HomeMy WebLinkAboutApplication and WC � � ���� I
' % � ► TOWN OF YARMOUTH BOARD OF HEALTH �
�, � � APPLICATION FOR LICENSE/PERMIT -2012 ��v 0� �G�1 �
�� * Please complete form and attach all necessary documents byDecemb ;- � p�pT. �
Failure to do so will result in the return of your application pac �
ESTABLISHMENT NAME: �� ID' '�'��`�`��
LOCATION ADDRESS: � ��• TEL.#: � C�•/ '
MAII.ING ADDRESS: �
OWNER NAME: 0 � �
CORPORATION NAME(IF PI�ICABLE): t V1 C
MANAGER'S NAME: e � 2�'M 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 certif'ication to this form. �
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Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid
and Community Cardiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of ,
employee certifications to this form. The Health Department will not use past years' records. You must �
pr�vide_�aew cnpiQs�nd nnaintain.a file_�t your gla�e czf business.- �
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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 Establishxnents, 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 copie and maintain a file at your establishment.
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PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge(P C) n site during hours of operation.
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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. ,
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OFFICE USE ONLY �
LODGING: '
LICENSE REQUIIZED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIltED FEE PERMIT#
_B&B $55 CABIN $55 MOTEL $55 �
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_INN $55 _CAMP $55 _SWIMMING POOL $80ea. I
_LODGE $55 _TRAILER PARK $105 _WHIRLPOOL $80ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMTI'# LICENSE REQUIIZED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_0-100 SEATS $85 _CONTINENTAL $35 _NON-PROFIT $30 `
�>100 SEATS $160 � .-(�97 �COMMON VIC. $60 _���3 _WHOLESALE $80
RETAII,SERVICE: —RESID.KITCHEN $80 ;
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_<50 sq.ft. $50 _>25,000 sq.ft. $225 _VENDING-FOOD $25
_Q5,000 sq.ft. $80 _FROZEN DESSERT $40 _TOBACCO $95
NAME CHANGE: $is AMOUNT DUE _ � Z�•Op
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*****PLEASE TURN OVER AND COMPLETE OTHER SID�1�****��� ''�
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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, UR
CERT. OF INSURANCE ATTACHED
. 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. PI.EASE CHECK
APPROPRIATELY IF PAID:
YES NO
MOTELS AND OTHER LODGING ESTABLIS��VVIENTS
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
elsev��he�e.Traz�sis:�t a;✓e�pan�y sh��l g�i.�ral ly�ref�r te cont:.�acus a�cupar.��c�f�ot rnore�k�n�i�y��0)days,an�
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 De�artment to schedule the inspection three(3)days
prior to opening.PLEASE NOTE:People are NOT allowed to srt m 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 OPEI�IING:
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 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,
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 prolubited.
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, 201 l.
Ai.1. RENOVATIONS TO ANY FOOD ESTABLISHMEN'Y' T R P (i.e., PAINTING, NEW
EQUIPMENT,ETC.),MUST BE REPORTED O B BOARD OF HEALTH PRIOR
TO CO N EMENT. RENOVATIONS Y E N.
DATE: I �I SICNAT
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PRINT NAME&TITLE: �
Rev.10/25/11
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' �'`"� The Commonwealth of Marsachusetts '
Deparhnent of Industria!AcciJents ',
N�IN�f1� I
600 Washington Street, 7`�Floo� ',
Boston,Mas�..02111 '
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Worl�ers'Compeasatios Iroeranet Aflidav�t: ' , � ,' . ' f
�t i�atly: Pka�e PRtNT ie�lbh . � � . . , ,„ �
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name: �
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addttss�� �
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work site laca'on(full addressl: �
❑ I am a homeowner performing all woric myself. �
❑ I am a sole proprietor a�have no one working in any capacity. '
�am an employer p�oviding wa�kkers' mpensati�far my employees wodcing on th�s job.
comaa�r�e: :�/�S �'��!/�� �S ��• �
address•
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--��I am a sore praprietor,geoeral eostractor,or 6omeowner(cc�rrde one)aad have Wred the contractors listed below who have
the Following workers'compensation polices:
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copy ot t�b�ta e�t may be firwardM t ot I�ve�ot tie DIA far c�vense veelAntli�.
!do b by cerefj patw o rry Ulr�t NYe twfonw�No�pr+avldsd obovr is lrwe ewd�mrt
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11/28/2011 11 :31 150852 3887 Ktt t �J~~' ` . �" "��"
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pTORKERS COMPENSATI N ANA EMPLQYERS •L=ABILZTX IN URANCE CERTI , CAT�
_ � INFORMATSO PAQE: RfiNBwAi, .AGRB�MENT
� ; rodacet: Agentif 548 ;
MA R�tail MerchAAt WC aroup Inc. I eefe Ineurarice Agency IAC. �
10 8ritieh America Blvd: � � i Wbat Central 9crett PO Box K
Latham, DTY 1z110 � I ranklin. MA .0 ;
tCarrier Code:. 3a3 5) � Ce ` f!•l.cate : 014005030285111
Arior e ; ica e : 01400 0 '.
