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HomeMy WebLinkAboutApplication and WC � r TOWN OF YARMOUTH BOARD OF HEALTH �ituruv�vu'vuiL� � � � APPLICATION FOR LICENSE/PE$R'�I.�'-�16:�� ,L�l�",�a ' ��� �"' * Please complete form and attach all necessary documents by�cemb Z � B 2015 Failure to do so will result in the return of your application pac �t. HEALTH DEPT. ESTABLISHMENT NAME: P� T ID: LocaTiorr aDD�ss: 13 � nu� a rmvui�, MA TEL.#: g � 8-a-+ �► a MAILING ADDRESS: Sd1 m4- �to E-MAIL ADDRESS: f,(Q,�11 � e• +� i V�/ WCl y a 0 rvIC4S`�. ✓�Q� OWNER NAME: �O/1 �� ��ve. CORPORATION NAME (IF APPLICABLE): 1 Y Q,� �.JG� L� S U MANAGER'S NAME: Z�i'� LQ,4'Y1 O TEL.#: � 3 9�- a I�l J- MAILING ADDRESS:J 2 fi. aC�� ,0�.t � r+'n Uu 1'"h , /'� � U at�� 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. 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 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�q✓io( �a 1 me,r Z. T�-+'� �ed I u n o( PERSON IN CHARGE: Each food establishment must have at least one Person In Chazge (PIC) on site during hours of operation. _ i._.�_i ltt� n LP,moS _ 2. ,� liSS� Hct�-r��g 1�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. i. N�-� iSSa �a��;nGi-o�^ a. �� � i i-�1 L��',�no5 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. � (iCC� �C�Y�I ��j 2. ��t'11 ��'Or1 L.Q.MOS 3. �O.Vi (1�Yvv1l 4. 2�11 SQ Q(v'i�G �1 RESTAURANT SEATING: TOTAL# �0� - - ----- - ---- _--- __-nF�rrc riSE-ONL,�'-- - --_ _ _ _- -_ - -- LODGIIYG: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# L[CENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $110 INN �� $55 CAMP $55 SWIMMtNG POOL$110ea. LODGE - $55 TRAILERPARK $105 WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT k LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 _CONTINENTAL $35 � NON-PROFIT $30 �>100 SEATS $200 l�(o �COMMON VIC. $60 � =RES�ID.KITCHEN $80 RETAIL SERVICE: L[CENSE REQUIRED FEE PERMtT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq.ft. $50 >25,000 sq.ft. $285 VENDWG-FOOD $25 <25,000 sq.ft. $150 _FROZEN DESSERT $40 _TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE _ $ 260.00 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM**•** i * A 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 � 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 ofthe limitations of Motel ar Hotel use,Transient occupancy shall be limited to the temporary and short terxn 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 Depaxtment 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 ceRified 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.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 thereafrer,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 Board 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 U S TE LAN. DATE: I� �. I � SIGNATURE: P�rrT NAME& TITLE: .I G1�f �,{ 47 S' S�' OC' fl� 1 � v�Q,rotcv2( Rev. 10/01/IS � The Commonwealth ofMassachusetts • Department ofindustrial Accidents Offace of Investigations I ' I Congress Street, Suite 100 Boston, MA 02I14-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Leeiblv '; Business/Organization Name: T�r V�W��( l.O �S�/ �Q�{� i � � 33� ��_ a��� Address: oac�t�y City/State/Zip: �OU� �Q�fY1p t,1 �'1 � M� Phone#: �g- 3 q g- a ► � a Are yyu an employer? Check the appropriate boa: Business Type(required): 1.�� I am a employer with �� employees (ful]and/ 5. ❑Retail or part-time).* 6. �RestaurantBaz/Eating Establishment I�I 2.0 I aar a sole proprietor or partaership and i�ave no �, � 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 are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §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, I 1.� Health Caze ce re . 12.❑ Other with no em lo ees. o workers' com . insuran 4l P Y CI`I P , 'Any applicant that checks box kl must also fill out the section below showing their workers'compensation policy information. . **If the co=porate officeis k�ave exempted tLemselves,but the corporation hzs other employees,a workers'compeasation policy is requ'ved md such an organi�ation should check box#1. I am an employer that is providing wn�kers'compensation ittsurance for my employees. Be[ow is the policy information. Insurance Company Name: M/� �Q,�G 1 1 I.