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Home My WebLink AboutApplication and WC � � TOWN OF YARMOUTH BOARD OF HEALTH . Ttf� ESQRPE (NN Y �� APPLICATION FOR L��iSTti1PERMIT- 13 W��d tiV C�D 1P 'a... . � * Please complete form and attach all necessary e ' y ec�e 2. Failure to do so will result i�e refiurtrbf�$ �plica o�packei. Fi�Ai�T Ff �7�F"1. ESTABLISIIMENT NAME: T��, �SCc(JC�S, �n h TAX ID: �� -� / � LOCATION ADDRESS: 1�'r o�.J' �o`( � TEL.#: Sa��l9Y-7/S� I MAILING ADDRES :�� 0 O S o o �r�o p GG OWNER NAME: � '� , CORPORATION NAM�IF AP LICABLE : Inoo 00 .—,y. � MANAGER'S NAME: � 4 e � TEL.#:Sa ' - '7/S3 � MAILING ADDRESS: � a d o � a G POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the desi�nated Pool perator(s) and attach a copy of the certification to this form. 1 --- ?. - -- �Q.�4.4�' ��'�-�`1`-��-r--- —�. Pool operators must list a minimum of two employees currently certified in basic water safety, standard 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 must provide new copies and maintain a file at your place of business. 1. 1 �� c,�.ae \ �ar��-T-'�� 2.�d� \��4c�e..\� � 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is ceri;fied 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 Deparhnent will not use past years'records. ; You must provide new copies and maintain a Cle at your establishment. i I 1. 2. j i PERSON IN CHARGE: Each food establishment must have at least one Person In Chazge (PIC)on site during hours of operation. i -- -=---- - _ _ _ - - - --__ . _- � , 1.___ . --=--_ - - - -- �. HEIMLICH CERTIFICATIONS. I All food service establishments with 25 seats or more must have at least one employee trained in the Heunlich Maneuver on the premises at a11 times. Please list your employees trained in an6-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. L 2. 3. 4. I RESTAURANT SEATING: TOTAL# ' OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&B $55 _CAB[N $55 �MOTEL $55 _INN $55 _CAMP $55 �SWIMMING POOL S80ea. I _LODGE $55 _TRAILERPARK $]OS WHIRLPOOL $80ea. � FOOD SERVICE: -- --� LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LtCENSE REQUIRED FEE PERMIT# _0-100 SEATS $85 �CONTINENTAL $35 _NON-PROFIT $30 >100 SEATS $160 COMMON VIC. S60 WHOLESALE $80 RETAIL SERVICE: —RESID.KITCHEN $80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. . $50 � >25,000 sq.ft. $225 _VENDING-FOOD $25 _C15,000 sq.ft. $80 _FROZEN DESSERT $40 � _TOBACCO $95 NAMECHANGE: $15 AMOUNTDUE _ $ 1�70 .00 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***'* --...�.. ADMINISTRATION ` ' Under Chapter 152, Section 25C, Subsection 6,the Town of Yazmouth 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 1� 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 ofnot more than tl�irfy(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 Departsnent prior to opening. Contact the Health Department to schedule the inspection three(3)days prior 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 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. — •F��dD SERVICE i 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 norify the Yarmouth 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.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 I 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 prior approval from the Board of Health. OUTDOOR COOHING: Outdoor cooking,preparation,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 RESPONSIBILITl'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 MAY RE IRE I PL DATE: �oZ' �� SIGNATURE: ��/�Z�� PR1NT NAME & TITLE: � c, �Q c r e� � �(�� S� �`� Rev. 10/09/12 � � � � - � � I � �- � ` J � � � � � � � � - - a , - � �— . , . ` � The Commonwealth of Massachusetts Department of Industrial Accidents Office ofinvestigations 1 Congress Street,Suite 100 i Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses AnnGcant Information Please Print Leeiblv I Business/Organization Name: ��ob S�G \o��„�� j�� \��scc.�� h Address: �a2`,j �o cJ� 02� City/State/Zip: �d �ar w�oJs`1 1� oaGG�Phone#: J`^O S_- G��{ , 7�5� Are you an employer?C6eck the appropriate box: Business Type(required): 1. I am a employer with S employees(full and/ 5. ❑Retail ' _ �__ I or Pyi:t-tune)�- �cce So1�4 - -- . �J�estautanT7�az� sE Ya-6ltsTimeiit --- — - _ _ -�-- - - I 2.❑ I am a sole proprietor or pazMership 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. ❑ Entertainment �'i their right of exemption per c. 152, §1(4),and we have 10.0 Manufacturing no employees. [No workers' comp. insurance required]* 4.❑ We aze a non-profit organization,staffed by volunteers, �1.�Health Caze ` ( with no employees. [No workers' comp. insurance req.] 12.