HomeMy WebLinkAboutApplication and WC ~ a TOWN OF YARMOUTH BOARD OF HEALTH �`�
��� APPLICATION FOR LICENSE/PERMIT -2016 NOV ? j (�j�§
* Please complete form and attach all necessary documents by Dece ber I S 2015.
' Failure to do so will result in the return of your application p ket LTH DEPT.
ESTABLISHMENT NAME: e ftr.SohJ �kr KC T TAX ID•
LOCATION ADDRESS: �11 � St. Gy a✓�.�o,h TEL.#: Su�'-3�Z - �{Y 7
MAILING ADDRESS: �8 bai.. S�-• k�..,s✓ a�r
E-MAIL ADDRESS: � C-1C�S�� SM RMGP T�+ C( 0�• � M
OWNER NAME: /_. +�
CORPORATION NAME (IF APPLICABLE):�S�y,,,, � / Cl� �I���t�' 0 Y�h'+n*� a�r. LLL
MANAGER'S NAME: , P �F� L�I�.+kP�Sl.i,� TEL.#: Sod' •.J�fd - Vy�/
MAiLnvG aDD�ss: � 9 S N-e�d wa�ei ,��� av� ���, k�� v i b�l s
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.
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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 a11 times. Please list the
employees below and attach copies of their certifications to this form. The Health Department will not use past
years' rewrds. You must provide new copies and maiutain a file at your place of business.
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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 yoar establishment.
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PERSON IN CHARGE:
Each food establishment must have at least one Person In Chazge (PIC) on site during hours of operation.
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ALLERGEN CERTIFICATIONS:
t311 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.
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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.
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3. 4,
RESTAURANT SEATING: TOTAL #
OFFICE USE ONLY_
— �:ese:tv�:-----. _ -- - ---- --- _ - -- -- —
LICENSE REQUIRED FEE PERMIT�t LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_B&B $55 CA6IN $55 MOTEL $110
_INN $55 CAMP $55 SWIMMING POOL$110ea.
_LODGE $55 _TRAILER PARK $105 _WHIRLPOOL $ll0ea ��,
FOOD SERVICE: � '�..
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �
0-100 SEATS $125 _CONTINENTAL $35 NON-PROFIT $30 �
_>I00 SEATS $200 _COMMON VIC. $60 —WHOLESALE $80 �
RETAIL SERVICE: � —REStD.KITCHEN $80 � .;
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �
<50 sq.R $50 >25,000 sq.ft. $2S5 VENDING-FOOD $25 �
�QS,OOOsq.ft. $150 �0 =FROZENDESSERT $40 �TOBACCO $110 � 7 !
NAME CHANGE: $IS AMOUNT DUE _ $ 260.00 '
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*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** j
i
ADMINISTRATION Y �
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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 i
AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR 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 ,
� MOTELS AND OTHER LODGING ESTABLISHMENTS I
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 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 OPEIVING:All swimming,wading and whirlpools which have been closed for the season must be inspected
by the Health DeparGnent prior to opening. Contact the Health Deparhnent 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 certified lab, and submitted to the Health Department three (3) days priar 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 establislunents 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 Yannouth must notify the Yannouth 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.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 thereafter,with sample results
submitted to the Health Deparhnent. 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.
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 QUIRE A SI PLAN.
_�
DATE: / a�fi/ SIGNATURE:
PR1NT NAME & TITLE: I-3i��v %- ��'-� (s�',t.rt.�
Rev. 10/01/15 �
' - � The Commonwealth ofMassachusetts
Department of Industrial Accidents
Office of Investigations
I Congress Street, Suite I00
Boston,MA 02114-20I7.
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
A�plicant Information Please Print Le¢iblv
Business/Organization Name: �c -K �s�„��i1�, k eT
Address: � l 2� Ma�v. S'r��e t
City/State/Zip: 0.✓r�or�, Y OJJ.75 Phone #: So8 '.3(vZ ' 02141
Ar,e._y,�an employer? Check the appropriate bos: Busin Type(required):
1.� I am a employer with ,3 ( employees (ful]and/ 5. �etail
or part-time).* 6. ❑RestaurantBaz/Eating Establishment
- _ — _ - - -
-2. �am a soTe ro netor or artnershi an3hadeho- �" -� -- - - -
P P P P 7. ❑ Office and/or Sales (incl. reat estate,auto,etc.)
employees working for me in any capaciTy.
