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Home My WebLink AboutApplication and WC � i� ��= , . �-<.,�.. . -,.��.�., . � TOWN OF YARMOUTH BOARD OF HEALTH �d��^' �� APPLICATION FOR LIG�Iu$E �4 �-�� I 3 L013 � * Please complete form and attach all nece _, d 'ts y ece er 13 2013. Failure to do so will result in th�re�.tj,f'yqurs`�p�I�a n ESTABLISHMENT NAME: — � TAX • - LOCATION ADDRESS: o � a TEL.#: O -4 - 7 - MAILING ADDRESS: O o 1L C> g o a c W�o v+ E-MAILADDRESS: N V P1�`2�,�TTT �Q 4 r�4 , � � eo� OWNER NAME: C1 : c Iw�e,l 'T'a c�r c_�-�� CORPORATION NAME (IF AP ICABLE): S �nm a a�.a �� '�C MANAGER'S NAME: I`'l: a e.� --P� r�'�-�`, „ TEL.#; 5oQ'34'7- ��;Z MAILING ADDRESS: `�� o Y ��'� o� a t o m� G� POOL CERTIFICATIONS: The pool supervisor must be ceM�ed as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to tlus form. i. ��c��e,� �� c ce�'F'��, z. Pool operators must list a minunum 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 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 £ile at your place of bus�ness. 1. �: c.�,.n�� C�-�, z. {`� �l l� `�4 �r �•, 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one fixil-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 Charge (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 application. The Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment. 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 fimes. Please list your employees trained in anfi-chokuig procedures below and attach copies of employee certifica6ons to this form. The Health Department will not use past years' records. You must provide new copies and maintain a�le at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY � LODGING: LICENSE REQUIRED FEE . PERMIT# LICENSE REQUIRED FEE PERMIT N LICENSE REQUIRED FEE PERMTT# . B&B $55 CABIN $55 I MOTEL $55 / -03 INN $55 CAMP $55 �SWIMMINGPOOL $80ea 0 LODGE $55 —TRAILERPARK $]OS WHIRLPOOL $80ea FOOD SERV[CE: � LICENSE REQUIRED FEE PERMITl� LICENSE REQUIRED FEE P RryIIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $85 LCONTINENTAL $35 �l`F—/�J,4 NON-PROFIT $30 >I00 SEATS $160 COMMON VIC. $60 WHOLESALE $80 — —RESID.KITCHEN S80 RETAIL SERVICE: � LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIILED FEE PERMIT# . , <50 sq.ft. $50 >25,000 sq.ft. $225 VENDING-FOOD $25 � � =<25,000 sq.ft. $80 �ROZEN DESSERT $40 _TOBACCO $95 NAME CHANGE: $15 AMOLTNT DUE _ $ I�J G.CJO � ••***PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM**"** _. .f_ . .. ... . L.�_ �; � • } ADMINISTRATION Under Chapter 152, $ection 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renew�al 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 MIJST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED � � I 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 OTHER LODGING ESTABLISHMENTS — _-- — ---- -� _ ___ _ - -- - --- - _ _ - --- _— 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 thirly(30)days,and an aggregate of j . 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 �I 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 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 i opened. I POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a II 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. �- _---- - — FODD�RVICE _ _ __-- ---- — -- -- 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: I Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Departrnent by filing the required i Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health Deparhnent, or from the Town's website at www.varmouth.ma.us under Health Department, Downloadable i Forms. FROZEN DESSERTS: Frozen desserts must be tested by a State certified lab prior to opening and monthly thereafter, with sample results subxnitted to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Pernut 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 COOKING: 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 13, 2013. 