The URL can be used to link to this page

Home My WebLink AboutApplication and WC a TOWN OF YARMOUTH BOARD OF HEALT GiCs�C��O I�DD ` ' • E�� APPLICATION FOR LICENSE/PERI4�IT�^� � � G{' �' " ��' DtC : q 2015 , �"� * Please complete form and attach all necessary doc � ertt r IS 2015. � ' Failure to do so will result in the return of your application pac et. HEALTH DEPT. ESTABLISHMENT NAME: o Ba7£. 70 TAX ID: ' � �� LocaTlorr aDD�ss: 69 Ri 8 TEL.#:�g-3 —5n / MAILING ADDRESS: .O• o v <v E-MAIL ADDRESS: i(' $,�j �r/y!/}< • �rYi OWNERNAME: ov oo t t' 70 CORPORATION NAME IF APPLICABLE): y 1/d O 005£ �.�/r/ou �� MANAGER'S NAME: /G�'7/� % /i7S TEL.#: �'�� MAILING ADDRESS: .Q POOL CERTIFICATIONS: The pooi supervisor must be certified as a Poo1 Operator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. ---__ _ _ 1 _ _ _ „ L. 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. Z• 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 Managex, 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. Yau must provide new copies and maintain a file at your establishment. �. ;so��oti rl,�a�� z. .�,��«'�,�,��, PERSON IN CHARGE: Each food establishment must have at least one Person In Chazge (PIC) on site during hours of operation. i._�os��, -�.�►4h-- _-_- -_ --- 2..--!`-ti��w�LL1��ins=---- 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. i. M��.�►w,�t,(� C��G✓.�v� 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 fi►e at your place of business. i. �f'o�f r✓I�. �-�aaw,. 2. 5-r��an�� l'�bLLL. 3. 'j—i4� o vt � 4. RESTAURANT SEATING: TOTAL# 3 3 3 _- -_ _ _ �3r�`IC� L7$E @N�Y_ LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $1!0 INN $55 CAMP $55 SWIMMING POOL$I l0ea. � LODGE $55 TRAILERPARK $105 WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQOIRED FEE PEItMIT# LICENSE RF,QOIRED FEE P MI / 0-IOOSEATS $125 _CONTINENTAL $35 1 NON-PROFIT $30 ��0 >I00 SEATS $200 . COMMON VIC. $60 WHOLESALE $80 —RESID.KITCHEN $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 _<25,000 sq.ft. $150 _PROZEN DESSERT $40 _TOBACCO $I10 NAME CHANGE: $15 AMOUNT DUE _ $ 30.00 *****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 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 Yazmouth 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 of Motel 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: Peopie 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 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 U IT AN. DATE: /�/S�� SIGNATURE: � PRINT NAME& TITLE: M/�i�L , � /�1/�J ' � �''��` � Rev. 10/O1/IS . t� The Commonwealth of Massachusetts , Deparlment oflndustrial Accidents ' Offace of Investigations � I Congress Streef, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses A�►plicant Information Please Print Le¢iblv Business/Organization Name: y�¢Gl4?tD c�!'1 �"!OD S� LG��vb�7� Address: �� a�g CiTy/State/Zip: �3�I"�L �i4�Grvtov� �/� ��ne #: SO �6''.3�Y � �� Ar�e y an employer? Check the appropriate box: Business Type(required): 1.L►�f I am a employer with�_employees (full and/ 5. ❑ Retail or part-rime).* 6. ❑ RestaurantBaz/Eating Establishment — — -- 2. I am a sole propnefor or partnership and have no �, � Office and/or Sales (inc1.real estate, auto, etc.) employees working for me in any capacity. [No warkers' comp. insurance required] g• �Non-profit 3.❑ We aze a corporarion and its officers have exercised 9. ❑ EnteRainment their right of exemption per c. 152, §1(4),and we have 10.0 Manufacturing no employees. [No workers' comp. insurance required]* 11.❑ Health Caze 4.❑ We aze a non-profit organizarion, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.0 Other •Any applicant that checks box#1 must also fill ouT the section below showing the'v workers'compensation policy informstion. **If the cotpornte officers have exempted themselves,but the corporabon has otha employees,a workets'compensaaon policy is required md such an organization should check box#I. Iam an employer that isproviding workers'compensation insurance for my ployees./Be+low is thep/olic�y i/nf+ormation. Insurance Company Name�(�c,�T'�"� .��i�iA1� LL �D l4 � r}�it)�(7'-Y C.m Insurer's Address: �� 7 �� City/State/Zip:k�_�,�?� C � �0' ��7� �� Policy#or Self-ins.Lic.