�Q.(C�n ol�� W C �9�� �PI C� Insurer's Address: � O �1� � 5� a a�-- I �-aa c��is��iz�p: �J�a� M A 0 a� 8� Policy#or Self-ins. Lic. # o �� o 0 5 03 a aa a � � 5 EXp;�on Da�: � � a� � L Attaeh a copy of the workers' compensafion policy declaration page(showing the policy nnmber an espiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a - -gine up�o$T,50D:OII anc7"ior one=yeaz imprisonmen as weil as civil penaiiies inTtie form of a9TOP�'BRK OAriE�and a nne 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 Invesrigations of the DIA for insurance coverage verificafion. I do hereby c ;fy, th'C/V— ld penalties of perjury that the injormation provrded above is true and correct. Sianature: � Date: �O�5 I l� Phone#: ��" ����oZ� �OZ � Officaal use only. Do not write in this area,tn 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. Liceasing Board 5. Selectmen's Office 6.Other Contact Person: Phone#: www.mass.gov/dia . AC R� CERTIFICATE OF LIABILITY INSURANCE oa�Irnwoomvr� THI3 CERTIFICATE IS 13SUED AS A MATTER OF INFORMATION ONLY pND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER,'THIS CERiIFICATE DOES NOT AFFIRMqT�VELY OR NEGATIVELY.pMEND, F�(TEND OR ALTER THE COVER4GE APFORDED BY THE PO�ICIES BELOW. TNIS CERTIFICATE OF INSURqNCE DOES NOT CONSTRUTE A CONTRACT BETWEEN THE IS3UING INSURER(S), qUTHORIZED REPRESENTATIVE OR PRODUCER,AND TME CERTIFICA7E HOLDER, IMPORTANi: If the eertiflcate holtler Ia an ADDITIONAL INSURED,the policy(ies)must pe endorsed. If SUBROGATION IS WANED, subJeet to the tertns antl condittons of the poiiq,perp��Pa�����may�ulre an entlorsement A sfatament on this cert�cate doea not coMer rlghts to the cert�cate holtler in lieu Msueh entloBement s), PRODUCER � � Mark Sylvia lnsurance Agency,LlC • xn e TKris 404 Main Street PXONE � � 508 957-2125 F� o: 508 957-27g1 Centerville,MA 02632 �� •mark marks Iviainsurence,corn � INSURE 8 AiFORWNWCOVERqGE NAICk iNsuneo � iNsunErta:Ma Retail Workers Com Gr Inc Riverway Lobster House,IfIC. INSURER B: 7338 Rt28 . South Yarmouth,Mq 02664 INEURERC: - INSORER�: INSURER E: COVERAGES � CERTIFICATENUMBER; �N ua�RF: THIS IS TO CERIIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD REVISION NUMBER: INDICATED. NOiW11}{S7ANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIPICATE MqY BE ISSUED OR MAY PERTAIN, THE INSURfWCE qFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE 7ERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN Mqy F{qyE gEEN REDUCED BY PAID CWMS. �LTR TYPE Of WSURqNCE GENERqLIIABILITy ��YNUMBER . M�CYE �1LY P IJMIT3 COMMERCIAIGENERALWg�LIN �CHOCCURRENCE $ CWM$-MqpE ❑OCCUR PR e � $ MED EXP fM ma rap�) S � PERSONALSADVINJURY g CaEMLpGGRE6ATEL�MRAPp��ESPER: . � CaENERALAGGRECaA'fE § POLICY PR0. LpC PRODUCTS-COMP/pPAGG S AUTOMOBILE Llqg���7y S ANYAUTO COM IN INGLEUM N10WNED ai ent AUTOS � AUTOSULED BOOILYINJUftV(Pppa�) a 'HIREOAUTpq A�os�`'ED BODILYINJURV(Petpeqyyg) s � P OPE e��Ah1AGE S UNBRq.tq�Jpg OCCUR $ ���e CLp�MS�MADE EACFIOCCURRENCE g DED RETEMION$ AGGREC�qTE g A �OMKERSCOMPENSpiIpN $ ar+oavwrens•uaewrv 014005032222174 1/1/2014 7/1/2015 K'CSTATU- �Y��ETORIPARTNEWFj(ECUTIVE Y/N 014005032222115 X OTH- OFFlCERMENBERE%ClUDE09 � N/A V1/2O1$ �/�/20�6 (M����Y��MM) E.LEACHACCIDENT $ 1,000,000 Myes.Gasuiee uMer �ESCRIPTIONpFOPERATONSbelox � E.L.DISEASE-EAEMP�OYE S ��OOO,DOO ELDISEA$E-POLICVLIMR 5 i3OOO,OOO DESCRIP7ipN OF ppg�q}pNg��qnON3/VEXICLE$ (qryaeh ACORD 101�ACNBp'u�Remark�ge�etlulq Nman spees b nq�lntp Restaurant Jason Siscoe is coyerep under the workers cpmpensation policy. CERTIFICATE HOLDER CANCELLATION SFIOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TNE EXPIRpTION DATE THEREOF, N0710E WILL BE DELNERED IN ACCORDANCE WITH THE POLICV PROVISIONS. AUTNORREDREPRESENTATVE �-��- � 6.,'�' �/� '�._ �� '. ACORD 25(2p1p/pg) The ACORD name and logo are registered marks of qC0 DORD CORPORATION. AII righffi reserved. ------._--------- >> _.......---------- .