HomeMy WebLinkAboutApplication and WC� �c.�s�r�c� : y�s S-�rncN ii�✓✓� �8 • . ��s�nE
" TOWN OF YARMOUTH BOARD OF HEALTH , – "
c� � APPLICATION FOR LICENSE/PER1�4Ffi,� � ,�y�D ��� 2 6 70�5
`� * Please com plete form and attach a11 necess a r y docum ,�tif� . eceivtb IS � _ 4; ��o r
Fai lure to do so wi l l resu l t in t he re t u rn o f yottr a�S p lica hon pac k . ---
ESTABLISHMENT NAME: 5 E EL 5 Grt PG– `v t w C ktb� Spi g �-tS TAX ID:
LOCATIONADDRESS: � 1 S'C�k"CIoU �UE So 1/4rarr�r11� TEL.#: �D�`S'��/Y'7�$Y
MAILING ADDRESS: �� S�C fF'i"1 ru O. Z.
E-MAIL ADDRESS: �o�� S�ikSC� P�� �B S '� �+.�
OWNER NAME: lZ-ot�I.c.'i� iMu R,� tt 7
CORPORATION NAME (IF APPLICABLE): S�hS�tP� � Y 1 L�o� S Z LG
MANAGER'S NAME: �� 1�Jv'�LG 2 TEL.#: SO�'6 4 `1'7�"�S Y
MAILING ADDRESS:� i k'Clbu ✓C (/4fiNou�h dUlr� 07� �
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.
; i. _ _ __ _ _ 2: _
� —
Pool operators must list a minimum of two employees currently certified in 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 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 co ies of certification to this a lication. The Health De artment will not use ast ears' records.
P PP P P Y
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 operation.
1. �
ALLERGEN CERTIFICATIONS:
All t'ood 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 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 #
_ _ ------
--- E�,{SE a:�� ___ ----
_ -- -- — –
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT H
_B&B $55 CABIN $55 MOTEL $110
_INN $55 CAMP $55 SWIMMING POOL$110ea.
_LODGE $55 _TRAILER PARK $105 WHIRLPOOL $I IOea.
FOOD SERVICE:
[,ICENSE REQUIRED FEE PERMIT# WCENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
0-]00 SEATS $125 _CONTINENTAL $35 NON-PROFIT $30
_>I00 SEATS $200 _COMMON VIC. $60 —WHOLESALE $80
RETAIL SERVICE:
—RESID.�KITCHEN $80
LICENSbq REQUIRED FEE PERMIT It LICENSE REQUIRED FEE PERMIT# UCENSE REQUIRED FEE PERMIT#
<25,OOOfts ft. $150 >25,000 sq.ft. $285 � VENDING-FOOD�$25
I 9� � � =FROZENDESSERT $40 �TOBACCO $I10 �—��
NAME CHANGE: $15 AMOUNT DUE _ $ 2�O. 00
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*****
N
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 Inswance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE
AFFIDAVTT 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 OTHER LODGING ESTABLISHMENTS
TRANSIENT OCCUPANCY: For purposes of the limitations ofMotel or Hotel use,Transient occupancy sha11 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 thirry(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 DeparGnent prior to opening. Contact the Health Department to schedule the inspection t6ree(3)
days prior to opening. PLEASE NOTE: People aze NOT allowed to sit in the pool area undl 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:
All food service estab}ishments 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
required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be
obtamed at the Health Department,or from the Town's website at www.yarmouth.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 tlie 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 Boazd of Health.
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 RESPONSIBILITY TO RETURN
THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 15, 2015. '
ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT, ETC.), MUST BE REPORTED TO AND PPROVED BY THE BOARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY Q RE SITE PL N.
DATE: I� ,2'���J� SIGNATURE:
PRINT NAME&TITLE: U•t..� f' �A�
Rev. 10/Ol/IS ' �
_ , � The Commonwealth ofMassachusetts
Department oflndustrialAccidents
Offzce oflnvestigations
' I Congress Street, Sui[e 1 DO
Boston,MA 02114-2017.
