HomeMy WebLinkAboutApplication and WC . �_..� _ j. . - .. ,""�� 1J �V .. �
� T(���YN OF YARMOUTH BOARD OF HEAL"FH �.� NOV 2 Q?��q j
APi'LYCATION FOR LTCENSE/PEI�MIT-ZOlq -�, �:-
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* Please complete form and attach all necessary do�ainen�s�y�Decemb
Failure ta do so will result in the return af your application pac et.
NAME OF ESTA$LISHMENT: A�'��D TEL. #J�•7(��'�S�
LOCATION ADDRESS: �3 S f�1�1''Vl •
MAILING ADDRESS• � `
OWNER NAME: c�c� r` FE or
CORPORATION NAME APPL�CABLE): �
MANAGER'S NAME: " QS �7 TEL. # 3
MAILING ADDRESS: 3�/' ` �
POOL CERTIFICATIONS:
The poal supervisor must be certified as a Pool Qperator,as required by State law. Please list the designated �
Paal Operator(s)and attach a copy of the certification to this fortn.
1. 2.
Pool operators must list a minimum o£two employees currently certified in basic water safety,standard First A.id and
Commwuty Cardiopulmonary Resuscitation(CPR). Please list these employees below and attac�copies o�employee �
certifications to tlus 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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FOOD PROTECTION�vIANAGERS - CERTIk'ICATIONS: '
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 Faod 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. �
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PERSON IN CHARGE: __;
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Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. �
1. � '1 � �CX 2. �„�
HEIMLICH CERTIFICATIONS: '
All food service e�tablishments with 2S seats or more must have at least one employee trained in the Heimlich ;
Maneuver on the premises at all tunes. Please list your employees trained in anti-chokuig procedures below and
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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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3. —r�— 4 i
RESTAURA.NT SEAT'ING: TOTAL#f�
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OFF'�CE USE dNLY �
LODGING: '
LICEN5E REQUIRED FE� PERMIT# LICENSE REQUIRED F�$ PERMIT# LICENST REQUITtED FEE PERMIT# '
rBBcB $55 ,rCAB1N $55 `MOTEL �55 '
�INN $55 �Ct�� $55 �„SWIMMlNG POOL S80eR. -�
___,LOD4E $55 ,�TRAILERPARK $105 „iWHIRLPOOL $80ea.
FOOD SERVICE: �
LI�ENS�REQUIRED FEE P�RMIT# LIC£NSE REQUIRED F�E PERMIT# LICENSE ItEQiJIRED FEE PERMIT# ;
0-100 SEATS �85 _CONTINENTAL $35 NON-PROFIT $30
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1 >100 S�ATS $160 �!a--�33 �COMMON VIC. $60 ()—0! _,_,_WHOLESALE �80
RET�IIL 5ERVICE: —RESID.KITCHEN $80
LICENSE REQUIItED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQLTIRED FEE PERMIT# ;
<50 sq.R. �50 >25,000 sq.ft. $225 VENDING-FOOD $25 •
I ,�,¢25,000 sq.8. $80 _....FROZEN DESSERT $40 �TOBACCO $55
NAME CHANGE: $ts AMOUNT DUE _ $ 2Zo.Oo s
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*****�L�ASE TURN OVER AND COMPLETE OTHER SIDE OF FORM"*"*"
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� ' � AD►MINISTRATI�N
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� Under Chapter��l52, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal
of any license or pernut to operate a business if a person or company does not have a Certificate of Worker's
Compensation Insurance. THE ATTACH�D STATE WORKER'S COMPENSATION INSURANCE
' AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR
'; CERT. OF IlVSURANCE ATTACHED _ _
OR
WORKER'S COMP. AFFIDAVTT SIGNED AND ATTACHED
Town of Yarmouth taxes and liens must be paid prior renewal or iasuance of your pennits. PLEASE CkTECK
' APPROPRIATELY IF PAID:
YES NO
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M4TELS AND OTAER LUDGING ESTABLIS�IYIENTS --
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� TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be
i limited to the temporary and short term occupancy, ordittaril�and customarily associated with motel and hotel use.
Transient occupants must have and be able to demons�-ate that they maintain a principal place of resid�ce elsewhere.
Transient occupancy sha11 generally refer to conti.nuous occupancy of not more than t�►irty (30) days, and an ;I
aggregate of not more than ninety(90)days within any six(6)manth period. Use of a guest unit as a residence or �
dwelling unit sha11 not be considered transient. Occu anc that is sub'ect to the collection of Rpom Occu an
P Y J P �Y
Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transieirt.
POOLS
POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be ivasp� ;
by the Health Department�prior to opening. Coz�tact the Health Departmetrt to schedule the inspection�(3)days !
III pnor to opening.PLEASE NOTE:People aze NOT allowed to sit m the ool area until the ool has been,ins ected
r and opened. p p p '
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POUL 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 openinng, and quarterly
, thereafter.
