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HomeMy WebLinkAboutApplication and WC� � �-R� N � �* ► TOWN OF YARMOUTH BOARD OF HEALTH G3C�C�C��J[�D � � � APPLICATION FOR LICENSE/PE�i�T 1 -`�� �q (� 2U16 ''"''� � ` * Please com lete form and attach all necessary d�oeu����� " �rre �� r 1��b13? . � p ' Failure to do so will result in the return o�you�°�ap�ic�t�r� ' t. HEALTH DEPT. ESTABLISHMENTNAME:'�q� c►a car � �a� TAXID: LOCATION ADDRESS: q �'Z. t2�►�.c.'� �� TEL.#: S'b8�39�s-�i �^3'i/ MAILING ADDRESS: �t�� �..� T� �d — E-MAIL ADDRESS: rv►a��+-��n C� �cc ncR�� i►�►�.s�c.oM I��� OWNER NAME: ' _ CORPORATION NAME (IF APP�yICABLE): '�h c ��. a d41�•�t MA�, L tA MANAGER'S NAME:�csL►ti�-� r, �b('(�v� TEL.#�6 g-��1-e�3 y MAILING ADDRESS:� b '6vK �31 I�uknn►s (�� .�'' �I�t�k o�y7 � POOL CERTIFICATIONS: ! The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pqol Operator(s) and attach a copy of the certification to this form. - 1 -----____—_— _ � 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. 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. 1. � ... `�� � �bl�s w� 2• PERSON IN CHARGE: Each food establishtnent must have at least one Person In Charge (PIC) on site during hours of operation. � � b � _ _ _ _ _ _ __ __ - __ - � _ _ _ - -- - - � � `` -�-`-�'-`-'L'�-� ----- - ?. ALLERGEN CERTIFICATIONS: All food service establishments axe required to have at least one full-time employee who has Allergen certification, as c�efined in�he 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. ��% �'c�`'c�, �'"C�.� �p r^.^ 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. � �c c� � t..t 2. �y ►.1 J �A��1�..�..� c�l 3. 4. RESTAURANT SEATING: TOTAL# 1�� _ _ ----------- -— --- ---�—--- ---- , - 1 -�-- 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 PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 CONTINENTAL $35 NON-PROFIT $30 =>100 SEATS $200 �2 �COMMON VIC. $60 �(� _WHOLESALE $80 —RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE FERMIT# <50 sq.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 =<25,000 sq.ft. $150 _FROZEN DESSERT $40 _TOBACCO $I10 NAME CHANGE: $15 AMOUNT DUE _ $ 260.�O *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** ADMINISTRATION � ' f � 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. OFINSURANCE 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. 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 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 area until the pool has been I inspected and opened. ', POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count I�, by a State certified lab, and submitted to the Health Department three (3) days prior to opening, and quarterly I thereafter. � POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of II closing. I FOOD SERVICE �I SEASONAL FOOD SERVICE OPENING: ' All food service establishments must be inspected by the Health Department prior to opening. Please contactthe i-- ' 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 t�e 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 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,pre�aration,or displ�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 PPROVED BY THE BOARD OF HEALTH PRIO� TO COMMENCEMENT. RENOVATIONS MAY A SITE PLAN. � DATE: J!J�'i— 1 � SIGNATURE: PRINT NAME & TITLE:� �5'��C�- � 4 / �� Rev. 10/O1/15 i � � The Commonwealth ofMassachusetts � : Department of Industrial Accidents Office of Investigations �� � 1 Congress Street, Suite 100 Boston,MA 02I14-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Le�iblv Business/Organization Name:� G �t��J �QK�F M AN, _ Addxess: � �1- 'K e�u.'C�. 2 � City/State/Zip: ,�� y.P�Q.���,�.�h �.-� Phone#: S�� � ��l� �'�l� J�y' Are ou an employer? Check the appropriate bo�: Business Type(required): 1.� I am a employer with�employees(full and/ 5. ❑Retail ___ or part-time).* 6. [�Resta.urantlBar/Eating Esta.blishment - ---------__ _ - - __ _- - - - -- - - ___ _ 2. I am a sole proprietor or partnership and have no �, � Office and/or Sa1es(incl.real estate,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.Q Manufacturing ; no employees. [No workers' comp. insurance requiredJ* 11.� Health Care 4.❑ VJe are a non-profit organization,staffed by volunteers, with no employees. [No warkers' comp. insurance 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. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: /t 1�T,��T Lt�Q�-- ��_� ���L.�A�cE- �,� Insurer's Address: � 1 �+. r � J en�-r� City/State/Zip: �c I�v 1 n �"b►� i'' 1.� D l �6� � '1 (� Policy#or Self-ins. Lic.# �W G'� ' b v -�� � � � ��-Zo !„�Expiration Date: F f � - �.l� Attach a copy of the workers' compensation policy declaration page(showing the policy number and ezpiration date). ___ ___Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a f - --—_ -- - ---- fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a firie 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 c n r the pains and penalties of perjury that the information provided above is true and correct. Si ature: Date: t �` y' � � Phone#: � D�o ' J ��- q.���� Official use only. Do not write in this area,to be completed by city or town offacial 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 ! I ; �-=- WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POUCY INFORMATION PAGE �� # � � A.I.M. Mutuai lnsurance Company . 54 Third Avenue, Burlington,Massachusetts 01803-0970 �800�876"2765 NCCI NO 26158 � POLICY NO. VWC-1 00-601 601 1-201 5A ' PRIOR NO. VWC-100-6016011-2014A � � ITEM 1. The Insured: Pancake Man Ltd DBA: � Mailing address: P O Box 148 FEIN:*="** Hyannisport,MA 02647 e � �� Legal Entity Type: Corporation � .� •� � � Other worl�places not shown above: See Location MJ� 2. The policjrperiod is from 08/01/2015 to 08/01/2016 12:01 a.m.standard time at the insured's mailing address. � 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the � states listed here: MA < "� B. Employers'Liability Insurance:Part Two of the policy applies to work in each state listed in item 3.A. >� '� The limits of liability under Part Two are: Bodily Injury by Accident $ 500,000 each accident Bodily Injury by Disease $ 500,000 policy limit � >� Bodily Injury by Disease $ 500,000 each employee • � � , ��� C. Other States Insurance: Covera e Re laced b Endorsement WC 20 03 06 B 5�: 9 P Y . ,f� D. This Policy includes these Endorsements and Schedules: SEE SCHEDULE ' � 4. The premium for this policy wili be determined by our Manuals of Rules,Classifications,Rates and Rating Plans. ,� All information required below is subject to verification and change by audit. ClassifiGations Premium Basis Rates � Code Estimated Per$100 Esttmated `��� No. Total Annual Of Annual Remuneration Remuneration Premium • ;� �;; INTRA 39923 INTER SE CLASS CODE SCHEDU E '��° .� �- Minimum Premium $269 Total Estimated Annual Premium �4 $3,420 GOV GOV � Deposit Premium $3,591 � STATE CLASS MA 9079 State Assessments/Surcharges $2,947.00 x 5.8000% $171 �' This policy,including all endorsements, is hereb countersi ned b ��-�'��'""'`O`�`��.-�� 07 1 2 Y 9 Y /0 / 015 Authorized Signature Date � � iFs Service Office: '�Ide Cape Cod ins Agency Inc �' 54 Third Avenue 300 Winter Street i; Burlington MA 01803 Hyannis,MA 02601 < `. WC 00 00 01 A(7-11) � Includes copyrighted material of the National Council on Compensation Insurance, used with its permission. .