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Home My WebLink About Application and WC, , _ ,. ��./,aeac�5v,�rs � . TOWN OF YARMOUTH BOARD OF HEAL �, iF�� APPLICATION FOR LICENSE/� 2 � � � OCT Z � PO15 �, � * Please complete form and attach all necessary�erits y bec�'mb r 1 _ . D�_PT. Failure to do so will result in the return of ydur�pplication pac . ESTABLISHMENTNAME: a<r1o�-�.-t 'W:re t� �.t ��( � TAXID• LOCATION ADDRESS: �SS' � W S't.o..'��or� �M1�C ��`�G.Cv�nou..t� (`M TEL.#: 5�-7 toD-ao�ld MAILING ADDRESS: So,�e- E-MAILADDRESS: Frnc..u��(Z Co�c.a6� t�et OWNERNAME: FCcvS\C K`�\o��Q\i CORPORATIONNAME (IFAPPLICABLE):�p,SMow�n W�h�e t SO�r�tS. �..�-L MANAGER'S NAME:f c � G.�cS � �TEL.#: � - 7 - �-8 MAILING ADDRESS: C�rc-1� So, n 5 VY1 �3 (�IoD 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. r �------- -- _ _ _ 2: - Pool operators must list a minimum of two employees currently certified in standard First Aid and Community Cazdiopulmonary 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 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 CERTIFICATIONSi 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. 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 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 Tile at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL # __ _ _ _ __ _ _OF_FIC_E__USE ONLY____,__ _---- -- -_ -- __ . __ - _- - — LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $110 � INN $55 CAMP $55 SWIMMINGPOOL$l�0ea. LODGE $55 TRAILERPARK $105 WHIRLPOOL $ll0ea. FOOD SERVICE: - LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 _CONTINENTAL $35 NON-PROFIT $30 _>I00 SEATS $200 _COMMON VIC. $60 WHOLESALE $80 . —RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMtT fk LICENSE REQUIRED FEE PERMIT If <50 sq.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 �Q5,000 sq.ft. $I50 �-6� 7� _FROZEN DESSERT $40 �TOBACCO $I10 ��Z NAMECHANGE: $IS AMOUNTDUE _ $ 2ko.�o *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***•* � , r 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 �C 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 X 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 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 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 area 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 therea8er. 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 establishxnents 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 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 revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waih�ess service),must have prior approval from the Board of Healttt. 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 APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: � � \a l laOl S SIGNATURE: �� 1'C .C�' w✓� � PRINT NAME & TITLE: �"CG`��C � • ��' ��'nef��o��e,(' Rev. 10/Ol/IS ' ' ` � The Commonwealth ofMassachusetis Department of Industrial Accddents Office oflnvestigations ' I Congress Streei, Suite 100 Boston, MA 021I4-2017 wwwmass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Leeiblv Business/Organization Name:� Cti�C M o�-'�� ^'e � �� 5 Address:�� -� S'�cG.."t. � � �U� 0:l fobN City/State/Zip�O.�(i�V`n o �,�.�,h �� Phone#: �6 8 -7(o O' 7�1� Ar�e y(ou an employer? Check the appropriate bos: Business Type(required): 1.IJ I am a employer with �5 employees(full and/ 5. �Retail or part-time).° 6. ❑ RestaurantlBazBating Establishment . -- - - -- - — ' - - --- 2� I am a so(e propnetor or partners�p ancrhave no �, � Office and/or Sales (inc1.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 their right of exemption per c. 152, §1(4),and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]` 1 l.❑ Health Care 4.❑ We aze a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.❑ Other � *Any applicant that checks box#I must atso 5ll out the section below showiag their workexs'compensation policy mformatioa. •'If the coiporate officeis have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should checkbox#I. I am an employer that is providing workers'compensation insurance for my employees/.� Be[ow is the po[icy information. Insurance Company Name: �� 2't Ou� ��tCl�c.1�}S � ('. 11.�O ir� 1 n C—• Insurer's Address:l � \JOX �5`��.`a`��"1`�-��. City/State/Zip: �CG,�,��.c.QQ "�1� � `ol l �S 5 Policy#or Self-ins. Lic.# � ��-a-3 b ti L � E�cpiration Date: t`O 1 \�.��o Attach a copy of the workers' compensation policy declaration page(showing the policy number and ezpiration date). ' Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penakies of a fine up�o $T>SDD:Ob an�tar orie-y�aiaz i ' • ' ' �i ' '�ue�u,�-tbrnr�faS�P R-�i�ORDER an8-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. Ido hereby/cer�tify,under the ain \andpenalties fperjury thai the informationprovided above is true and correct. Sis?nature: v��` ��J' �/`^""' Date• ��\a��o��` � Phone#: ��`7��— 0�0�� Offuial use on[y. Do not write in this area,to be completed by city or tawn officiaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2. Building Department 3. City/Town Clerk 4.Licensing Board 5. Selectmea's O�ce 6.Other Contact Person• Phone#• � www.mass.gov/dia � NOTICE NOTICE TO d TO EMPLOYEES � EMPLOYEES The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 1 Congress Street, Suite 100,:Boston, Massachuselts 02114-2017 617-727-4900 - http://www.state.ma.us/dia As required by Massachusetts General Law,Chapter 152, Sections 21,22&30,this will give-yau notice Yhat I(sve}have provide�fer psyment to out injarad employees under the above-menfloned chapter by insuring with: MA Retail Merchants WC Group Ina NAME OF INSURANCE COMPANY PO Box 859222-9222 Braintree,MA 02185 ' ADDRESS OF INSURANCE COMPANY 014000502236115 1/Ol/2015 - 1/O1/2016 POLICY NUMBER EFFECTIVE DATES Association Benefits Insurance 299 Ballardvale St, Suite 1 Wilmington,MA 01887 NAML OF INSURANCE AGENT ADDRESS PHONE# Yarmouth Wine&Spirits LLC 484C�Station Avenue South Yarmouth,MA 02664 EMPLOYER ADDRESS EMPLOYER'S WORKERS' COMPINSATION OFFICER¢F AN� DATE ____�4�BIGA� T�AT-M�RT� _ _ --- - _ The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the pmvisions of the Workers' Compensarion Act. A copy of the First Report of Injury must be given to the injured employee. The empioy�may select his or her own physician. The reasonable cost of the ser- vices provided by the treating physician will be paid by the insuret,if the treatment is necessazy and reasonably connected to the work related injwy. In cases requiring hospital attentioq employee.s are hereby notified that the insurer has arranged far such attention at the ca,.�� coa. H �sp�� NAME OF'HOSPITAL ADDRESS TO BE POSTED BY EMPLOYER