POOL CLOSING: Every autdoor in ground swimming pool must be drained or covered within seven(7)d�ys of '
closing. �
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FOOD SERVICE '
CATERIlYG POLICY: �
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health I�partme�t by filing the ed
Temporary Food Service Application form?2 hours prior to the catered event. These forms can be obtain�the
Health Department. ;
FROZEN DESSERTS: '
Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health ;
Department. Failure ta do so will result in the suspension or revocation of your Frazen 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 ofHealth.
OUTDOOR COOKING:
Outdoor cookin�pre aration�ar dis�l�of any food product by a retail or faod service establishnnent is prohibited. ____
NOTICE:Permits run annuaUy&om January 1 to December 31. iT IS YOUR RESPONSIBILITY TO RET'tJRN
THE COMPLETED RENEWAL AP'PLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 1 S, 2009. �
ALL RENtJVATIONS TO ANY FOOD E I �
STABL SF[MENT, MOTEL 4R Pt)OI. (i.e., PAINTTNG, NEW
EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TI-iE BOARD OF HEALTH PRIOR ;
TO COMMENCEMENT. RENOVATIONS E ,
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DATE: �` �` O SIGNAT
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PRINT NAME&TI L • � �
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The Commonweatth of Massachusetxs �
Department of Industrial Accidents i
Nli�ciN�rr�1�s
600 Washiagton Stree� f”'Floor
Bostoa,�fass. 02111
Workers'Compeasalloa Iesaraace Affidxvih Bailding/Plsmbi�g/Etectrical Coatractors
�: 65 cxT�r 1 , i
aadress: (S�`� Q�cGL((Ytt� (�.�.(.c_.�
city � ` �/1 �'I �--V�'1• state-4%'I!i`�L• zin��� �hoae# t�a C�C)lJ' /c� �
wotk site location ffiill addressl:
❑ I am a homeowner perfornaing all work myself. Project Type: ❑New Conshvcti�QR�nodel
❑ I am a e proprietor and have no one working in any capacity. Q Building Addition
am an employer.�oviding workecs'compensati�f�my eanployees working on this job. l
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add['ess: 77 J` . ,
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❑ I am a soie proprieEor,ge'�ai codtractor,or homeeww�(cirde one)and have lured tbe�t�ocs listed below who have
the following workers'compensation polices: i
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�lU1t.Kr:ttS L:UIIYENSATIOPd r�P�TD EMPLOYERS LIABILITY INStJF',t;rdCE CERTIFICATE
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. ` INF�R.MATION PA�E REIdEWAL AGREE�iF1VT
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Producer: Agent�6 548 j
rfti Retail P�erchants WC Group Inc. Thamas F Keefe Insurance Agency, I i
10 Brir_ish AmQrican Blvd. 51 West Central Street PO Box K �
Latham, NY 12110 Franklin, MA 02038 i
(Carrier Code: 34355) Certificate �#: 014005030285109 r
Prior Certificate 4�: 014Q05030285108 �
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l. The Employer: Ardeo j
South Side Tavern, LLC
Mailing Address: 23V Whites Path
South Yarmouth, MA 02664 -
Fein:
Other workplaces not shown above: Type of Business: Limited Liability Co �
SEE SCHEDULE OF OPERATIONS Risk ID:
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2. The certificate period is from 12:01 a.m. on 1/dl/2009 to 12:01 a.m. on �
1/O1/2010 at the insured's mailing address. i
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3. A. Workers Compensation Coverage: Part 4ne of the certificate applies to the � �
Workers Compensation Law of the states listed here: �
MA
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B. Employers Liability Coverage: Part �ao of the certificate applies ta work in !
each state listed in Item 3.A. The limits of our liability under Part �ao are: '
Bodily Injury by Accident $_ 500.000 each accident �
Bodily Injury by Disease $ 590 000 certificate limit '
Bodily Injury by Disease $ 500 000 each employee
C. Other States Coverage:
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D. This certificate includes these endorsements and schedules:
WCOOOOOOA{04/92) WCOOQ308(04/84) WC004414(Q7/90) WC000422A(09/08) WC2d0301(04/$4) I'
WC200302(05I86) WC204303B(07/99) WC200405(06/Ol) WC200bQ1(06/92} ;
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4. The cantribution for this certificate will be determined by our Manuals of Rules,
Classifications, Rates and Rating Plans. Al1 information required below is subject
ta verificatian and change by audit.
Classifications Code Contribution Basis Rate Per Estimated '
Na. Total Estimated $100 of Annual '
Annual Remuneration Remvneration Contributiot�
SEE SCHEDULE OF OPERATIONS �
Tatal Estimated Annual Contribution 10,187 .00 �
Minimum Contribution $ 268.00 Expense C�nstant $ .pp
WC 00 00 Ol A Issue Date: 1/06/2009 Cauntersigned by ,�.��. .,;, ;�. ��� ���a� �
�s+�, =,�' �.� °�a� ��.iS�.�
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SCHEDULE OF OPERATIONS FOR: PAGE: 1
n�ue� Cerciiicate #: U14UV5USUL�51U�
South Side Tavern, LLC Fein:
23V vrhites Path
South Yarmouth, MA 02664
OTHER WORKPLACES:
Ardeo
South Side Tavern, LLC
Kings Way
81 Kings Circuit
Yarmouthport, MA Q2675
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WC 00 00 01 A
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