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Home My WebLink AboutApplication and WC. y9/1.P�ZZA �Y E✓Af� '�^ � TOWN OF YARMOUTH BOARD OF HEALTH �� APPLICATION FOR LICENSE/PERMIT -2016 � ` �=^'�' ' �'� �:-� 14113 " � `" * Please complete form and attach all necessary do�uments l�y ` ceraber 1 2 � 2 2��5 4 Failure to do so will result in the return of your applicaUou��G . � » --�r � �� . ESTABLISHMENT NAME: / T ID: "�' LOCATION ADDRESS: S TEL.#• �j MAILING ADDRESS: E-MAIL ADDRESS: OWNER NAME: " CORPORATION NAME IF APPLICABLE): ^ — MANAGER'S NAME: �(z� L'— � TEL.#: 2 MAILING ADDRESS:S 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 t �certification to this form. -- - _ — L 2. Pool operators must list a mini um of two employees cunently 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 provi new copies and maintain a file at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments aze 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 Establishxnents, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years'records. Yoy.�c�t provide new copies and maintain a file at your establishment. 1. /��S l'f/�Z�i r�riI 2. UJ ��l�E� GDNGI�L 1/'�S PERSON IN CHARGE: _ Each food establishment must have at least one Person In Chazge (PIC) on site during hours of operation. _ 1-- __.�� -_ L�L � �l/�� 2. W�� C'��i��(��S 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 Establishrrtents, 105 CMR 590.009(G)(3)(a). Please attach copies of certification to this application. The Health DepaMment will not use past years' records. You must provi w copies and maintain a file at your establishment. �. �� -�� C/�(�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. t��T�I.L� C��T1S7C�C�1 2.�lf�zSl �IUE Y�1LDG�-. �(.� 3.uawL?�- �on�� _�� ' 4. RESTAURANT SEATING: TOTAL# --- -- -- --_ ___ �(}FL'Tz�� i�,T��NI.Y _ _ — _ _ --- --- - - LODGWG: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $110 INN $55 CAMP $55 SWIMMING POOL$110ea. _LODGE $55 _TRAILERPARK $105 WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT N UCENSE REQUIRED FEE PEItMIT# LICENSE REQUIRED FEE PERMIT# �0-1005EATS $125 b�01Z CONTINENTAL $35 NON-PROFIT $30� _>100 SEATS $200 �COMMON VIC. $60 ��(( —WHOLESALE $80 —RESID.KITCHEN $80 RETAIL SERVICE: LICF,NSE REQUIRED FEE PERMIT# LICENSB RBQUIRED FF.E PERMIT# LICENSE REQUIRED FEE PERDIIT# <50 sq.ft. $50 >25,000 sq ft. $285 VENDiNG-POOD $25 � _Q5,000 sq.ft. $150 =FROZEN DESSERT $40 TOBACCO $I10 NAME CHANGE: $15 AMOUNT DUE _ $ lR5.6 � . � ;,,i�,:...� *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***��.-' -s ' ""is°' w ._�. ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yannouth 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� Town of Yannouth taxes and liens must be paid prior t 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,ordinazily 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 inspectiou 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 opened. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard 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 establishxnents must be inspected by the Health Department prior to opening. Please contact the Health Departrnent 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 resuks 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 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 A OVED B THE BO OF LTH PRIOR TO COMMENCEM NT. NOVATIONS MAY QUIRE SI . DATE: SIGNATURE: � P �T�AME&TITLE: � � Rev. 10/01/IS '. .. � � � The Commonwealth ofMassachusetts Department of Industrial Accidents Offzce oflnvestigations 1 Cangress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance AfSdavit: General Businesses Applicant Information Please Print Le�iblv Business/OrganizationName:�(��.L.� Ih1C' f7`/.h/A��iQ/yfi'C/I -� 1��N Address: S City/State/Zip. �G, S Phone#:��`Z—��'� Are y an employer? Check the a propriate box: Business Type(required): � P Y � 5. ❑ Re 1 1. I am a employer with — em lo ees full and/ -acpart-time).