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Home My WebLink AboutApplication and WC " a TOWN OF YARMOUTH BOARD OF HEALTH `� �� APPLICATION FOR LICENSE/P�IT��0�2 , NOV 6 3 ZU1`J " * Please complete form and attach all necessar��cw�ents by �cem er IS 2015. Failure to do so will result in the return�yo�appiic��on pac et. DEPT. ESTABLISHMENT NAME: OAGQETTS��p�J�g TAX ID• � LOCATION ADDRESS: '1071 RTE.28 TEL.#;,��' �� MAILING ADDRESS: ' �H� MA 02 E-MAIL ADDRESS• �S � OWNER NAME: r e' CORPORATION NAME�3F' PPLI ABLE):��'/r-i-O�J� �4 MANAGER'S NAME: . U �� TEL.#: 33r - - G� MAILING ADDRESS: (o Gt / O o POOL CERTIFICATIONS: The pool supervisor must be certi£ed 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 a11 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 f►le at your establishment. 1. 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. 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. 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. 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY__,_____ __ --- _--te�tac:—— — - -- - - ---- --- LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# UCENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $1I0 [NN $55 CAMP $55 SWIMMINGPOOL$110ea. _LODGE $55 TRAILERPARK $105 WHIRLPOOL $1IOea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 _CONTINENTAL $35 NON-PROFIT $30 >100 SEATS $200 COMMON VIC. $60 WHOLESALE $80 —RES[D.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE RMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �<SOsq.ft. $50 P �� >25,OOOsq.ft. $285 VENDING-FOOD $25 � _<25,000 sq.ft. $150 _FROZEN DESSERT $40 �TOBACCO $I10 � NAME CHANGE: $15 AMOUNT DUE _ $_l(�,0.00 �. ***'"*PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM****• � ., ✓ i 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 ST�+��Ti4i(�Ii�b�COMPENSATION INSURANCE , AFFIDAVIT MUST BE COMPLETED AND SIGNED,^'O�'�' `'�' �� _ . .,:;i. . i 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 � i MOTELS AND OTHER LODGING ESTABLISHMENTS � TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be I 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 thiriy(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 i dwelling unit shall not be considered transient. Occupancy that is subject to the collection of Room Occupancy i 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 standard plate count ; by a State certified lab, and submitted to the Health Department three (3) days prior to opening, and quarterly i thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of i closing. - FOOD SERVICE SEASONAL FOOD SERVICE OPENING: �, All food service establishments must be inspected by the Health Department prior to opening. Please contact the i 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 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,prepazation,or display of any food product by a retail ar food service establishment is prohibited. i NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RET[JIZN 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 REQUIRE A SITE PLAN. DATE: ��°� I �� SIGNATURE: PRINT NAME&TITLE: �o S E D K N Ol� � s pv'rN�� Rev. 10/O1/IS , , „ � � The Commonwealth ofMassachusetts Department of Industrial Accddents Office of Investigations 1 Congress Sireef, Suite I00 Boston, MA 02114-20I7. www.mass.gov/dia Workers' Compensafion Insurance Affidavit: General Businesses Applicant Information Please Print Le�iblv Business/Organization Name: DAGGETTS UQUORS 1071 R7'E.28 Address: SC•YARMOUTH, MA 02664 City/State/Zip: Phone#:{�U� .��d'— � � �� Are you an employer? Check the appropriate bos: Busin Type(reqnired): 1.� I am a employer with�employees(full and/ 5. [/�Retail or part-time).* 6. ❑ Restaurant7Baz/Eating Establishment T, am a so 0 r�oi or ers i� av� _ - ---- -- --- -- P P P P 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 corporarion and its officers have exercised 9. ❑Entertainment their right of exemption per c. I 52, §1(4),and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]* 11.0 Health Caze 4.❑ We aze a non-profit organization,staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.❑ Other *Any appGcant that checks box#1 must also fill out the section below showing the'v workers'compensation policy infocmation. **If the coipo2ate officers have exempted themselves,but the corporation has other employees,a workets'compe¢sation policy is Ieqaired and such an organiution should check box#1. I am'an employer that isproviding workers'compensation insurance jor my emp[oyees. Be[ow is the policy information. ` Insurance Company Narne:��i � �l D✓'L/e r"��!�v� �nG Insurer's Address: ��6� �-�l �a� `9 a a Z CiTy/State/Zip: �r'QI ��e� � .4 �a � �S Policy#or Self-ins. Lic. # D l.��Qf D a� L>Db j� S Expiration Date: � '! //�C Atfach a copy of the workers' compensation policy declaration page(showing the policy number and eapiration date). Failure to secure coverage as required under Secuon 25A of MGL c. 152 can lead to the imposition of criminal penalries of a ' �ine up to ,�ODA6 andlor one-year imp`nsonme�as welYcs c,iT p€i��ie�'u�i��#'arm af aSY'6P R�dRK�RI�R�d a fin� 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,under the pains and penalties ojperjury that the information provided above is ttue and correct Si ature: Date: y��a �� Phone#: Y 9�— �lP r�'� Official use on[y. Do not write in this area,to be compfeted 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 NOTICE � NOTICE TO " > T� EMPLOYEES � EMPLOYEES 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, Sections 21,22&30,this will give you no6ce that I(we)have provided for payment to our injured employees under the above-mentioned chapter by „ insuring with: MA Retail Merchants WC Group Inc. NAME OF INSURANCE COMPANY PO Box 859222-9222 Braintree,MA 02185 ADDRESS OF INSL7RANCE COMPANY 1/Ol/2015 - 1/Ol/2016 014001022000115 POLICY NUMBER EFFECTIVE DATES Association Benefits Insurance 299 Ballardvale St, Suite 1 Wilmington,MA 01887 NAME OF IN5URANCE AGENT ADDRESS PHONE# Da gett's Li uors 1071 Route 28 South Yarmouth MA 02664 EMPLOYER ADDRESS � EMPLOYER'S WORKERS' COMPENSATION OFFICER(IF AN� DATE MEDICAL TREATMENT The above named insurer is required in cases of personal injurias arising ouY of and in the course of employment to furnish 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 employee. The employee may select lus or her own physician. The reasonable cost of the ser- vices provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably connected to the work related injury. In cases requiring hospital attention, employees aze hereby notified that the insurer has arranged for such attention at the NAME OF HOSPITAL ADDRESS TO BE POSTED BY EMPLOYER