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Home My WebLink AboutApplication and WCI . s �. _.U E�G� :6�€�M' ' � ► TOWN OF YARMOUTH BOARD OF HEALTH ' � � � APPLICATION FOR LICENSE/PERMIT' � ,Q� r � � �;� ��( f; 4 ��j5 ; � � � `""' * Please complete form and attach all necessary docum J c � i•1 S � Failure to do so will result in the return of your a p p�ication pac c .`�'��=�' `�''-='`!u_m I E�TABLISHMENT NAME: G� T D• • � LOCATION ADDRESS: c�� CL . TEL.#: � . � �p� MAILING ADDRESS: E-MAIL ADDRESS: � , OWNER NAME: �" CORPORATION NAME (IF APPLICABLE): �s� � 1VIANAGER'S NAME:"�S,o�Lo�Id �Cr�T TEL.#: ,S"'�g' �(ol} /�(� MAILING ADDRESS�s��s G f��r 1,Pi ; 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.; f..J�/l�� -� _ _ __ _ ._ � f ��a�r�s �i�:�� __ --� � 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 m�tst provide new copies and maintain a file at your place of business. 1.' GG?i/lio�n /�}�FT 2. � � �af� 3.J�ualas ,�/oF-y 4. �= FbOD 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 �le 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. __ a .. ___—_— - -----__ _-- - —�- AL�,ERGEN 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. 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. i RESTAURANT SEATING: TOTAL# �' _ _ __ _--- __— _ __ T��H��--___—.__,_ LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# L CENSE REQUIRED FEE P I�IT# _B&B $55 CABIN $55 � MOTEL $110 !6—O{ _INN $55 CAMP $55 �SWIMMING POOL$1 l0e . _LODGE $55 TRAILER PARK $105 WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE IT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 �CONTINENTAL $35 �� NON-PROFIT $30 _>100 SEATS $200 _COMMON VIC. $60 WHOLESALE $80 —RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<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 = $ 2S5•OO *****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 INSURANCE ATTACHED f1/�r 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�� 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 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 ha�e 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) i days prior to opening. PLEASE NOTE: People axe 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 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 Deparlrnent, 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 prohibited. NOTICE: Permits run annually�rom January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN I 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 R�QUIRE A SITE PLAN. / ' � DATE: / y t� SIGNATURE:,(�/I .��-�� r'%� �'� PRINT NAME & TITLE: P V�Y� �� a�� r�S f j� � � Rev. 10/O1/15 � � �' � The Commorcwealth ofMassachusetts • • � Department of Industrial Accidents E � Office of Investigations ` � Congress Street, Suite 100 _ Boston,MA 02I14-2017 www.mass.gov/dia _ f Workers' Compensation Insuranc� Affidavit: General Businesses � . � Auplicant Information Please Print Le�iblv ' � , Business/Organization Name�/��-�7c �� . Address: !c� � G City/State/Zip: Phone#: , � � Are you an employer?Check the appropriate boz: Business Type(required): ' 1.�} I am a employer with �employees(full and/ 5. ❑ Retail or part-time).* 6. ❑ RestaurantBar/Eating Esta.blishment _ __--—_—_ —-- -- -- - 2.❑ I am a sole proprietor or partnership and have no - - - __ _`_ _ --- 7. ❑ Office and/or Sa1es(incl.real esta.te,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 10.0 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. insura.nce req.] 12.�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. �am an employer tlz'at is providing workers'compensation insurance for.my employees. Below is the policy information.;: Insura�ce Company Name:/'YO r C'�SUdC f�' .. �U-__Q f d__��iz 5' ��. : — - Insurer's Address: /— Q ,�O sC � � �/ � CitylState/Zip: � /77��E' � 0"2��1P'%!-- .,2 7 / � , rn �, Policy#or Self-ins.Lic.#�f�C �'�� 'J�� Expiration Date: � At�ach a copy of the workers' compensation policy declaration page(showing the policy nnmbe and ezpiration date). - — �ailvr�_t4 sscure�overa�e as re�uired under Section 25A of MGL c. 152 can lead to the imposition of crimina.l penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP O E and a�ine of up to$250.00 a day against the violator. Be advised that a copy of this sta.tement may be forwarded to the OfFice of Investigations of the DIA for insurance covera.ge verification. I do hereby cert� der the pains andpenalties o perjury that the information provided above is true and correct. Si ature• /' Date: �l � /� Phone#: Officdal use only. Do not write in this area,to be completed by cdty or town officia[ 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 , f ,� ��r�""'rr� r� �� , �, / � �� • � �/,'//� r �?r.+� 3t ��1.�it� '�' $ERKSNIRE HATHAWAY �ht4�+'�.`�ornaensahos�at�,Emuloy�s U�1��[Policv � �! INSURAMCE ��UAt�J►Insurance Company- A Stock Cornpany 1,7��D C+DMPANIE5 Ralicy tW�rnber PMWC55S630 Renevva!af PMiNC445$30 IVCCI rb.[25844] Policy Infarmation Page �[i]Plamed Inrsured and Maiting Address ♦TAgency ______ _ Ip M g lnc SYLVIA&CUMPMtY IRiS AGY P. 0. Box 39 5U0 Faur,ce Corner Road � South Yarmoutn,MA 02b64 8uilding 1Qfl -Suite i20 , � Dartmo�th, MA �2747 � ; Ager�cy Code: MASYl.V10 i Pederal Employer'S ID � It1Su1'ed is Corpor�tion ; � � " M t Additionaf Names of Insurer! � � tN2) village Greer� Motel E � I loca#ions on Pt�t�cy � � (l�) 33-37 Seaside Vllaqe Rd , �'armouth, tti3A 026ii� , t06129/2fl14 -G6/29/2035) � ___._.....______.__________ _____. .__._._.._.�. _._�.._-----. ' __ ___. _ __ .____. __ _ __�.._,_� _- � (Zj Poiicy Perad j From June 29, 20J4 to lure 29, Z�15, i2 Di AM, standard time al the ±nsured's mailing address. { � . � : _____ � _�_______�.._______.._.._ �..___. � � __.._ .. _ .__ _. ._ ._--_ �_._.._ � [31 Coverage j A. Workers' Compensation 1-�sucance - Part fJne a!th�� palicy appiles to the Workers' Compensation � � L.aw of the f�lic�vsrrng states: �lassachusetts � i B. Fmptoy2r'S lidbility Insurance - P:lrt Two of;h�s pol+cy applics to work in each of the states tisted , � in item�3)A. .The lirnits of our liabiiity unaer�art Two are: ' ! � Bodiiy injury py Accident - each accadent $140,000 ! ! � Bodily lnjury by D�s�as� � ead^ employee $1t?+6,DUG � i � Bodily Ir�jury ny Qisease -pc�licy iem�t a500,G00 f i t � � C. Other States Insurance -�ar ihree of this po�icy dppiies to aii states, except any state listed in ' � �tem [3jA. and the sTates of North [7ako[a,flhio,Washinqton,and Wyoming. F � � D. Th�s policy �ncsudes these endorsemer�ts �rid sch�dules: I 4 ; See Extensiun t�f inf�rmation Fage -Scheduie ofi f�orn�s { __._.�__ __�..,� i .w ___._.__._._..__._._. �..___._ , � [4] Preinium � The 're�um Bas�s anc,theretore, the premium tivil!be c3etermined bY our Manual af Rules, � I Classifications, Rates,and Rating P;�ns. AI! required ;nfflrm�tion is subject to verification and change s �_Y_y__�_`by audst. (Coniinued on another page; �� ' � .......�,..,. � Total Estirnated POlicy Premium � 1r272 ; Total5�rrcharges/Assessments � 33.40 p Total Estimat+ed Cost � 1,305.00 � !hl"�RNAL US�, xx �age - � - [nformation Page j n�cA PMwCS55634 WC 400001A Cett: 36l09;201� � MANOTE j i ,� � .., � r, . n n a n ;.i ,�r � c on i o-�n� nn�n ,.,,,,,,, .,��or.� .-..�„