* ___ 6. estaurantBaz/Eating Fstablishment 2.❑ I am a sole proprietor or parmership 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 ue a corporarion and its ofFicers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4),and we have 10.❑ Manufachuing no employees. [No workers' comp. insurance required]* 11.❑ Health Caze 4.❑ We aze a non-profit organizarion,staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.❑ Other *Any applicant that checks box#I must aLso Sll out the section below showing the'v workers'compensation policy informatioa. ••If the coipornte officers have exempted themselves,but the cocporation has other employees,a workers'compensation policy is required and such an � organimtion should checkbox#1. � I am an employer that is providing workers'compensation insurance for my employees. BeLow is the po[icy informa8on. InsuranceCompanyName:AIOQ. ��IW2D �ISUR-I�F/l�� MPr4/�� Insurer'sAddress:�(,�,��Cj�T,�+��-�-k�'6�}��,�/�" ��—Q� � City/State/Zip: W 3-� Policy#or Self-ins. Lic. # PF"W G��-853 Expiration Date: �� Attach a copy of the workers' compensation policy declaration page(showing the policy number and ea ation date). Failure to secure covera�e as required under Section 25A of MGL c. 152 can lead to the imposifion of criminal penalties of a - - - - - fine up to $1,500.00 and/or one-year imprisonment,as well as civil penalties in tha�orm of a STOP W ORKOADER arid aTine — of up to $250.00 a day against the violator. Be advised that a wpy of this statement may be forwazded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby c ' , er t s and p alties perjury that the information provided abo e is tr and correct. Si ature: Date: � � � Phone#: b — O�cial use only. Do not write in this area,to be completed by city or town officiaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2. Building Department 3. City/Town Clerk 4.Licensing Board 5. Selectmen's Office 6.Other Contact Person: Phone#: www.mass.gov/dia ,acoizo� CERTIFI ATE' OF LIABILITY INSURANCE °°'�'"��°'"""' --=��i,i�5� THS CERiIFICAIE IS ISSUED AS A MATTER F IIFORMATION OPLY/WD CONFERS NO RIGHTS UPON THE CERfIFiCATE HOLDER THS CERTIFICATE DOES NOT AFFIPMATVELY NEGATNELY AMElD, EXTEND OR ALiER TFf COVERAGE AFFOROED BY THE� BELOW. THS CERTIFlCATE OF INSURANCE DOES NOT CONS7ITUTE A CONTRACT BETWEEN THE ISSIANG INSURER�S), AUfFpPoZED I REPRESENTATIVE OR PRODUCER,PND 7HE RfIFCATE HOLDER. � IMPORTANT: M the certificate hdder is an AD I710NAL�.INSURED,Ihe policKes)must be antlased. M SUBROGA710N IS WNVED,su6ject W '�, the terms and contlido,s of the policy,ceRain licies r�ay require an entloraement A ffiabme�R on this cerlifiiate doea not cmkr righls to tlie j ceRificate holder in lieu of such endasemeng � caooucen T � NAME: __ Austin Chandler Insurance ' -PiaNE �-�� --�-�--- ------rax . �7ei� s3a-osoz � 17 Railroad Ave, Suite 1 '�, E�a� � ��81) 934-7200 �. a rv.. _ Dux6ury, MA 02332 ; '��. aoortess: Robin@AustinChandlerInsurance.com � �, I INSl1fEf�S)FFfOftDINGCOVERAGE NqICp . _ — ._... .. . . _._ . ___ �_._._ INSUREN A AR$EI.I.P. � IfSURED. ._ . . . .__ INSU0.ER6 GU]�D _. .._ .. PERIKLIS INC I �. ��Re3C . .. .-- - .. YARMOUTH PIZZA � vsunmo . __ ._ ._ ... 559 MASN STREET �� i�R�E - �� YARMOUTH PORT, MA 02675 I �. --- ... _- ... INSURER F: COVERAGES CERTIFICA NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT iHE POLICES OF INSU NCE L1SiED BELOW HAVE BEEN ISSUED TO THE INSlF2ED NAMm A900E FOR THE POLICV P6210D INDICATED. NOTMTHSTANDNG NJY REaUIREME ,TERM:OFi CONDITqN CF ANY CONTRACT OR OTHER DOCUMENT WRH RESPECT TO WHICH THIS CERTFICP.TE M4Y BE ISSUED OR MAY PERTAPJ, HE INSIRANCE AFFOF�ED BY TFE POLIGES DESCRIBED HEREW IS SUBJECT TO ALL THE TERMS. EXCLUSIONS ANDCONpTIONS OF SUQi POLICIES. MfTS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAMAS. _.