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1. Tha Employer: ArdeO �
South Sidt Tavern, L1.0 . •
Mailing Addree : a3V White$ Path�, . " • .
� Souch Yarmouch, MA 02669 • , .
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Ochet,workplaC 6 nOt shown ahovec � • Type o� 8usiaesa: Limiced Liabillcy Co _
� SEB .SCHEDVI,E OF OPSRATZONB • •, ' . � 12isk YD: �
2. � The certificat period ia fron1�12;01 d.n�. 1/01/,2011 i eo 12;01 a.m. on '
1)o1j2012 t che lneured�e malling addr ea. � � �
3. .A. Workere Co peneation Coverage: para one of:the.ce�cif' Cata agp11e9. Co the, .
Workera Co pensation Law of Che atacee iaced here:• � � � � .
!SA � . .
B: 2mployere iabilicp Coverage: Part 14so f che cerLifi ace appliea ta work in • ,
� each etate lieced iri ICem 3.A.. The lim te oP Our 11a 'ility under P$rt 1'wo aTe: .
'. Bedil injury by,Accident � $ 500 o0n • i each accideaL
Hodil =n•jury by Diaease S 500 000 . ' cercific$ce limic �
Hodil znjury by Dlesaae $ 500 000�� � each employee . •
. C. Ocher 9Cat s Coverage: �. ' • • '
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D. Th1e cexti icste includes theee. endorsa ente and ache ulea: ' .
� WCOOOGOAA4 4/92) WCOQ0308{04/84} :� WC000 iS�O?/90) � 6�IC G0422A{09/08} wcaao3ozto+le4)
• WC20Q302(u /86) WC200303a(0?/99) WC200 05{OBr01) NC 00601(O6/92?
4. The contzibuti n foz Chia certiflCdCe Will detern►lned y our Manuale .of Rulee, !
Claeeificatioa , Ratee and It�Ging Plans. A 1 Snformation;required helow is aubjacc '
. Co verificatio and change by audic. • • �
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,Ciassification Code Coat'zib cion 8asis Rate Per � Eatima�ed. �
. A1o. Tocal timated �. $1Q� of � .Arttival j
• � A:sr►ual R neXatiori � Remunezation • Contribution
S8L 3CHE E OF OPBRATIONS � •
� Tota3 �stlmate Ai►puai Contrihution 7,8 3.00 _ . .
iaimulq CotitYibuticn'S ' 2 6.00 ' Bxpe�,ae' Constant S .00
WC OC o0 oi A �Is e Dace:. 1/il/2011 Coun ezalgned�by ! , '
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11/28/2011 11 :31 150852 3887 Ktt t ���y, � . ���,���
SCHEDLT�B �O OPERATIONS F4R: PAGE: � 2 � �
� � �*** CERTzFICATE INFO TION .FOR' *�►++* . . �
�d�o Cercific� te #: 0140050302851i1 ' � .
South S�de Ta ern, LLC � Fein: ,
23V .Whites Pa �
South Yarmout , MA 026.64 � . � � . . ,
Cade Classificacion ' Fayro, l ��tate Contribution . .
8810 CLERI OFFICE EM�PLOI'EES' NOC . 25;00�. � 0 � � .09 � . � 23.00 .
9079- . RESTA NOC . . � . . 517,.A2�4. ' 0: . � l.07 5,536.QQ . .
Manual Contrib Cion . 5;559.Q0 .
Rate Deviation 15.:00$ i � • • . 834.00
� Increased Empl yere �,i.ability Limits � 1.000� ; � � . 5�0.00 .
F•xpe'riertce Mod f i�ation. - List�d below . . .� • 6,112.00 .
Standard Contr bution � . � 6,112.00 .
ARAP. CharSe � � 1:250Q�;�� � � � 1,528.00 .
Normal COntrib tion . , 7,690.00 :
Expense. const t ' '
Foreign Terror sm : - 163.00 �
Annual Gontrib tion � � � �,.803�.00. .
D�A As$essment (0093Q} Z,8004$ / I 80Q0$ ' 129.00 ' . .
Experience MQfl fiere . . . '
1..2800 1/O1/2o1 ' � '
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SCHEDULE OF OPERATIQN6 FOR: P�E� Z - '
Ardeo Certif.ic te #: 0140Q5030Z851•11 . .
South Side; Ta rn, LLC i�ein: • . •
23V Whitea Pat : •
South Yarrnout , MA 0266� � � . •
OxHER WORKPLA S: ' . -
Ardeo
South 8ide Ta rn, LLC . . •
Kings Way . , ' .
81 Kings ,Gir� it � '
Yarmouthport, 426�5 � , , ,
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