HomeMy WebLinkAboutApplication and WC '.___.._.__ . .G7A�R-�WO `S� ..
F � TOWN OF YARMOUTH BOARD OF HEALTH �
��� APPLICATION FOR LICENSE/PERMIT�s; . 1 I�LI' i
* Please com lete form and attach all necess d�eamen���� ` G ��I 5
m r IS 2015.
j ' Failure to do so will result in the return q�ou�ap�c�n a et.
ESTABLISHMENT NAME: �.4R Dia J H� r.� .. TAX ID:
LOCATIONADDRESS: � �l R�N .fT- /�T•a1P TEL.#: SOp-�rr=o33�
MAILINGADDRESS: I.v+c1,��v�R�2NBk�iS� . MR. a6 ?
E-MAILADDRESS:� cZ o.,L .?/N,2 Q Ad�. Cor►
' OWNER NAME:�t.4 w�n�i /��tt/�// �f T A-�/UA� T
CORPORATION NAME (IF APPLICABLE): S M'�
MANAGER'S NAME: T8 H G-�/f2o iu r� TEL.#:,S'O�'�y�lS=D3.�3
MAILINGADDRESS: �� �f�/fi�,n. ST �QT.et ��(/�4a� /�'9. D�G7'�
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.
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1. - -- 2.
Pool operators must list a minimum of two employees currently certified in standazd 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.
L 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. ,
I. �(Z/', �i /� R.�I/sV d 2. �D (s-i /¢/1.U/�✓I
PERSON IN CHARGE:
Each food establishment must have at least one Person In Chazge (PIC) on site during hours of operation.
l._ / O/y �'i �-D/ n�� 2. U�� ���0/n, � .
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 application. The Health Department will not use past years' records. You must
provide new copies and maintain a file at your establishment.
�._ T� �, .�Ro,N.� 2. E.D G �eo,tia
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 riot use past years' records.
You must provide new copies and maintaima file at your place of business.
1. / �h (rj/�-2Q/ .o/1 2._ �,� �i�QDi�►.i7
3. 4.
RESTAURANT SEATING: TOTAL # o?o'Z O
_._ __ - __ . _ _------- —J9��'irc ric� n��,----
-- - - -- -
LODGING:
LICENSE REQU[RED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_B.@B $55 CABIN $55 MOTEL $I10
_�N1V $55 CAMP $55 SWIMMINGPOOL$110ea
_LODGE $55 =TRAILERPARK $1p5 _WHIRLPOOL $110ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# WCENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
0-100 SEATS $I25 CONTINENTAL $35 NON-PROFIT $30
�>100 SEATS $200 I��pay �COMMON VIC. $60 �'� —WHOLESALE $80
RETAIL SERVICE: �
� —RESID.KITCHEN $80
LICENSE REQUIRED FEE PERMIT# LICENSE REQU[RED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_<50 sq.ft. $50 _>25,000 sq.ft. $285 VEND(NG-FOOD $25 �
_<25,000 sq.ft. $I50 _FROZEN DESSERT $40 _TOBACCO $I10
NAME CHANGE: $15 � AMOUNT DUE _ $ z.(o0.�0
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*****
� �
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 Cer[ificate 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
Town of Yarmouth taaces and liens must be paid prior to renewal ar 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 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 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
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 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 Yannouth 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.yannouth.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 Departrnent. 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 APPROVED BY THE BOARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. „ �
DATE: �I� I S SIGNATURE: c� i�
PRINT NAME & TITLE: �n �,,¢2/J �i �ji r¢/1 Di.�d `T/�
Rev. 10/Ol/IS � P�J��eNr .