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. RE OVATIONS MAY REQUI SITE LA� DATE: 1 ! SIGNATURE: PRINT NAME"&TITLE: ` � P � r � P Rev. 10/OS/13 . �. .-^+r.�>.. �� :' i � The Commonwealth ofMassachusetts Department ojlndustrial Accidents O,ffice ofinvestdgations 1 Congress Street,Suite I00 Boston, MA 02I14-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Apnlicant Information Please Print Le¢iblv Business/Organization Name: ��no g�q�c�c��,. �jc��e � SC ��h Address: (a.� 7� ov�� f �"�o � � oo� (�� City/State/Zip: Phone#: �'a�- �� y - 7/S� Are you an employer?Check the appropriate box: Business Type(required): 1.� I am a employer with ��"s employees(full and/ 5. ❑ Retail or part-time).* �� 6. ❑ RestauranUBar/Eating Establish.men: 2.❑ I am a sole proprietor or partnership 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 corporation and its officers have exercised 9. ❑ Entertauunent their right of exemption per c. 152, §1(4),and we have 10.❑ Manufacturing no employees. [No workers' comp.insurance required]* I i.� 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 5ll out the section below showing their workers'compeusation policy information. ••If the corpornte officers have exempted themselves,but the cortwration has other employees,a woiicers'compensadon policy is required aad such an organizaflon�shouldcheckbox#1. - � �� - � � I am an employer that is provt ing workers'compen�hbn insurance for my em loyees. Below is the po[icy infor�. Insurance Company Name:�.-, � , o ,,,�� „� �� r c.,�,t ,ro v(�_�(�m a., (J u Ll ✓ � a r��C� c.� 1 1 / Insurer's Address: I I G � �0 1-u w� � a S/ � , �� oG� i City/State/Zip: y ,�, � �j `� �Q ! Policy#or Self-ins.Lic.# � �'E-LJ �' �� Q Expiration Date: � a / Attach a copy of the workers' compensation poGcy declaration page(showing the policy number and e iration date). , Failure ta�eoverage asreqt�ired under Section 25?;o€MFiLc:I S2 eax lead to the imgosition of eriminal per;alties 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 Invesfigations of the DIA for insurance covemge verification. ' I do hereby cert�,u er the pa'ns and ena ' erjury t t information provided above is ue and c rrect. ! Signature• Date �� 5j I Phone#: S�D � 7 '/� 7 -�o� � eC I Officda[use only. Do not write in this area,to be completed by city or town officiaL II City or Town: yp�2Mp�1fZf- Permit/License# � Iss � ' le one): .Board of Health . ildiug Department 3. City/Town Clerk 4.Licensing Board 5.Selectmen's Office 6. ContactPerson: Phone#: Sa8-�i9Y,'- / Xl2Y� www.mass.gov/dia , � ' GUARD INSURANCE ' GROUP ' www.gusrtl.00m DIRECT DRAFT WOTICE Workers' Compensation Insurance Premium 7ransactions as of 05J23/2013 Shooshalo Inc Agent: 800-807-0598 1237 Route 28 COMa1PAY INS. SV6., INC. South Yarmouth, MA 02664 1401 Forum Way Suite 500 West Palm Beach, FL 334�3 StatemeM Date: OS/23/2013 Policy Number: SHWC470869 Carrier: No�UARD Inwrance Company Policy Period: OS/22/2013-OS/ZZ/2014 Chargeable Wag�for Cheek Date OS/23/20i3 # 19938 Total Charg�ble Wag� $ 199.38 CurroM Amount Due-OS/29/2013 $- 5.88 Your bank account will be debited on the date(s)shown above for the mrresponding amourrt(s) due. Pleassip do�wt sand �Syment. If your bank a000uM has changed, contact us immediatety. We hope you are enjoying the benefits of tl�is simpie, easy method of making payment. 'If your direct draR dce date falls on a weekend or hol'�day, your payment wlll be drafted on the nex[business day in � � which both your bank and GUARD are open; th�delay will not have arry negative effeU on your aaourn's spnding. �. Feei free to direct any questions you might have to our Customer Service RepreseMatives at 1-800-673-2465, exte�ion 1300, or e-mail csr�guard.com. i GUARD INSURANCE GROUP i ShooshaloInc � 1237 Route 28 fnld��JL�'dJL.�1.�1.�61.I.J1.��iI.I�d�.�IL6d..�ll South Yarmouth, MA 02664 GUARD Insurance Group PO BOX 62479 Poliq Number: SHWC470869 BALTIMORE MD 21264-2479