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Home My WebLink AboutApplication and WC « �a� TOWN OF YARMOUTH BOARD OF HEALTH pQ6Qp�p APPLICATION FOR LICENSE/PERMIT - �... ��O 2015 * Please complete form and attach all necessary documents by,Dece er�Q�2B1�. Failure to do so will result in the return of you�,�ppl�cat�ort pa ket. � HEALTH DEPT. ESTABLISHMENTNAME: i ' T�'tC �2i[b'�' A �-/ LOCATION ADDRESS: / A U/YY! TEL.#: � !0 2-�� MAILING ADDRESS: �9G�-vY�- E-MAIL ADDRESS: / $Q . C'-dYv� OWNERNAME: ri;�..�/� d7% CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: �2CscsZ. I�CM O�n TEL.#: �SC2ryL� MAILING ADDRESS: .5��"'�� 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 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. 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. �QSStSz- �C �C�-.�ICT.n 2. (��(�t.�-1t�. �{ 117/�-/ PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. �. .T�s�..e.. M.c ILt.a.h a�n 2. ��,��u�a- ��t�-n�.r- _ _ 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 5le at your establishment. i. .'fpSs.�e, f�c►�lc�crn 2. d�V'�i,v�o�- �l�'Y�� 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.� �1��Sf�a- �1 2. �v1:� ��'ri.9-� 3. 4.—� RESTAURANT SEATING: TOTAL# � - -- _----- — - - - --�F�I�"-E�;rS��NL-'� _ ---__ _ _ LODGING: LICENSE REQUIRED FEE � PERMIT N 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# LICENSE REQUIRED FEE PERM[T# LICENSE REQUIRED FEE PERMIT# �0-100 SEATS $125 �OI _CONTINENTAL $35 NON-PROFIT $30 >100 SEATS $200 �COMMON VIC. $60 (�$ =RE�DEKITCHEN $SO RETAIL SERVIC& � LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 _<25,000 sq.ft. $I50 _FROZEN DESSERT $40 _TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE _ $ I SS. OO *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM•**** ADMINISTRATION T ' Under Chapter I 52,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 ta�ces 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,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 Deparhnent 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 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 Deparhnent 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 obtamed at the Health Department,or from the Town's website at www.yarmouth.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/waitress service),must have prior approval from the Board of Health. OUTDOOR COOKING: 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 RE UIRE�SITE PL DATE: ��/� /� SIGNATURE: PRINT NAME&TITLE: �n S�/i111-- D��jyt.l� �/1-Q/d2� Rev. 10/O1/IS a_ � The Commonwealth ofMassachusetis • ' Department of Industrial Accidents Offzce of Investigations ' I Congress Street, Suite I00 Boston,MA 02114-20I7 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legiblv Business/OrganizationName:��65(.�-/�CcS �l�` �'�/ ��`�-�-�'��sl ��7�- Address: ��'-� F� �PTT City/State/Zip: G�-/" � !�'� �/� �Ph ne#: �8 � a —f d a� Are you an employer? Check the appropriate box: Business Type(required): 1.'�I am a employer with��employees(full and/ 5. ❑ Retail or part-time).k 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 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]* 11.❑ Health Care 4.❑ We aze a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.� Other *Any applic�t that checks box#1 must also fill out the sectio¢below showing theu workexs'compensation policy information. **If the corpomte officers have exempted themselves,but the coxporaaon has other employees,a workers'compensation policy is requ'ved and such mm organizadon should checkbox#L . I am an employer that is providing w�'-k,e`rs' ompe�r�.surance for my employees. Below is the policy informarion. Insurance Company Name: �►� L Insurer's Address: O�.Q �i�N f"TZ1r0� /�/Q�lf� CiTy/State/Zip:� f /Na . �°� ��O�5 ✓ Policy#or Self-ins. Lic.