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Annlicant Information Please Print Le�iblv
Business/Organization Name: S ��sG�p� �U t xs i, �r �j�t�� y
Address: LIS 1 S'a"��"lo/!> LEtI� �. Ugrw(0�"("1�1 N'` /k D"Z 6 6 �(
City/State/Zip:_�� rwto�C�L Phone#: J a�"lp � r-( - ?J�� �(
Are you an employer? Check the appropriate box: Busin Type(required):
1.❑ I am a employer with�_employees(full and/ 5. [ Retail
or part-time).* _ _ 6. ❑ RestauranUBaz/Eating Establishment
� 2.0 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] $• ❑ Non-profit
3.❑ We aze a corporation and its officers have exercised 9. ❑ Entertainment
their right of exemption per c. 152, §1(4),and we have 10.Q Manufacturing
no empioyees. [No workers' comp. insurance required]*
4.❑ VJe aze a non-profit organizarion,stafFed by volunteers, 11.0 Health Caze
with no employees. [No workers' comp. insurance req.] 12.❑ Other
*Any applicant that checks box#I must atso 5ll oat the section below showing their workecs'compensatio¢policy informffiion.
� •*Lf the corporate officers have exempted themselves,but the cosporation has otha employees,a workecs'compensation policy is Iequ'ved md such an
orgauization should checkbox#1.
I am an employer that is providing workers'compensation insurance far my employees. Below is the poldcy information.
Insurance Company Nazne: � �c gC�l �Cc L IM.E2GtC.rt.v�S 49 G ��o� � s�
Insurer's Address: �� �x �SS�I Z�Z ' `l 22 Z
City/State/Zip: � (7�F(d/ ( �E� �I�. .� 6 7�1 Sl S
Policy#or Self-ins. Lic. # D l y DQ�D� Z,8 N'-� � I \ Expira6on Date: / � t ( � �
Attach a copy of the workers' compensation policy declaration page(showing the poticy number and eapiration date).
� _ Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposifion of criminal penal6es of a
— -- - -
fine up to $1,500.00 and/or one-year imprisonment,as well as civiI penalties in the fonri oT aST6P R�6RK 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
Investigations of the DIA for insurance coverage verification.
I do hereby ,under the pains and penalties of perjury that the information provided abave is true and correct.
SiQnature: �\I""`j� �"`� narP• li"� 17 �-` I � �
Phone#: �D� � ( y �-/ ` � ��f y
Official use anly. Do not write ix this area,to be comp[eted by city or town offtciaL
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2. Building Department 3. City/Town Clerk 4. Liceasing Board 5. Selectmen's Office
6. Other
Contact Person• Phone#•
www.mass.gov/dia
� .Nov 25. 2Q14 12:54FM Brigar Express Stns 518-438-0214
No. 4114 P. 1/1
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INFORMATION PAGE RENEWAI, AGR�T
Insurer: PRODUCER: Agent� 5960
MA Retail Me�chants fJC Group Inc. Association Benefits Insurance Age
PO Box 859222-92 �99 Ballardvale St, Suite 1
Braintr�c, M,q 185 Wilm3ngton, MA 01887
(carrier Cod 34355) Carrier Policy #: 014005032844115
Carrier Prio� Policy �: 014005032844114
1. Insured: Seascape Spirits, LLC
� Seascape Wine & Spirits '
� Mailing Address: 451 Station Ave.
South Yarmouth, MA 02664
Fein:
Other wrkplaces not shown above: Type of Business: Limited Liability Co
SEE SCF�DULE OF OPBRATIONS Risk ID:
2. The policy period is from 12:01 a.m. on 1/Ol/2015 to 12•:O1 a.m. on 1/O1/2016
at the insured's mailing address. ; . _ _- _ _ _
3. A. Workers Compensation Insurance: Part One of the policp, applies to the Workers
Compensation Law of the states listed here: '
MA
B• Employers Liability Insurance: Part �.ro of the policy gpplies to work in each
state listed in Item 3.A. The limits of our liabilitylunder Part 7tro are:
Bodily Injury by Accident $____100.000 Ieach acciden�
Bodily Injury by Disease $__ 500 000 _�! policy limit
Bodily Injury by Disease $____ 100,000 _',each employee
C. Other States Insurance:
D. This policy includes these endorsemeute and schedules: '
WCOOOOOOB(07/11) WC000308 WC000414(07/90) WC000422A(09/OS) WC200301(04/84)
WG200302(OS/86) WC200303B(07/99) WC200465{06/O1) WC200501(06/92)
4. The premium for this policq will be determined by our Manv�].s of Rules,
Classifications, Ratee and Rating Plans. All information �eqvired below is subject
to verification and cbange by audit.
__ ___ _ _ _ _ _ _----_ —
Classifications Code Premium Basis Rate Per Est3mated
No. Total Estimated $100 of [��1
Annual Remuneration !Remuneration Premium
SEE SCFIEDUIy OF OPIItATIONS
Total Est3mated Annual Premium $ 1,326_00 '
Minimum Premium $ 218.00 Expense Constant ,.00 Deposit Premium ,