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Home My WebLink AboutApplication and WCi , � _�_ �$. R. WR�F'P�NT d TOWN OF YARMOUTH BOARD OF HE LTH Towro kt-ouSES �� APPLICATION FOR LICENSE/PERMIT 20�sT 2 6 2015 _ �"' * rlease complete form anl attzch all necessary docum nts _ S ' 015. 'tjlo� Failure to do so will result in the return of your � '� ��D'� ESTABLISHMENT NAME: i c mri d U S{S ID: - LOCATION ADDRESS: ` e u TEL.#: - - 37- 0!0 MAILING ADDRESS: Lv P ' o G E-MAIL ADDRESS: � p . C � O WNER NAME: CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: 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 Operator(s) and attach a copy of the certification to this form. —�� y/.�1 �I _ . _ _ �. _ _— __ _ _ T FT177 S 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. 1. �Pq�� C.• l�"6Y.Sr5n .S 4. JO �e h L ffP � 3. )J 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 Ma�ager, 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. 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. l. 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# ------ _ --- — —__�EFII'�IT.S�-(�N��'--- ---- - -- - — - - LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT It B&B $55 CABIN $55 MOTEL $110 _INN $55 CAMP $55 =SWIMMINGPOOL$IlOea. ,�/� _LODGE $55 _TRAILER PARK $105 WHIRLPOOL $1IOea. .�- FOOD SERVICE: � LICENSEREQUIRED FGE PERMITl1 LICENSEREQUIRED FEE PERMIT# LICENSEREQUIRED FEE PERMIT# 0-IOOSEATS $125 _CONTINENTAL $35 NON-PROFIT $30 _>I00 SEATS $200 _COMMON VIC. $60 WHOLESALE $80 - —RESID.KITCHEN $80 RETAIL SERVICE: . L[CENSEREQUIRED FEE PERMIT# LICENSEREQUIRED FEE PERMIT# UCENSEREQUIRED FEE PERMITIt _<50 sq.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 � _<25,000 sq.ft. $150 . _FROZEN DESSERT $40 =TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE _ $ (l a . OO **•**PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM****• i ADMINISTRATION �.� .�s I i 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 V f OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid p ' r to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: I YES NO I 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 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 sha11 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 sha11 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 Departrnent to schedule the inspection three(3) days prior to opening. PLEASE NOTE: People aze 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 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: II 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.varmouth.ma.us under Health Department, Downloadable Forms. FROZEN DESSERTS: Frozen desserts must be tested by a State certified lab prior to opening and montttly 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 RESPONSIBILTTY 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 PLAI�., DATE: / SIGNATURE: !1J G/ PRINT NAME & TITLE: fSbh S � G u/'�✓� Rev. 10/OU15 I� � The Commonwea[th ofMassachusetts ;; ` DepartmentoflndustrialAccidents Office oflnvestigations I Congress Street, Suite 100 Boston, MA 021I4-20I7 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Aunlicant Information Please Print Le�iblv Business/OrganizationName: (kS K ,�uer ��t �l�c.Nh l�IO�lS�1' Address: 710 �/' � S� Il /�1 i /�� 02�L : .5�� - 7.37 ' y�Olo City/State/Zip: � 7 Q/`�'!Ol.r l� / / Phone Are you an employer? Check the appropriate box: Business Type(required): L�I am a em loyer with .�employees(full and/ 5. ❑ Retail or rt- 'u�s .* 6. ❑ RestauranUBaz/Eating EstablisTiment - __ --- - - — --- 2. I am a sole propriefor or partnership and have no 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 ue 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.❑ Heaith Caze 4.❑ We aze a non-profit organization,staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.�Other •Any applican[that checks box#1 must aLso fill oui the section below showing the'u worke:s'compensation policy infoimatio¢. ••If the cocpomte officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required md such an ��. olgani7ation should checkbox#1. I am an employer that is provz ng workers'c�o1mpensation insurance for my emp[oyees. Below is the policy information. Insurance Company Name:�j YN �U TG a J TI'i SG/'Q N C� �o. Insurer's Address: l- 0 Z�a �l -!b 7� City/State/Zip: f � O Q � d�- � 7� Policy#or Self-ins. Lic.# ' OO ' �a2 �.0 - � �cpiration Date: �� I� Attach a copy of the workers' compensation policy declaration page(showing the policy number. d e piration 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 $1,500.0�and/or one-year imprisonment,as weli as civiI penaTties in the form of a ST6P Vva1�K GRUEk ancTa 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 Investigations of the DIA for insurance coverage verificarion. I do hereby cerC ,under the ' s and penalties ofperjury that the information provided above is true and correct Si ature: � Date: �D G o?�/ � Phone#: - 7- 7 0 �� O�cia[use only. Do not write in this area,to be completed by city or town o�ciaL City or Town: Permit/License# Issning 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 � � - . A.I.M. Mutual Insurance Company � ,pr1. Mutual Massachusetts Employers Insurance Company New Hampshire Employers Insurance Company INSURANCE COMPANIES Associated Empioyers Insurance Company �'r RENEWAL PROPOSAL WORKERS' COMPENSATION Policy#:AWG400-7029102- Insurance Company:A.I.M.Mutuai Insurance Company 2015A Insured: Producer: 1005—1 — 1 Bass River Waterfront Townhouses HUB International New England LLC 1376 Bridge Street-#19 299 Ballardvale Street C/o Peggy Parsons&Joe Frey Wilmington, MA 01887 South Yarmouth, MA 02664 Employers' Liability: Renewal Effective Date: 06/01/2015 Bodily Injury By Accident 100,000 Each Accident Anniversary Rating Date: O6/01/2015 Bodily Injury By Disease 500,000 Policy Limit Quote Date: 03/26/2015 Bodil In'u B Disease 100,000 Each Em lo ee Unit i -Bass River Waterfront Townhouses Massachusetts From 06l01l2015 to O6l01/2016 Total Estimated Rate Per Estimated Annual $100 of Annual ClassifiCations Code No. Remuneration Remunera�t�io�$ Premium� CLERICAL OFFICE EMPLOYEES NOC 8810 If any BUILDINGS NOC-OPERATION BY OWNER �t5 8,042 2.99 240 OR LESSEE 240 Manuai Premium 240 Standard Premium 20 260 Loss Constant 250 5�p Expense Constant Z 512 Terrorism Act Surcharge 5�2 Total Estimated Premium 5$� 14 526 DIA ASSESSMENT 526 Total Estimated Premium&Surcharge(s) Cd Thir�l AVPf111P � P.O. Box 4070•Burlington, MA 01803-0970•Tel: 781.221.1600/800.876.2765• Fax: 781.270.5599 . .._...,..,� ...n�onnnuCu