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HomeMy WebLinkAboutApplication and WC �N(V ��K�N�S �* ► TOWN OF YARMOUTH BOARD OF HE T � •:� , P��v �� ��15 � � � APPLICATION FOR LICENSE/P�R'� 1 A 'f,,�,,'� � � ' * Please complete form and attach all.necessary docun�en�,s.: �:De��er 15 �1-`�:�!-! �E�T Failure to do so will result in the return of your application packet. ESTABLISHMENT NAME: N I'1�S TAX ID: LOCATION ADDRESS: . �N1 > G° G EL.#: � �'75- 777 MAILING ADDRESS: � `l� � 1"• . a E-MAIL ADDRESS: � OWNER NAME: 7?ebr� T��% �^� CORPORATION NAME (IF APPLICABLE): 7'"'��1 MANAGER'S NAME: % r TEL.#: d � ' - 7 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. . 1 _ _ Pool operators must list a minimum of two e oyees currently certifie 'n standard First Aid and Community Cardiopulmonary Resuscitation (CPR), h ' g one certified emplo on premises at all times. Please list the employees below and attach copies of t ir certifications to this . The Health Department will not use past years' records. You must provid ew copies and mainta' a file 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. i. ��/�r 7t��..r'� 2. ,1������1� PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. _ _ � T�/��'-- l�rr�,�-�e, _ _ 2. ��tr� _ l��_��h�ll_ --_ ALLERGEN CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who has Allergen certification, as defned 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 fle at your establishment. 1.—�yi e r �� 2. ���d �l�f�bi�l 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. Piease 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. � 1�r � �U,t{�- 2. 3ar 3. 4• RESTAURANT SEATING: TOTAL# 37 _ —---- - -- � � -- 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 TRAILER PARK $105 _WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE P MIT# LICENSE REQUIRED FEE PERM[T# LICENSE REQUIRED FEE PERMIT# �0-100 SEATS $125 (0�0 CONTINENTAL $35 NON-PROFIT $30 >100 SEATS $200 l COMMON VIC. $60 �50 _WHOLESALE $80 — —RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq.ft. $50 • >25,OOOsq.ft. $285 VENDING-FOOD $25 =<25,000 sq.ft. $150 _FROZEN DESSERT $40 TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE _ � �S S.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 1NSURANCE ATTACHED f ! 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 J NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy sha11 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: People are NOT allowed to sit in the pool axea 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 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 Department, i 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,prepaxation,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 UIRE A SITE PLAN. DATE: /�-aE�/�j� SIGNATURE: ��,�� PRINT NAME&TITLE: ��-a L, �uq.,i►"� Qiuvtej^ Rev. 10/O 1/I S � � � , � The Commonwealth ofMassachusetts � _ Department of Industrial Accidents f � Office of Investigations ! ' I Congress Street, Suite 100 � _ Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legiblv Business/Organization Name:�I�lhl�d- �l� ��i�G�1� Address: y7�_�,� �� Vl�� �GLd''/1�1d U� ,, /�/`� � � City/State/Zip: 'V- M Do�7 3Phone#: ,�0�' ,,�,�� 77�� Are ypu an employer?Check the appropriate boz: Business Type(required): 1.� I am a employer with .� employees(full and/ 5. ❑Retail __ or art-time).* 6. ❑RestaurantlBar/Eating Establishment - — -- __—-- -- -- — ---- 2. I am a sole proprietor or partnership and have no �, � Office and/or Sales(incl.real esta.te,auto,etc.) employees working for me in any capacity. [No workers' comp. insurance required] g• ❑Non-profit 3.❑ We are a corporation and its o�cers 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 Care 4.❑ We are a non-profit organization,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 their workers'compensation policy information. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'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 Name: �1 °t� ��,/�1�'.�0� Insurer's Address: / /Tl�,/�`�'�l'"G� ��Z/l �tf T���)�lilPr�iLGl 6(0/ S.� � City/State/Zip: Policy#or Self-ins. Lic. # �� ��C �.'