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Home My WebLink AboutApplication and WC a�c��ad�� TRklS �2 r, a TOWN OF YARMOUTH BOARD OF HEALTH *' � E�� APPLICATION FOR LICENSE/PERMIT -2016 D�C .;; 8 2U 15 �"°' * Please complete form and attach a11 necessary documents by Decem r DEPT. Failure to do so will result in the return of your application packet. � '�j„ ,��C� �-�•c�ri ESTABLISHMENT NAME: �t K! i i'L2+� T ID: LOCATIONADDRESS: S-'t7 ��' � k �y�9�t/� M�- o?1r�EL.#:,�'t�S-'��' 3�3I MAILING ADDRESS: E-MAIL ADDRESS: OWNER NAME: Si el/� 1>'//✓'� / r4 EN CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: TEL.#:�d� MAILING ADDRESS: 5�'7 �`'�L9 ) 7v f� '-c..t - �'9-✓�-)''�s e�`�td' /w�- 02�7-� 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. 1. L 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 file at your place of business. L 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service estabiishments 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 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 _ _ _ ? _ _ --_ ___ 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 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 # __ __ __ _ _ _ _ _ - OFFiC'ET1� _ ___ _ _ ---- - _ _ LODGING: �� Li^SNSF,R£QU�RED FEP PF.RMIT# - LIC.�NSF–xFl?UIREQ FEE PERbIIT# _ LICFNSE REQUIRED FEE PERMIT# _ B&B $55 CAB1N $55 MO"CEL $I16 INN $55 CAMP $55 SWIMMING POOL$110ea. LODGE $55 TRAILER PARK $105 _WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE P RMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �0-100 SEATS $125 � �O`I I CONTINENTAL $35 _NON-PROFIT $30 _>100 SEATS $200 �COMMON VIC. $60 ��$ _WHOLESALE $80 —RESID.KITCHEN $80 RETA[L SERVICE: � LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT k =<2� q >25,000 sq.ft. $285 VENDING-FOOD $25 ,000 sq.ft. $150 —FROZEN DESSERT $40 _TOBACCO $I10 NAME CHANGE: $15 AMOUNT DUE _ $ �85.00 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** .� ADMINISTRATION � Under Chapter 152, Section 25C,Subsection 6,the Town of Yannouth 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 Yarmouth tases 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 of the limitations of Motel or Hotel use,Transient occupancy shall be limited to the temporary and short term occupancy,ordinarily and customazily 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 Deparhnent 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. 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 priar 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 Departxnent,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 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 RESPONSIBILIT'1'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 REQUIRE A SITE PLAN. DATE: SIGNATURE: PRINT NAME & TITLE: Rev. 10/OIAS � The Commonwealth of Massachusetts � Department of Industrial Accidents Office of Investigations I Congress Street, Suite l00 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legiblv Business/Organization Name: y�} K1 S /"� Z Z-� Address: �i1� iM Y4 l W �t ' City/State/Zip:(it�•yA �'Mo�`+�3 �t7 oZC�%S Phone#: �i-e"�'�' �7"�l — 3�3 � Are you an employer? Check the appropriate box: Business Type(required): 1.❑ I am a employer with ,� employees(full and/ 5. ❑ Retail or part-time)* 6. estaurantBaz/Eating Establishment 2.[�I am a sole proprietor or parmership and have no �, [� pgice 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 are a corporation 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.❑ Health Caze 4.❑ We aze a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.❑ Other 'Any applicant that checks box#1 must also 5ll oat the section below showiag the'u workexs'compensation policy iaformation. •'If the corporefe officecs t�ave exempted themselves,but the corporation has other employees,a workets'compensation policy is required and such an organization should check box#1. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Nazne: Z, _ /LLl14,f- ,� Insurer's Address: � d /3 fJ �' 3 S � c�ty�sraze�zip: w _ `� '-� ,z r--c _ su b4 _ b z67 3 Policy#or Self-ins. Lic. # �Z�� 'tl76�,�f/t9fd— �— /� Expiration Date: �� • �G'/� Attach 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 penalties of a fine up to $I,500.00 and/or one-yeaz imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine 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 certify, under the pains and penalties ofperjury that the information provided above is true and correct. �f'�t- � 1��.�-�_ /Z- - Sienature: � s Date: �� ! J Phone#: {`f� � — ��9' ", C� �'Z d 6 Official use only. 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/Town Clerk 4.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: www.mass.gov/dia }{` VDAC � zuR�cH WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY TYPE AR INFORMATION PAGE WC 00 00 01 ( A) POLICY NUMBER: (6ZZU6-0762N0o-8-15) RENEWAL OF (6ZZUB-0762N00-8-14) INSURER: AMERICAN ZURICH INSURANCE COMPANV _ NCCI CO CODE: 17965 1. INSURED: PRODUCER: VARETIMOS, STEVE DBA CHAGNON INS AGENCY INC TAKIS PIZZA P .O. BOX 355 547 MAIN STREET ROUTE 28 WEST VARMOUTH MA 02673 WEST YARMOUTH MA 02673 Insured is AN INDIVIDUAL Other work places and ident"rfication numbers are shown in the schedule(s) attached. 2. The policy period is from o5-22-t 5 to 05-22-16 12:01 A.M. at the insured's mailing address. 3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers Compensation Law of the state(s) listed here: MA — B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed in '— item 3.A. The limi[s of our liability under Part Two are: „� _ Bodily In�ury by Accident: S 10000o Each AccideM ,_ Bodify Injury by Disease: S 50000o policy Limtt o_ Bodily InJury by Disease: S t o000o Each Employee = C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, 'rf any, listed here: �� COVERAGE REPLACED BY E�ORSEMENT WC 20 03 066 o� = D. This policy includes these endorsemeMs and schedules: �— a� SEE LISTING OF E�ORSEMENTS - EXTENSION OF INFO PAGE � o� — 4. The premium for this policy will be determined by our Manuals of Rules, GYassffications, Rates and Rating — Plans. All required information is subject to verification and change by audit to be made ANNUALLY. DATE OFISSUE: 05-11 -15 wC ST ASSIGN: MA