HomeMy WebLinkAboutApplication and WC CsEY[ARD t s
� � ^' TOWN OF YARMOUTH BOARD OF H�AJ.TH
��� APPLICATION FOR LICENSE/P��MI'��„�Offii.,��
� " - r ��L�F'7
* Please complete form and attach all necessaty�ocy�m i�ts by D'�eer►Eber 15���15.< <�1�5
Failure to do so will result in the return o your application pack$t.
ESTABLISHMENT NAME: i3 A� � TAX ID:
LOCATIONADDRESS: qOZ Rt. ZB lNtainc .1S.�prYn.�t�n TEL.#: SO83qy3 //
MAILINGADDRESS: '� � -� 7 1.{�)L
E-MAIL ADDRES S: i�KO V i G h@ hdtvna� L•CGwI
OWNERNAME: _ D1 E�fO d[ncl. G�Sh,c- �ierttr2l�
CORPORATION NAME (IF APPLICABLE): /',�,q,�p; z CR�F /n a
MANAGER'S NAME: �� Qc�p (�Q�i rZj� TEL.#: �,Qg77la0(o�1L
MAILINGADDRESS: 1� F5� i D� Pa�M P�l. $rtwSdu ILt� oZ�e�J
r�
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.
1. 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. Z.
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 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.
�. D ► �e� o � e �� �t �' 2.
PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
1. �l e�� �l .¢TG(v-yl r� . . 2. ��� Q �L�i _
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 Establishments, 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
provide new copies and maintain a file at your establishment.
1. I 1 I �°�� Cl .e rG[ r� r 2.
HEIMLICH CERTIFICATIONS:
All food service establishxnents 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 ftle at your place of business.
' l. JGc S Lt� G .e �Gt 21 I 2.
� 3' 4.
RESTAURANT SEATING: TOTAL # S�
L6uu�nG: _ .- -- —__—_ OFFICE USE ONLY_ _
_ - ___-- - _ _
LICEI�E REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# UCENSE REQUIRED FEE PERMIT#
_B&8 $55 CABIN
�� $55 MOTEL $110
_LODGE g55 _CAMP =SWIMMINGPOOL$ll0ea.
. _TRAILERPARK $$OS _WHIRLPOOL $110ea.
FOOD SERVICE:
LICENSE RF,QUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT M
��IOOSEATS $200 �`��`3 CONTINENTAL $35 NON-PROFIT $30
— �COMN[ON i'IC. $60 ���G�Z —WHOLESALE $80
RETAILSERVICE: —RtiSID. KITCHEN $80— — -�
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_<SOsq.ft $50 >25,OOOsq.ft. $285 VENDING-FOOD $25
_<25,000 sy.ft. $150 _FROZEN DESSERT $40 =TOBACCO $I10 � - �
NAME CHANGE: �15 � AMOUNT DUE _ $ 1 $S,OO �
'****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM**�� +-� �
�
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E' - ..
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
AFFIbAVIT 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 of Motel or Hotel use,Transient occupancy shall be
limited to the temporary and short term occupancy,ordinarily and customazily 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) j
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 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 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 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.yarmouth.ma.us under Health Deparhnent,
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/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. ,
NO'TICE: Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RE�TJRI�' ----- ,
THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEM�ER 15,2�?15.
ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW
, �QUTPMENT, ETC.), MUST BE REPORTED TO A?�.'.�'�ROVED BY THE BOARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY REQ SITE PLAN.
