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HomeMy WebLinkAboutApplication and WC � - . - G3[� � TOWN OF YARMOUTH BOARD OF HEALTH ��� APPLICATION FOR LICENSElPF.I�MIu����6g� � NOV � 0 2015 ` * Please complete form and attach all necessary doci s y ece' ber EPT. Failure to do so will result in the return of your application pa ESTABLISHMENT NAME: � — TAX I : - LOCATION ADDRESS: " a� l. L.#: - 6a -� (r MAILINGADDRESS:�G �1 ���1; csii{-��j�4 GR/�`/(L� E-MAIL ADDRESS: ;¢r LE ` ,r OWNER NAME: CORPORATION NA (IF APP ICABLE):f; � ►.� , — MANAGER'S NAME: r+ ca114 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 Operatar(s)and attach a copy of the certification to this form. - - - — . - -- � 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 £►le 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. 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Chazge (PIC)on site during hours of operation. 1. 2. 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 at[ach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a Cle 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. I. 2, 3. 4. RESTAURANT SEATING: TOTAL# -�� —. . --_ . . 11FFi('F iTCF ONi V �. -- --------� �. LODGING: .... .-...-.._ LICENSE REQUIRED FEE PERMIT# 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 $ll0ea. �. FOOD SERVICE: � LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# L[CENSE REQUIRED FEE PERMIT# ! 0-100 SEATS $125 CONTINENTAL $35 NON-PROFIT $30 I �>100 SEATS $200 � �COMMON VIC. $60 �7� =W[jpLESALE $80 ', —RESID.KITCHEN $80 RETAIL SERVICE: ' LICENSB REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 s ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 _Q5,000 sq.ft. $150 _FROZEN DESSERT $40 —TOBACCO $I10 �� NAME CHANGE: $15 �``�'� �. c :� s��-b;z -�;�TT DUE _ $ 3 1 v.00 ! *****PLEASE TURN OVER AND C(�]P�.GTF'n'ruco m..�.+r FORM***** I , , , i Y . _ ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yazmouth 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 Warker's '� Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE I AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR j CERT. OF INSURANCE ATTACHED ✓ I 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 �f MOTELS AND OTHER LODGING ESTABLISHMENTS li TRANSIENT OCCUPANCY: For purposes of the limitations of Motel orHotel use,Transient occupancy shall be limited to the temporary and short term occupancy,ordinarily and customarily associated with motel and hotel use. i 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 ninery(90)days within any six(6)month period. Use of a guest unit as a residence or j 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 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. I i 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: i All food service establishxnents 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 Yannouth Health Department by filing the required Temporary Food Service Application form 72 hours priar to the catered event. These forms can be obtamed at the Health Deparhnent,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 COOHING: i Outdoor cooking,prepazation,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. i ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MO L OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND PPROV D, Y THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY RE . - DATE: � SIGNATURE: PRINT NAM�jjE & TITLE: /� �i/,�,��1 ,///1 r i /' I'! Rev. 10/OIAS /� /�/" V� i ��z��-- i ' ' . � ` The Commonwealth ofMassachusetts Department oflndustrialAccidents Offace oflnvestigations I Congress Street, Suite l00 Boston, MA 02I14-2017 www.mass.gov/dia Workers' Compensation Insnrance Affidavite General Businesses Applicant Information Please Print Legiblv Business/Organization Name: Address: City/Staxe/Zip: Phone #: Are you an employer? Check the appropriate bos: Business Type(required): 1.❑ I am a employer with empioyees (full and/ 5. ❑Retail or part-time).* 6. ❑ Restaurantl�3az/Eating Fstablishmeni 2.�I am a sole proprietor or partnership an ave no 7, � Office and/or Sales (incl.real estate,auto,etc.) ' employees working for me in any capacity. [No workers' comp. insurance required] $• ❑Non-profit 3.