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Home My WebLink AboutApplication and WC � � TOWN OF YARMOUTH BOARD OF HEALTH �� u`v 3 `� ` APPLICATION FOR LICEPFSE�i'ERMIT -2016 ' ��y ( y ��)15 * Please complete form and attach all necessary documents:�y Dece ber I S 2015. Failure to do so will result in the return of yoi[tr application p c eH EPT. ESTABLISHMENT NAME: 1 TAX ID: ` � LOCATION ADDRESS• '�� c.�� S�rr�� ck, c2R S. Yurmoulh cbT6G 4 TEL.#: 5U S - 771 -010() MAILINGADDRESS: Same0.� AbaJ� E-MAIL ADDRESS: m a OWNERNAME: +�+ts �MdcC �u9r CORPORATION NAME (IF APPLICABLE): `{n1 I..I.C- lC.crltF �QosEa,�s..k+- 2 MANAGER'S NAME: TEL.#: MAILING ADDRESS: 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. i. "n,oma� Nl�it(':Gfmic� __ 2. Pool operators must list a minimum of two employees currently certified in standard 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. �. Cc<< 1�� 5�.,� Il ,v�,v, 2.Cm� lu Bon�bc.r �� er 3. � »�in �eesoh a. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishxnents 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. TLe Health Department will not use past years'records. You must provide new copies and maintain a file at your establishment. i. �-�Ln s�� H "�t-�^ z. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. i. c�G��iS��-�/ �"I � 2. 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 Department will not use past years' records. You must provide new copies and maintain a file at your establishment. �. ��s bpl�,� 1-+�, �,�� . 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 i 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. i. � ieeson 2. �vn;1u @�m6a�c�irr 3. 'a,� liN SullNan 4.� RESTAURANT SEATING: TOTAL# rZ� I OFFICE USE ONLY , ..,.�,..,. _ - — - _ ----- — __- — — - -- - � LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $1l0 � 00 _I1V1V $55 CAMP $55 �SWIMMINGPOOL$IlOea. eoq _LODGE $55 _TRAILERPARK $105 �WHIRLPOOL $110ea. FOOD SERV[CE: WCENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT t! I 0-100 SEATS $125 a�'�G-02� CONTINENTAL $35 NON-PROFIT $30 _>100 SEATS $200 �COMMON VIC. $60 _�� =RES�IDE TCHEN $80 RETAIL SERVICE: � LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq�ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 _Q5,000 sq.ft. $150 _FROZEN DESSERT $40 TOBACCO $I10 NAME CHANGE: $15 AMOUNT DUE _ $ 625 . 00 � *****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 �i 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 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 ofMotel 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 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) 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 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 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 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 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 l 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 A dVED Y THE BOARD OF HEALTH PRIOR i TO COMMENCEMENT. RENOVATIONS MAY RE � I LAN. ' DATE: r I�L �6 � S SIGNATURE: PRINT NAME & TITLE: C,l{�Qll'�(7DFfC',� U'I�. �L✓/lfE� � i Rev. 10/O1/15 : � The Commonwealth ofMassachusetts � Department oflndustrialAccddents Office oflnvestigations � I Congress Street, Suite I00 Boston, MA 02114-2017 www.mass.gdv/dia Workers' Compensation Insurance Affidavit: General Businesses Aualicant Information Please Print LeEiblv Business/Organization Name: /�� L L�' Address: 0 22- I�Z� Zb City/State/Zip: �D, /F�NNt-D J7 Ff MA ��6 hone#:�� ? / ` � 16Q Are u an employer? Check the appropriate bos: Business Type(required): 1.�I am a employer with�Q_employees(full and/ 5. ❑ tail or part-time).* 6. Q�estaurantBaz/Eating Establislunent — -- -- — 2. I am a sole ptoprietor or partnership and have no �, QOffice and/or Sales (incl.real estate, auto, etc.) - employees working for me in any capacity. [No workers' comp.insurance required] g• ❑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.❑ Heakh Caze 4.❑ We aze a non-profit organization,staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.0 Other 'Any applicant that checks box#1 must also 5ll o�xt the section below showing their workers'compensation poGcy information. "If the corpoxate officecs have exempted themselves,but the corporation has other employees,a wockers'compensation policy is requued and such an organization should check box#1. I am an employer that is provi^ding workers'compensation insurance for my empfnyees. Below is the po&cy information. Insurance Company Name: /1��/� Insurer's Address: 1 .�. �� 3 b"� QU��t 1 -\� " � City/State/Zip: v � �� Policy#or Self-ins. Lic. # "[ L c�-5��7 Q d� � Expiration Date: 3 �� !6 Attach a copy of the workers' compensation policy declaration page(showing the policy number and eapiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a €t�e agfis$1-,590�0 a.�d/oF ane ye�i�tgris��nen°.,-as ..�'�o�.=-m,c:��-peite#'tes in-the faFnt o€s STEH'�VARK 9RB£�t-and a fi:ie 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 c i un e pains and penalties ofperjury that the information provrded above is true and cnrrect. Si ature• Date: Phone#• dJ Or� 77� — �l�� Ojficial use only. Do not write in this area,to be completed by city or town offuiaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2. Building Department 3. CitylTown Clerk 4.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: www.mass.gov/dia , -----. ARBELLA PROTECTION INSURANCE COMPANY ; WORKERS' COMPENSATION AND EMPLOYER' S LIABILITY POLICY , INFORMATION PAGE Policy Number: 9125370315 Renewal of: 9125370314 Agent Code: 0226 1 . Named Insured and Address: A ent Name & Address MACLYN LLC & IRISH VILLAGE RESTAURANT & RESORT LLC 822 ROUTE 28 ' S YARMOLTTH, MA 02664 Named insured is: Limited Liability Other workplaces not shown above: 2 . Policy period: From: 03/13/15 To: 03 13 16 12 : 01 A.M. standard at address of named insured 3 . A. worker' s Compensation Insurance: Part One of the policy applied 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 our liability under Part Two are: Bodily Injury By Accident $500, 000 Each Accident Bodily Injury By Disease $500, 000 Each Employee Bodily Injury By Disease $500, 000 Policy Limit � C. Other States Insured: Part Three of the policy applies to the states, if any, listed here: CT NH RI D. This policy includes these endorsements and schedules: WC00-03-10 WC00-04-14 WC00-0406A WC00-0422B WC20-03-01 � WC20-0302A WC20-0303D WC20-04-05 WC20-0601A ,� 4 . The premium for this policy will be determined by our Manuals of Rules, 'I Classifications, Rates and Rating Plans. All information required on the '�� attached extension of Information Page is subject to verification and I change by audit. '' Total Estimated Minimum Premium Deposit Premium Annual Premium $234. 00 $2, 871 .44 $11, 793 . 83 The premium adjustment period is annual . Countersigned by ��j� Date ;;-(3 ap�3' WC 00 00 O1 A i �