____—�_ . _ _ __ _ ... __—. — ._ __-- _______' 'lTR TYPEOfINSURONCE �A�L��R .. . PWCYNIIRffiER .. . M�1�1'�� I�MAA�'YYYY � � LIMTS . �GENFRaLUnBIUtt � '�i �. 10/26/15'��. 10/25/161 EqCN OCCURaErvCE ,S _1�000,000 7520047908 �� '�oaxwcE ro a€+rEo - � ..conmteauAicecEanwnaiurv I'�i . '�. .,vpEmisesfea«aure�cel .s 50 000 � � ��.cum.umnoe �. X ��oaue ��I '. ��, . r,�o errenMore_o i �.s .. . 10�0_0_0 �_ . ... �., ,. .__. - -- --- � ; ��. ', PERSOracLBnnVIwURT S I,OOO,OOO . . .. . . _. .. .. . . �'I ,, .. .cErvea,��nccaecnre s �_2 000 OOQ.�I GEN'LI�GGREGATELHMTAPPLIESPER � '� i, PROOUQS �hPIJPAGG $ 2�000�000 � ._.:POLICY' ��PRO- ._:LOC .li . . , ._ _. _ . �'�..S I. AUTOMOBLLELIABWTY � ' IN M L L ', �� ,, . �.IEa Ca�nl____ 5 ._ _ .. ....I ANVAUlO , � BOORYINJURY(PerppSon) $ I PLLOWIEO SCHEDl1LED �. .� '� � BO�ILYINaURT(Pe� Oenp S AUTOS AUTOS I I '� . __. ___. . ... _.. .. HIREDHUTOS NCN OWNED �i '., '�PROPERfV DPM4GE .g ' � _ __ AUrOS �, .. , . ��.IPer awtleMi..__. . . . .... . ... ,, ..,., . .,, .b ��. . UMBRELLALIAB OCCUR �... ''.. � �'..EAGHOCCURRENCE S ��. E%CESSLIAB CLFIMS-MOOE ' ��'.. . '�.AGGREGHTE $ , —_._.___ _._ . _... ,. , � _— __- I � � DE� RETENTION$ ' � � '�E B '.VAPKFRSCOMPENSATION "', EWC229329 � 9/1/15�.� 9/1/161 WCSTNTLL . ...OTH-... ' �PND@.1PLOYERS'LIABILJTV . _-�51RYLIMlIS'—�ER. _ . - � FNYPROPRIEIORIPPATNEPoE%ECUTNE YI� � I .�ELEhCHFGGOEM ,S ZOO�OOO '�. OFFlCERMEMBERE%CLlAEOp � NI A � ,�, '',. ., ._. ._ _— _ �. �� MaMabryinNH) , �j �, ,. I. '�.EL.OISEASE�EAEM1PLOYEE��S LOO.00O ir es egmeeur,oe� .i. ,.. . , �___ _____— ___. . . ... . o�scwP*ionoFovEaarioHso�bw '��.I �� 'E� ois�sE-vo�icv�Mnrt�s � 500 000 . . . ,� .'�'� . � �ESLRIPTONOFOPERPPONSILOG1T10N51VEH1CLES�AtlxM1A FO101.A8Yuanal0.e,nrkaSJwdule�itmwespems��requreO� LIQUOR LIABILITY IS INCLUDED IN NERFS. LIABILITY PACI(AGE AT $1,000,000 PER OCCURRENCE � $2,000,000 AGGREGATE. j '. �, i I � I CERTIFICATE HOLDER '' CANCElLAT10N I, ' SHOULDANYOFIHEABOVEDESCRIBE�POLICIESBECANLELLEDBEFORE �' �� THE EXPIRATION �AIE TNEREOP, NOTIGE WILL BE OELIVEREU IN . TOWN OF YARMOUTH I ACCORDANCE W�1H iHE POLqY PROVISIONS. �. � PERMIT DEPARTMENT �'� �� YARMOUTH MA 0267�J FUIHORQED EPRESENTAINE �� , , � I, - « � i `, i � I_- �� 1 .2070 ACORD CORPORATION. All rights reserved. ACORD 25(207 d05) The PCMtD name and logo are registered marks of ACORD Phone: Fax: i, �, E-Mail: NOTICE � NOTICE TO � ; d TO EMPLOYEES � EMPLOYEES / 9� '1 5�0 The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 1 Congress Street, Suite 100, Boston, Massachusetts 02114-2017 617-727-4900 - http://www.state.ma.us/dia As required by Massachusetts General Law, Chapter 152, Secrions 21, 22 & 30, this will give you notice that I(we)have provided for payment to our injured employees under the above-mentioned chapter by insuring with: NorGUARD Insurance Company NAME OF INSURANCE COMPANY P.O. Box A-H, 16 S. River Street, Wilkes-Barre, PA 18703-0020 ADDRESS OF INSURANCE COMPANY PEWC667853 09/O1/2015 09/O1/2016 POLICYNUMBER 17 Railroad Ave Suite 1 EFFECTIVEDATES AUSTIN CHANDLER INSURANCE Duxbury, MA 02332 781-934-0648 NAME OF INSURANCE AGENT ADDRESS PHONE# PERIKLIS INC. 559 Main Street Yarmouth, MA 02675 EMPLOYER ADDRESS 08/10/2015 EMPLOYER'S WORKERS' COMPENSATION OFFICER(IF AN� DATE MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of employment to fumish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the injured empioyee. The employee may select his or her own physician. The reasonable cost of the ser- vices provided by the treating physician will be paid by the insurer, if ihe treatment is necessary and reasonably connected to the work related injury. In cases requiring hospital attenrion, employees are hereby notified that the insurer has arranged for such attention at the NAME OF HOSPTTAL ADDRESS TO BE POSTED BY EMPLOYER