� ��-��l Expiration Date: �o - �7—/G Attach a copy of the workers' compensation policy declaration page(showing the policy number and ezpiration date). ___ _Failure to secure coverage as re�uired under Section 25A of MGL a 152 can lead to the imposition of criminal penalties of a ----- ---- --— — fine up to$1,500.00 andlor one-year imprisonment,as well as civil penalties in the form of a ST P ORDER an�a�ne of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of � Investigations of the DIA for insurance coverage verification. � I do hereby certify,un er the pains and penalties of perjury that the information provaded above ds true and correct. � Si ature: Date: / � � Phone#: � ' � ` 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 r I i9 (Policy Provisions: wc o0 00 0o B) 62 C4 INFORMATION PAt�E wEc WpRKERS COMPENSATION AND EMPLOYERS LIABILITY POUCY ' INSURER: �RTFORD ACCIDENT AND INDEMNITY COMPANY QNE HARTF012D PLAZA, HARTFORD, CONNFsCTICUT 06155 NCC�Company Number: 1o44e THE Company Code: 5 ��T�(}RD � i i 4 i Suffhc i lARS RENEWAL ! POLICY NUMBER: 08 WEC CQ6219 �—�01 i Previous Policy Number: 08 wEC CQ6219 f HOUSING CODE: SB � 1. Named Insured and Mailing Address: TTDK , LLc (No., Street, Town, State,Zip Codej l 38 STONEY HILL DR ! FEIN Number: SOUTH YARMOUTH, MA 02664 ! r State Identification Number(s�; UIN: ; The Named Insured is: LIMITED LIABILITY COMPANY �i Business of Named Insured: RESTAURANT - FULL SERVICE (WAI i Other workplaces not shown above: 47� RT 28 i WEST YARMOUTH MA 02664 2. Policy Period: From 06�2�I15 To o6/z�/i6 ; 12:01 a.m., Standard time at the insured's mailing address. � Producer's Name: MCSHEA INSURANCE AGENCY INC � r � 1550 FALMOUTH ROAD SUITE 2 C CENTERVILLE, MA 02632 f Producer's Code: oss4o2 f Issuing Office: THE HARTFORD 301 WOODS PARK DRIVE i � CLINTON NY 13323 �; (800? 962-6170 ' Total Estimated Annual Premium: S1,300 ; Deposit Premium: ' Policy Minimum Premium: 5216 t�tA Audit Period: �UAL Instailment Term: The policy is not binding unless countersigned by our authorized representative. i f Countersigned by �"��"'"� C��`�-' os/io/is � Authorized Representative Date Form WC 00 00 01 A (1) Printed in U.S.A. Page 1 (Continued on next page) Process Date: 05/lo/i5 Poltcy Expiration Date: 06/2�/i5 iNfORMATtON PAGE (Continuedj Poticy Number: oe wEc cQ6ar9 " 3.A. Workers Compensatlon Insurance: Part one of the policy applies to the Worksrs Compensation�aw af the states listed here: MA ' B. Empioyers Liability lnsurance: Part Two af the policy applies to work in each state listed in item 3.A. The limits of our liability under Part Two are: 8odily tnjury by Accldent Sloo,ono each acc#dent i Bodily injury by Disease $500,o0o policy limit " k Bodily injury by Disease $ioo,o0o each employee ` C. t)ther States trtsurartce: Part Three ofi the pot�cy appties to the states,ifi any , f sted here; r � ALL STATES EXCEPT ND, OH, WA, WY, US TERRITORIES, AND ` i ST1�'FES DESfGNA�ED IN �TEM 3.A. OF THE INFORMP,TION PAGE. � D. This policy includes these endorsements and scheduls: i WC 00 04 22B WC 20 03 03D WC 99 03 OOD WC 00 04 14 WC 20 03 O1 � WC 20 03 02A WC 20 04 O1 WC 20 04 OS WC 20 06 OlA , t 4. The premium for this policy will be determined by our Manuals ofRules,Classificatlons, Rates and Rating P�ans. Aii informatfart reqvired beiow is subject tv verificaYron and change by audit. `' Premium Basis f Classificatians Total Estimated Rates Per Estimated � Code Nurx�ber ar+d Annual $4ffa of Anrttxat � Description Remuneration Remuneration Premium 9079 108,500 1.15 1,248 � DOUGHNUT SHOP - RETAIL MA RATE DEVIATION PREMIUM CREDIT (.20) (9037) -250 � TOTAL PREMI�M SUBJECT TO EXPERIENCE MODIFICATION 998 � F MA - MERIT RATING CREDIT (9885) .95(3 � PREMIUM ADJUSTED BY APPLICATION OF FsXPERIENCE MODIFICATION 948 ; TOTAL ESTIMATED ANNtJAL STANDARD PREMIUM 948 � EXPENSE CONSTANT (0900) 250 � MASSACHUSETTS DIA ASSESSMENT 5.800 PERCENT 69 f TERRORISM (9740) 108,500 .030 33 � TOTAL ESTIMATED ANNUAL PREMIUM 1,300 i i f � '� ; � � � �I i Total Estimated Annual Premium: $1,300 Deposit Premium: Policy Minimum Premium: 5216 M� ; Interstatellntrastate Identification Number: I o 0 0 75 s e 9� i rrAzcs: � Labor Contractors Policy Number: SiC: 5ei2 UIN: NO. OF EMP: OOOO�L Form WC 00 00 01 A (1) Printed in U.S.A. Page 2 i Procesa Date: 05/10/15 Policy Expiration Date: 06/27/16 ; !