�Other �d�C-\ ��JC4S�n4, "Any applicant ffiat checks box#t must also 511 out the section below showing their workers'compensation policy information. ,� "•If the corpomte officers have exempted themselves,but the wrporafion has other employees,a workers'compensation policy is required and such an ,� organiration should check box#1. �', I am an employer that is providing workers'compensadon insurance for my e loyees. Below is the policy informnNon. Insurance Company Name: �, � Insurer's Address: � �f r '� �� U' � ' I CiTy/State/Zip: � �, � c S" �a f f� `� � Policy#or Self-ins.Lic.# \ t1 �� g76 � Expiration Date: 5'v2 �^ � ?J Attach a copy of the workers' compensatian policy declaration 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 penalties of a _ _finestRt9�1,509:4Qand/or one-�ceacimprisnnn,Pnr, as weJ��-s+s;�pr �t�-�she.f�n�s�a�"�9�'W-0R�49RB&R an�a�ne- _ ___ _ of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwazded to the Office of ' InvesrigaUons of the DIA for insurance coverage verificarion. ' I do hereb�der the ins a pen f perju hat the information provided above is true and coneM. I Sienature• Date• �a �� I /L i Phone#: �a � � � ! �I — 7 l�� '� Official use only. Da not write in this area,to be completed by city or town official City or Towu: yA$ll.��kF7d Permit/License# I circle one): 1.Board of Healt 2.Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office Contact Person: Phone#: - Q - ( �2 i� www.mass.gov/dia I �� Workers' Comoensation and Emolover's Liabilitv Policv NorGUARD Insurance Company - A Stock Company '��+�A�G+� Policy Number SHWC358162 ��■ ■� Renewal of NEW U NCCI No.[25844] Policy Information Page [1] Named Insured and Mailing Address Agency Shooshalo Inc COMPUPAY INS. SVCS., INC. 1237 Route 28 1601 Belvedere Road South Yarmouth, MA 02664 Suite 1055 West Palm Beach, FL 33406 Agency Code: FLAAOCIO Federal Employer's ID Insured is Corporation Additional Names of Insured (N2} The EscapeInn [2] Poliey Period . From May 22, 2012 to May 22, 2013, 12:01 AM, standard time at the insured's mailing address. [3] Coverage A. Workers' Compensation Insurance - Part One of this policy applies to the Workers' Compensation Law of the following states: Massachusetts B. Employer's Liability Insurence - Part Two of this policy appiies to work in each of the states listed in item [3]A. The limits of our liability under Part Two are: Bodily Injury by Accident- each accident $100,000 Bodily Injury by Disease - each employee $100,000 Bodily Injury by Disease - policy limit $500,000 C. Other States Insurance - Part Three of this policy applies to ail states, except any state listed in item [3jA. and the states of North Dakota, Ohio, Washington, and Wyoming. D. This policy includes these endorsements and schedules: See Extension of Information Page - Schedule of Forms [4] Premium The Premium Basis and, therefore, the premium will be detertnined by our Manual of Rules, Classiflcations, Rates, and Rating Plans. All required information is subject to verification and change by audit. (Continued on another page) Total Estimated Policy Premium � 568 Total Surchargas/AssesSments g 17 Total Estimated Cost s 5S5 lNTERNAL USE ws Page- 1 - Information Page MGA :SMWC356162 WC OOOOOlA Date :06/07(2012 MANOTE 16 South River Street• P.O. Box A-H•Wilkes-8arre, PA 18703-0020•www.guard.com f � � � � � � �GUARD INSURANCE ' GROUP � iwww.guard.00m DIRECT DRAFT NOTICE Workers' Compensation Insurance Premium Transactions as of OS/23/2013 i Shooshalo Inc Agent: 800-807-0598 1237 Rouie 28 COMPUPAY INS. SVCS., 2NC. South Yarmouth, MA 02664 1401 Forum Way Suite 500 West Palm Beach, FL 33401 Statement Date: OS/23/2013 Policy Number: SHWC470869 Carrier. NorGUARD Insurance Company Policy Period; O5/22/2013-OS/22/2014 Chargeable Wages for Check Date OS/23/2013 $ 199.38 Total Chargeable Wages $ 199.38 Current Amount Due-OS/29/2013 ; g,gg Your bank account will be debited on the date(s) shown above for the wrresponding amourrt(s) due. Pleas�do not send payment. If your bank account has changed, contact us immediately. We hope you are enjoyi�g the benefits of this simple, easy method of making payment. *if your direct draft due date fails on a weekend or troliday, your payment will be drdfl:ed on the neM business day in which both your bank and GUARD are open; this delay will not have any ne.yative effect on your acmuM's standing. Feel free to direct any questio�you migbt nave to our Customer Service Representatives at i-800-673-2465, extension 1300, or e-maii csrQ�guard.com. 'GUARD INSURANCE GROUP 5hooshaloInc 12g7 Route 28 �n�.��u��q'��m�u�u��.�u��m��u�.a��n�m�� Sou[h Yarmouth, MA 02664 GUARD Insurance Group PO BOX 62479 Policy Number: SHWC470869 BALTIMORE MD 21264-2479