[No workers' comp.insurance required] $• ❑ Non-profit
3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment I
their right of exemption per c. 152, §1(4),and we have 10.� Manufacturing
no employees. [No workers' comp. insurance required]*
4.❑ We aze a non-profit organizauon, staffed by volunteers, I 1.❑ Health Care
with no employees. [No workers' comp. insurance req.] 12.❑ Other
•Aay appGcant thaz checl¢box#1 must also fill out the sectio¢below showing the'v worken'compensation policy infoimation.
•'If the coxporete officers have exempted themselves,buT the corporalion has other employees,a workecs'compensarion policy is Iequired and such an �
organizatioa should check box#1. .
I am an employer that is providing worker/s�'compensation insurance jor my employees. Below is the policy information.
Insurance Company Name: n'1 A I`G{'Ct � � �rrc.�,�,.��1-� �✓G G r0✓(�
Insurer's Address: �� �� �l� � 5 I ZLZ
C113'�5L2IC�ZSP: ,✓ f�,� V��p"�('C-L rM !� � � Z�� ,..
Policy#or Self-ins. Lic. # 0 � � �� S a 3 � -I � 8 � <<� _ _Expirafion Date: � 02 0/b
AE#ach a copy of the workers' compensation policy declaration page(showing the poticy nnmber and eapiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalries of a
- fineu1rtff�i;SQ�.BE�an�,�af�ney+ . . . . . -inLhefeano�aSTOF�VQRKORDEl�ands€rxe-__-
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwazded to the O�ce of
Investigations of the DIA for insurance coverage verificafion.
I do hereby cen�, under the pains and penalties ofperjury that the information provtded above is true and correcG
Si ature: ��^-y. �J/� Date: ���aY�do /S—
�
Phone#: �Od� � �Oa " al`f �
Official use on[y. Do not wrUe in this area,to be completed by city or town offzciaL ;
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2. Building Department 3. City/'I'own Clerk 4.Licensing Board 5. Selectmen's OfSce
6.Other
Contact Person: Phone#: '
www.mass.gov/dia �
.� .
INFORMATION PAGE RENEWAL AGRESMENT
Insurer: _ . PRODUCER: AgEnt# 932
MA Retail Merchan[s WC Group Znc. Dowling & O'Neil Insurance Agency
PO Box 859222-9222 PO Box 1990
Braintree, MA 02185 Hyannis, MA 02601
(Carrier Code: 34355) Carrier Policy #: 014005030998115
Carrier Prior Policy #: 014005030998114
1. The Insured: Smithfield Market of Yarmouthport, LLC
Peteraon's Market
Mailing Address: c/o Fancys Market
699 Main Street
Osterville, MA 02655
Fein:
Other workplaces not shown above: Type of Business: Limited Liability Co
SEE SCHEDULE OF OPERATIONS Risk ID:
2. The policy period is from 12:01 a.m. on 1/O1/2015 to 12:01 a.m. on 1/O1/2016
at the insured's mailing address.
3. A. Workers 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 our liability under Part Two are:
Bodily Injury by Accident $ 500,000 each accident
Bodily Injury by Disease $ 500,000 policy limit
Bodily Injury by Disease $ 500,000 each employee
C. Other States Insurance: �
D. This policy includes these endorsements and schedules:
WCOOOOOOB(07/11) WC000308 WC000406A(OB/95) WC000414(07/90) WC000422A(09/08)
WC200301(04/84) WC200302(OS/66) WC2003035(07/99) WC200405(06/O1) WC200601(06/92)
4. The premium for this policy will be determined by our Manuals of Rules,
Classifications, Rates and Rating Plans. All information required below is aubject
to verification and change by audit.
Classifications Code Premium Basis Rate Per Sstimated '
No. Total Hstimated $100 of Annual �
� Annual Remuneration Remuneration Premium
SfiE SCHEDULE OF OPERATIONS
Total Estimated Annual Premium $ 14,647.00
Minimum Premium $ 536.00 E�cpense Constant .00 Deposit Premium .00
SCHEDULE OF OPERATIONS FOR: PAGE: 1 .
Peterson's Market Carrier Policy #: 014005030998115
Smithfield Market of Yarmouthport, Fein:
c/o Fancys Market '
699 Main Street '
Osterville, MA 02655 �
DIV #: 00000 E/L Number: 0000000001 .
OTHER WORKPLACES : �
Smithfield Market of Yarmouthport, LLC �
Peterson' s Market �
918 Main Street State UE#:Z187
Yarmouthport, MA 02675 NJ Taxpayer ID#: 000090641 .
Eff date: O1/O1/15 ,
SIC:5411
DIV # : 00000
E/L Number: 0000000001 .
WC 00 00 O1 A '