❑ We are a corporarion and its officers have exercised 9. ❑Entertainment their right of exemption per c. 152, §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 applicant thaz checks box#1 must also fill out the section below showing their workers'compensation policy information. � •*If the wcpomte officers have exempted themselves,but the corporation Las otha employees,a workers'compensation policy is required md such an � organizarioa should check box#L � � �. I am an employer that is prnviding workers'compensatiod ansurance fm my employees. Below is the poGcy information. ', Insurnnce Company Name: Insurer's Address: ' CiTy/State/Zip: Policy#or Self-ins. Lic.# Eacpiration Date: Attach a copy'of the workers' compensation policy declaration page(showing the poGcy number and eapiration 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 $1,500.06 andToi one-year impnsorimenf,as weii-as civiI,pena7ties in ffie form oia STOP�JO�OItIIEIt an�a�ne of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwazded to the OfFice of Investigations of the DIA for inswance coverage verification. I do hereby certify, under the pains andpenalties ofperjury that the informafion provided above is true and correct. Si�ature• Date: Phone#: Offactal use on[y. Do not write in this area,to be completed by city or town officiaL City or Town: Permit/License# Issuing Authority(circle one): - 1.Board of Health 2. Building Department 3. City/'Pown Clerk 4.Licensing Board 5. Selectmen's Office 6.Other Contact Person: PLone#: wwwmass.gov/dia . � saCORd CERTIFICATE OF LIABILITY INSURANCE DAIE(MMIDD/YYYY) ��. 11/24/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON TME CERTIFICATE HOLDER TMIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIE$BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTRUfE A CONTRACT BETWEEN THE ISSUING INSURER(S�, AUTNORIZED REPRESENTATNE OR PRODUCER,AND TNE CERTIFICATE HOLDER IMPORTANT: If the certificate holder is an ADDRIONAL INSURED, the policy(les)must be endorsetl. If SUBROGATION IS WAIVED,subject to the terms and wndltions of the policy, eertain policies may reqWre an e�WorsemeM. A statement on this eertiFieate does not wnfer dghts W the certiFlwte holder in Ileu of such endorsemen s. � � � PRODUCER ��A�T KIRKILESB.ASSOCL4TES � �ac�ria �e:�8�-659-3300 Fi."�c Ho� COMMERCWL INSURANCE BROKERAGE LLC qDDRESS: 273RIVERSTREET NSURERSAFFORDMIGCOVERAGE NAICM NORWELL,MA 02067-2209 iNsuaEa n: MASS RETAIL MERCHANTS WSURED MSURERe: ANTHONTS CUMMAQUID INN�INC. NSUR RC: RT.6A wsuReR o: YARMOUTHPORT,MA 02675 MSURERE: � INSURER F: - BOVERAGES � CERTIFICATE NUMBER: 3195 � � �-'�" REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE�GSTEDbEiOW-tiAVE-BEEN+6SUED-TO-THE WSl1RED19A�AED ABOVE FOR THE POLICY PERIOD INOICATED. NOTWRHSTANDING ANY REQUIREMENT,TERM OR CONDRION OF ANV CONTRACT OR OTHER DOCUMENT WRH REBPECT�TO WHICFi TNIS � CERTIFICATE MHY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BV THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMRS SHOW N MAV HAVE BEEN REDUCED BY PAID CLAIMS. IN�SRR rypE OF INSURANCE IN8D W VD POLICV NUMBER �U Y EFF MPOLIC E1IP LINRS COMMERCW.GENERFLW1BILffY EACHOCCURRENCE $ CLAIMS-MADE ❑OCCUR PR�EMISE Eaacw��iance) $ MED EXP(M aro �san E PERSIXJFL 8 ADV INJURY E GEN'LAGGREGAIELIMRAPPLIESPER: GENERALAGGREOATE $ POLICV�JECT � �� PRODUCT3-COMP/OPAGG $ OTHER: $ AUTOMOBILE W181LITY � e���i)�1CaLE LIM s MIYAUTO � � BODILVINJURY�Perpareon) S AUTOS NED AUTO�SWULEO � . .. .. . BODILVINJURYryeracdtlant) S HIREDAUTOS AUTOS NED (P� E�DPMF E f S UMBREILALL�B p�CUR EACHOCCURRENCE EXCESS LUB CLAIMS�M1fADE AGGREGATE S DED RETENTION S s NqRKER3 COMPENSpiION x PER A ANDEMPLOYERS'WIBILRY 0140050310081014 1/1/2015 1/1/2016 ANVPROPRETOfLPAR71JERlEXECUTN�1 N�A E.L.EACHFCCIDENT E �JOO,OOO ,Nan�W1�InNH�EXCLLIOED'/ I �� I E.I.DISEASE-EAEMP�OYE E 500,000 � N�a tleecnbaimUer E.L.DISEASE-POLICVLIMR E 50��00� DESCRIP OPERAl10NS Eelav DESCRIPTION OF OPERATONS/LOCATON31 VENICLES(ACORU 107,A4tlMonal Rarerks SehetluM,may Oe atlachetl M more apaee is rpuMaE) CERTIFICATE HOLDER CANCELLATION � $HOULD ANV OF THE ABOVE DESCRIBED POLICIES BE CAHCELLFA BEFORE TOW N OF YARMOUTH . . rr�e EXWRATION DATE TNEREOF, NOTICE WILL BE DELIVERED IN HEALTHINSPECTOR � � ' ACCORDANCEVYITHTHEPOLICYPROVISIONS. 99 BUCK ISLAND ROAD . W.YARMOUTH,MA 02673 . nurHowgonerrseseNr�nve FAX:508-7603472 ��� i �1988-2074 A RD RPORAT N. NI rights reserved. 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