#�GG�Q— �1��DD( �6�� Expirafion Date: ��—�S^v�3/d Attach a copy of the workers' compensation policy declaration page(shawing the policy uumber and eapirarion date). Failure to secure coverage as required under Section 25A of MGL a 152 can lead to the imposition of criminal penalues of a --fine up to�T,5�i0.UQ andioi one-yeaTlmprisonmeiit�as w�i�as ct'v�tp��atfies in t`ne 2otm of a STOP WORI�OIZ7ER an�a�e 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 Invesrigations of the DIA for insurance coverage verification. I do hereby cenify,under t pams penalties ofperjury tha2 the information provided above is true and cnrrect. Sienature ��/i1A � � �� Date: �� —U—I J Phone#• ✓��' b / — 7 %y� i Official use only. Do not write in this area, to be compfeted by city or town oJfzciaL � City or Town: Permit/License# Issuing Authority(cirde 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 . . • �"ra�[:. �n` � NOTICE NOTICE Z TO ` , a TO EMPLOYEES e EMPLOYEES Y�t� M sV. 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 requued by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this will give you notice that I (we) have provided for payment to our injured employees under the above-mentioned chapter by insuring with: NOVA CASUALTY COMPANY NAME OF INSI.7RANCE COMPANY 726 EXCHANGE ST SUITE 1020 BUFFALO NY 14210 500-388-1569 ADDRESS OF INSI.JRANCE COMPANY LFR-WK-0012469-1 12/15/2015 to 92/15/2016 POLICY NiJMBER EFFECTIVE DATES LOCKTON RISK SERVICES, INC. P.O. BOX 410679 KANSAS CITY, MO 64141-0000 913-652-7668 NAME OF INSIJRANCE AGENT ADDRESS PHONE # YARMOUTH MOOSE LODGE#2270 769 ROUTE 28 SOUTH YARMOUTH, MA 02664 EMI'LOYER ADDRESS EMPLOYER'S WORKERS' COMPENSATION OFFICER(IF ANY) DATE MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out 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 his 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 are hereby notified that the insurer has arranged for such attention at the C��-�� °o�� l�o�PiT�9 � f��k cS�,� 1�YQnr1�S, d'Ifl oa6o/ NAME OF HOSPITAL ADDRESS TO BE POSTED BY EMPLOYER • ��(�'r') ,4co c�� CERTIFICATE OF LIABILITY INSURANCE 1.�� iii3uizuis 7HIS CERTIFICA7E IS ISSUED AS A MATTER OF INFORMATON ONLY AND CONFERS NO RIGHTS UPON THE CER7IFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATNELY OR NEGATIVELY AMEND, EXTEND OR AL7ER TXE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTI7UTE A CONTRACT BEiWEEN THE ISSUING INSURER(S), AU7HORIZEO REPRESENTAi1VE OR PRODUCER,AND THE CERTiFICAiE HOLDER. IMPORTANT: If the certificate�oltle�is an ADDIiIONAL INSURED,the pdicy(ies)must be erMorsed. If SUBROGA710N IS WAIYED, subject to the terms and corMitions of the policy,certain policies may require an endorsement. A statemeM on this certificate dces not coMer rights to the certificate hdder in lieu of such entlwsement�s�. vreooucac Np� Lockton A££iaity, T.TP Lockton Affiaity, LLC q�ciio bR:866-836-3373 ��;913-652-7599 E�1AiL e.o. Hwc 879610 AO�� RH[1888 City� MD 64187-9610 INSURFASAFFORDINGCOVFRAOE NAICi INSUftERA:tbva Cacualty co azssz INSUREO INSURER B: Yarmouth Moose Lodge ;2270 INSURER C: P.O. Hoa 186 INSURER D: 9. sarmoucn, c�a+ oz6ca �NSursvte: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: hilS IS TO CER7IFY THAT 7HE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO TF�INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICA7ED. NOTMhiSTANqNG ANY REQUIREMENT,lERM OR CONqTION OF ANY CONTRACT OR OTHER DOCUMEM WITH RESPECT TO WHICH hIIS CERTYFICATE MAY BE ISSUED OR MAY PERTAIN, hiE INSURANCE AFFORDED BY THE POLIGES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CANDIiIONS OF SUCH POLIGES.UhRTS SHONM MAV HAVE BEEN REDUCED BY PAID CLAIMS. I� TYPEOFINSURANCE � B PoLICYNUM� M�EfF M LICYEXP LIMITS LTR COMMERCIALGENERRLLIA&LITY EACHOCCURRENCE $ CLAIMS-MADE �OCCUR AMAGE O EM D PREAIISES a oecurtence $ Mm EXP(My one permn) S PFRSONAL b ADV INJURV S GEN'LAGGREGATELIMITAPPLIESPH2: GENERALAGGREGATE S POLICV�j� �LOC PROOUCTS-COMPiOPAGG S OTHER: $ AUTOMOBILELIA&LITY COMBINm51NGLELIMIT $ Ea aaitlem p�.ry p�p BODILV INJURV(Per pe�wn) $ ALLOWNm SCH�UIID BODILVIN.NRV(PeraooEe� $ AUTOS AUT0.S NON�OWNED PROPERIYDAMAGE $ HIREOAUTOS AIJrOS eccitlen 8 UMBRELLAlIAB p�CUR EACHOCCURRENCE 8 IXCESSLWB �qIMSMNDE qGGREGATE E DED RETENTION$ S A WORKQtSCOMPQISRTION LFR-SiR-0012969-1 12/15/2015 12/15/2016 p� ��E �H- ANOBAROYQt5L1ABILlTY y�N ANYPROPRIEfOR/P/.RTNERIIXECUTIVE ❑ NIA E.LFACHACpDFNT S1OO,O00 OFFlCERIMEMBER E%CLUDED? (Ma�wamryinNH) ELDISEnSE-EAEMPLOV 5100�000 If yes.Aeusibe untler - -..-....'..'- DESCRIPrIONOFOPERATIONSbelav E.LpSFASE-POLICVLIMIT 5500 000 OESCRIPfION OF OPERATION51 LOCATqNSI V@iICLES(ACORD 101,AOtlNonal Remarks5che0ub,may be Ylachetl R mare space is required) CERTIFICATE HOLDER CANCELLATION Proof o£ Coverage SHOULD ANY OF 7HE ABOVE DESCRIBED PoLICIES BE CANCELLm BEFORE THE IXflRATION DATE 7HEREOF, NOTiCE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PRONSIONS. AUTFIORIZID RES@1TATIVE 1988-2014 A ORD ORPORATION. All righfs reserved. ACORD 25(201M07) The ACORD name and logo are registered rks M ACORD 17950966 780345