, �
DATF_: /� T� SIGNATURE: >
PRINT NAME & TITLE: �rC 4 �Q�f'!�'GL/ G�/�-
Rev. 10/01/I S ,
. ,
t� The Commonwealth ofMassachusetts
� ` Department of Industrial Accddents
Offace oflnvestigatdons
� I Congress Street, Suite 100
Boston, MA 02114-20U
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Le¢iblv
Business/Organization Name:�P Y7.1 t�l S 1 d-C �/) C �
Address: �[�Z- �f�U(}
City/State/Zip: J� rrr�� ��OZ�/ Phone#: �48 39y���/
Are ou an employer? Check the appropriate box: Business Type(required):
1� I am a employer with�employees (full and/ 5. ❑Retail
ox�art-time).' 6. �RestaurantBaz/Eating Establishment
2.❑ I am a sole proprietor or partnership and have no �. � Office and/or Sales (incl.real estate,auto;eto:j —
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 exempuon per c. 152, §1(4),and we have 10.� Manufacturing
no employees. [No workers' comp. insurance required]* 11.❑ Health Caze
4.❑ W e aze a non-profit organization,staffed by volunteers,
with no employees. [No workers' comp. insurance req.] 12.� Other
'Any applicant that checks box#1 must aLso fill out the section below showing the'u workers'compensakion policy infoimation.
'*If the coiporNe officers have exemp[ed themselves,but the corporabon has otha employees,a workecs'compensation policy is required and such a¢
organization shoWd checkbox#1.
I am an employer that isproviding workers'compensation insurance far my employees. Be[ow is the policy information
Insurance Company Name: �'t�D1��pLIC� lk%���Gti �d J��O ��,y .
Insurer's Address: � Z� /�"I�S ,�f•
City/State/Zip: �Z
Policy#or Self-ins.Lic. # �F n_�7� � T� Expiration Date: �
Attach a copy of the workers' compeasation policy declaration page(showing the policy number and e piration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead tn the imposition of criminal penalties of a
gine up io �1,5�?0.0(taad/or ane-year imprisonr� �weH as civ'rl per.al�ies in the form of a�TOP RFOR�f OItDER ar,d a fiae
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 certify, �he pains and penalties ofperjury that the information provdde ab ve is true and correcK.
Si ature: � Date: O �
Phone#: C I S� �/L
Official 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
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WORKERS COMPENSATION AND EMPLOYERS' LIABILTY
INSURANCE POLICY----INFORMATION PAGE
iNSURER: POLICYNO: WE077044A
NORFOLK & DEDHAM MUTUAL FIRE INSURANCE COMPANY
222 AMES S1REfiT RENEWAL
DEDHAM, MA 02026 NCCI Company No: 21059
AccountNo:
FEIN:
ITEM 1. NAMED INSURED AND MAILING ADDRESS: AGENT NAME AND ADDRESS:
GBRARDI 'S CAFE, INC. DBA GERARDI'S CAFE NUMBER ONE INS AGCY, INC
902 ROUTE 28 C/O PIKE INSURANCE
SOUTH YARMOUTH MA 02664 AGENCY, INC
PO BOX 2743, 8 MAIN STRFET
ORLEANS, MA 02653
AGENT NO.: 20001P22
LEGAL ENTITY: CORPORATION
OTHER WORKPLACES NOT SHOWN ABOVE: (See Workers Compensation Classification Schedule)
ITEM 2. POLICY PERIOD: From: OS/19/2015 To: O5/19/2016
Effective 12:01 A.M. Standard Time at the Insured's mailing address.
ITEM 3. COVERAGE:
A. Wcrkers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the
states listed here:
MA
B. Employers' Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits
of liability under Part Two are:
Bodily Injury byAccident: $ 100, 000 each accident
Bodily Injury by Disease: $ 500, 000 policy limit
Bodily Injury by Disease: $ 100, 000 each employee
C. Other States insurance: Part Three of the policy applies to the states, if any, listed here:
SEE ENDORSfiMENT WC 20 03 06 B
D. This Policy includes these Endorsements and Schedules:
See Schedule of Forms and Endorsements.
ITEM 4. PREMIUM: The premium for this Policy will be determined by our Manuals of Rules, Ciassifications, Rates and
Rating Plans. All information required on the Workers Compensation Classification Schedule is subject to
verification and change by audit.
Total Estimated
Minimum Premium: $ zlg Annual Premium: $ 1,333
Audit Period: ��AL Additional/Return Premium:
Comments :
Issued At:
Date: 04/10/2015 Countersigned by
WC 00 00 01 A Copyright 1987 National Council on Compensation Insurence
iNsuaeo copv