRED FEE PERMIT# L[CENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMtT#
<50 sq.ft. $50 >25,000 sq.ft. $225 VENDING-FOOD $25
=<25,000 sq.ft. $80 _FROZEN DESSERT $40 _TOBACCO $95
NAME CHANGE: $15 AMOUNT DUE _ $ 2z-O�OO
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*•***
r
. a ��
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 INSiTRANCE 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
�
------------- --- _ MOTELS.AND DTHER LQDGIN� �STABI�I�HMENTS .__ --
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 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 j
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. f
POOLS i
i
POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected by i
the Health Department prior to opening. Contact the Health Department to schedule the inspection three (3) days I
prior to opening.PLEASE NOTE:People aze NOT allowed to sit in the pool area until the pool has been inspected and
opened. I
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. I
�
POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven (7) days of
closing.
___ __ _--- __ _ -------- - - --- - - - - -- _ _ _ _
I
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 Yazrnouth must notify the Yannouth 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.yarmouth.ma.us under Heakh Department, Downloadable '
Forms.
FROZEN DESSERTS:
Frozen desserts must be tested by a State certified lab prior to opening and monthly thereafter, with sample results j
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 priar approval from the Board of Health.
i
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 3 L IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 13, 2013.
ALL RENOVAT'IONS 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 f
COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. �
DATE: 1�/2S�)'3 SIGNATURE: `���`2�l"�' Lti !
PRIIV`f NAME&TITLE: Ci^�i�}�IfCj �IA� L I MQc�GQP.r •,
Rev. 10/08/13 �
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� , � The Commonwealth ofMassachusetts
• Deparm:ent oflndustrialAccidents
Office oflnvestigations
' l Congress Street, Suite 100
Boston,MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
A licant Information Please Print Le 'bl
�' Business/Organization Name: � 41 �
Address: ZZ ��� �/ w�Sl. ��!lLD�-�� • �'l1 `� D 7j
CiTy/State/Zip: /n � � � 0�67 J Phone#: ��d�'TT�����U
Are you an employer? Check the appropriate box: Business Type(required):
i.❑ I am a empioyer witn employees(full and! 5. ❑ Retail
or part-time).* 6. ❑ RestauranUBaz/Eating Establishment
2.❑ I am a sole proprietor or partnership and have no �, � Office and/or Sales(incl.real estate,auto, etc.)
employees working for me in any capacity.
[No worke�' comp. insurance required] 8• ❑Non-profit
3.❑ We aze a corporation and iu 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.❑ Health Caze
4.❑ We aze a non-profit organization,9taffed by volunteers,
with no employees. [No workers' comp. insurance req.] 12.� Other
'Any applicant that checks box#1 must also fill out the secflon below showing the'v workers'compensation policy informatioa.
"If the corporate officers have exempted themselves,but the corporation has o[her employees,a workers'compensation policy is required and such an
� organiza6on should check box#I. - � � �
� I am an employer that is providing workers'compensation insutance for my employees. Below is the policy information.
Inswance Company Name:
Insurer's Address: 1 S� 'CN�� '�(i(�7. �
� City/State/Zip:
Policy#or Self-ins.Lic.# ExpiraUon Date:
Attach a copy of the workers' compensafion poGcy declara6on page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 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 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 forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby cenify,under the pains and penalties ofperjury that the information provided abo e is d e and correct
Si ature: LI��' �^"' L �- Date• /��// 3
Phone#: ' —Z
Ojficial use only. Do not write in this area,to be comp[eted by cify or town officiaL
I City or Town: Y A-�MOv'Ctt Permit/License#
rfumg�uttrerity ircle oue):
� . • of He . Building Department 3. City/Town Clerk 4.Licensing Board 5. Selectmen's Office
� 6. Other
ContactPerson: PhoneiF: 5b8 39g-3�31 X (2'�(
www.mass.gov/dia
i {
. WQRKERS GOMPENaATlON AND EMPLOYERS LIABILITY INSURANCE POL;CY
I(VFORMATION PAGE
A.t.M. Mutual Insurance Company
54 Third Avenue, Burlington, �Aassachusetts Q18Q3-0970
(S00}876-27fi5 NCCI NQ 25158
POLICY NO. ��AWC-400-701084S20t 3A:
PRlOR NO. �AWC70".0845012012
ITCRA
1. The Insured: Cape Co0 Super Buffet inc
DBA:
Mailing address: 228 Maln St FEIN;'=`•'
W Yasmouth, MA 02873
Legal Entky Type: Corporafior,
Other workplaces not shown above: Ses Location
2. The policy perlod Is from 12/06/2013 fo 52/06/2014 12:Ot a.m.standard time at the ins4rec!`s mailing address.
3. A, Woricers Campensetion insurance: Part flns of ths poficy applies to the Workers Compensation Law of the
stetes listed here: MA
B. Enpioyars'Liabii{ty lnsurance: PSR Two of the policy applies to work in each state hsted in ifem 3.A.
'fhe fimfts of liabiliiy under Psrt Two ar2: Bo�lly Injury by Accident $ 100,0�0 each accident
Bodily fnjury by Disease y 500,000 poliylimft
Bodily injury by Dis=ase $ 100,000 esoh empioyee
C. Other States Insurance: Coverage Repiacetl by Endorsement WC 24 03 06 A
D. This Poiicy indu�es thsse Endorsements arxi Schedules: SEE SCHEDULE
4• The premium for this poli wiif be determined by our Manuals of Rules,Glassifir,ations,Rates and iiatkng Plans.
All ir.formation requirad tiejow is subject to verifica6on and change by audit.
Classifications Premium Basis Rates �
---,
. � Code Es:imaHtl � PerO100 Estimated �
No. Tatal Annuel Mnuel
Remuneratlon I Remurreration Prem:vm
! INTA.4 42'+833 I � I I
I ' I I
INTER �
" CLP,SS CODE SCHEDU E I
� I
Minimum Premium $7,16
Tofal EstimatedAnnua! Premium $1,085
STA E OLqgg Deposit Premium $T t�3
�---�— �9 N�A Assessment Chg.
387 i.00 x 3.40ppy,
�28
T��Pa�y, inctuding al!endorsements, is hereby countersigned by ��
. AUM7aiL?tlSignflNre 'a�-�_
Service Offrce:
6 rtington MA Ofgp3 C T Financial Service Co
200 Lincoln Strest, Unit#OOf
Bostan,fNA o2t 11
�C00000� k p.ity
�tm�oar�iNelbn terter m tne Natlo�d pounetl on cp�A .
. Pa^wtlon Inawaoroe