# �g �� g 8�J Expiration Date: aI�/�� Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration 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 to $1;�00.60 and/or one-yeaz imprisonmen�as well as c'ivil pen�ties in ttie farm af a STOP WORIf DRDER aa�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 eert' , under the�ains and p ealties ofperjury that the information provided above is due and corred. Sienature•� c �� Date• ��//�S Phone#: c�8'�l� Official use only. Do not write in this area,to be campleted by city or town offuiaL City or Town: Permit/License# Lssuing 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 � � ,� ,- . . .�� ,� f�� 15 (policy Provisions: wC o0 00 0o B) 4�rx ;; 8 8 � sr ,�r�,. cL INFORMATION PAGE �" � ��: �� WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY "�= INSURER: HARTFORD INSURHNCE COMPANY OF THn MIDiti�S= . ONE HARTFORD PLAZA, HARTFORD, CONNEC'T��'-- :-n'155 NCCI Company Number. zo5o5 THE � Company Code: � HARTFORD Suffix LARS RENEWAL POLICY NUMBER: oe v�C CL88i5 02 Previous Policy Number: oa t+Tsc cLaeis HOUSING CODE: DW 1. Named Insured and Mailing Address: �is'rzNA�S KITCHEN, INC. DBA (No., Street,Town, State,Zip Code) THE OPTIMIST ca.�'s 134 ROII'I'E 6A FEIN Number: YARMOUTiI PORT, MA 02675 State Identification Number(s): UIN: The Named Insured is: coxrolxaTzoN Business of Named Insured: �sTAmuNT - �'t�L SERVICE (wA2 Other workplaces not shown above: 134 ROIITE 6A YARMOUTH PORT MA 02675 2. Policy Period: From o2/oi/is To o2/oi/16 12:01 a.m.,Standard time at the insured's mailing address. PfOdUC8Y5N8fi1B: DOWLING & 0'NEIL INS AGENCY/PHS 301 WOODS PARK DRIVE CLINTON, NY 13323 Producer's Code: oeaz33 issuing Office: THE HARTFORD 301 WOODS PARK DRIVE CLINTON NY 13323 (866) 467-8730 Total Estimated Annual Premium: 51,161 Deposit Premfum: Policy Minimum Premium: 5266 t�s� (INCLUDES INCREASED LIMIT MIN. PR&M.) Audit Period: �� Installment Term: The policy is not binding unless countersigned by our authorized representative. Countersigned by �"�'� C�`�"� 12/13/14 Authorized Representative Date Form WC 00 00 01 A (1) Printed in U.S.A. Page 1 (Continued on next page) Process Date: 12/i3/11 Policy F�cpiration Date: o2/oi/i6 A INFORMATION PAGE (Continued) Policy Number: oa wEc cLasis £ 3.A. Workers Compensation Insurence: Part one of the policy applies to the Workers Compensation Law of the states listed here: � B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits of our liability under Part Two are: soo,o0o each accident Bodily injury by Accident $ Bodily injury by Disease Ssoo,o0o policy limit Bodily injury by Disease $soo,o0o each employee C. Other States Insurance: Part Three of the poiicy applies to the states,if any , listed here: ALL STATES EXCEPT ND, OH, WA, WY, US TERRITORIES, AND STATES DESIGNATSD IN ITEM 3.A. OF THE INFORMATION PAGE. D. Thts policy includes these endorsements and schedule: WC 00 04 21C WC 00 04 22A WC 20 O1 O1 WC 20 O1 02 WC 20 03 03D SEE ENDT 4. The premium for this policy will be determined by our Manua�s of Rules, Classiflcations, Rates and Rating Plans. All information required beiow is subject to verification and change by audit. Premium Basis Classifcations Total Estimated Rates Per Estimated Code Number and Annual $100 of Annual Description Remunerafion Remuneration Premium 8810 111,200 •08 89 CLERICAL OFFICE SMPLOYEES NOC 69,500 1.15 �99 9079 RESTAURANT NOC -133 MA RATE DEVIATION PREMIUM CREDIT (.15) (90371 8 INCREASED LIMITS PART TWO (9807) 1.00 PERCENT 42 TO EQUAL INCREASED LIMITS MINIMUM PREMIUM (9848) g05 TOTAL ESTIMATED ANNUP3+ 3TANDARD PREMIUM 250 EXPENSE CONSTANT (0900) 52 MASSACHIISETTS DIA ASSESSMENT 5.800 PERCENT Q3� 54 TERRORISM (9740) 180,700 1,161 TOTAL ESTIMATED ANNUAL PREMIUM - Totai Estimated Annual Premium: $1,161 Deposit Premium: Policy Minimum Premium: 5266 MA (INCLUDES INCREASED LIMIT MIN. PREM.) Interstatellntrastate Identification Number: NAICS: Labor Co�tractors Policy Number: SIC: 5612 UIN: NO. OF EMP: 000009 Form WC 00 00 01 A (1) Printed in U.SA. Page 2 Process Date: 12/13/i4 Policy Expiration Date: 02/o1/i6