, : . � The Commonwealth ofMassachusetts
Department oflndustrial Accidents
Office of Investigations
i ' 1 Congress Street, Suite 100
' Boston, MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Anulicant Information Please Print Leeiblv
Business/Organization Name:
I
! Address:
City/State/Zip: Phone #:
Are you an employer? Check the appropriate bos: Business Type(required):
1.❑ I am a employer with employees(full and/ 5. ❑ Retail
-- — ��p�*+-hmP)* 6. ❑ RestaurantBaz/Eating Establishment
-- -- _
- - -
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 corporarion and its officers have exercised 9. ❑ Entertaiiunent
their right of exemption per c. I 52, §1(4),and we have 10.0 Manufacturing
no employees. [No workers' comp. insurance required]*
4.❑ We aze a non-profit organizarion, staffed by volunteers, 1 LQ Health Caze
with no employees. [No workers' comp. insurance req.] 12.� Other
•Any applicant thaz checks box#1 must aLso 5ll out the section below showing their workers'compensazion policy informstioa. �
**If the coxpomte officecs have exempted themselves,but the corporaGon hss otha employees,a workers'compensation policy is required and such an
organization should check box#I.
I am an emp[oyer that is providing workers'compensation insurance for my empinyees. Be[ow is the po[icy information.
Insurance Company Name:
Insurer's Address:
City/State/Zip:
Policy#or Self-ins. Lic. # Expiration Date:
Attach a copy of the workers' compensation policy dedaraGon page(showing the policy number and ezpiraHon date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposiuon of criminal penalties of a
fine up to �1,-SO�DlTand7or one-year imprisonm�nt,as well as civil penalties in the fo:xn of a STOP WORK O��t and a£�e ---
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 certi , under the ains and pe alties of perjury th the information provided above is true and correct.
Si ature: Date: — ��/1
Phone#: �� � 7��� �,�.3 �
O�ciaL use only. Do not write in this area,to be completed by city or town ojficiaL
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2. Building Department 3. City/Town Clerk 4.Licensing Board 5.Selectmen's Office
6.Other
Contact Person: Phone#•
www.mass.gov/dia
BERKSHIRE H�THAWAY iNorkee's Comoensatian and Emolover's Liabelitv Q�li�
� ��A�D INSURANCE NorGUARD Insuranes Company- A Stack Compar.
COMPaNIES Policy Numhar GIWC6508E
Renewai of NE'
NCCI No. [2584�
Policy 2nfarmation Page
[iJNamed Insu�ed andi Mailing Add�esa Agency
Giardino's Tastee Tower Inc. DGP-MILES INSURANCE AGENCY, INC.
242 Main Street PO BOX 1018
Yarmouth, MA OZb73 Taunton, MA 02�80
Agency Code: MAIR6Q10
Federet EmployEer's ID Insured is Corporatfon
[Z] PoFicy Period
From September 1., 2015 to September 1, 2016, 12:Q1 AM, standard time at the insured's maiiing address.
[3] Coverage
A, Workers' Com;pensation Insurance - Part One of this palicy applies to the Workers' Compensatlon
Law of the foll�owing states: Massachusetts
B. Empioyer's L(ability Insurance - Part 7wo of this policy applies to work in each oF the states listed
in ItErT� (3]A. The timiis ot our liability under Part Two are;
Botllly� Injury by Acciden[ - each accident $500,000
Bodiiy� Injury 6y Disease - each empioyee $100,000
Bodily Injury by Diseese - policy limit $500,000
C. Other States I�nsurance - Part Three oF this poiicy applies to aN states, except any state iisted in
item [3]A. an.d khe states of North Dakota, Ohip, Washington, and Wyoming.
D. This policy incliudes these endorsements a�d scheduies:
See Exter•ision of Information Page - Schedule of Forms
[4] Premium
The Premium Basi�; and, therefore, the premium will be determined by our Manual of Rules,
Classificatians, Ra�es, and Rating Plans All required i�farmatipn is sub)ect to verffication and change by
audit, (Continued on another page)
Total Estima[ed Policy Wremium S 3,148
Total SurchargesjAsse�Sments S 156.00
Total Est(mated Cost � 3,304.00
lwtfarva�usE � � � Pa9e _ 1 -
MGA : GIwC55o887 Infomtation Page
Date : 0411 1/26 1 5 WC 006D01A �
MANOTE
Issuing �fffte: P..O. 8ox A-H, 16 5. River StreaL Wllkes-Barre, PA 187Q3-0020 �www,guard.com