HomeMy WebLinkAboutApplication and WC -�.. G°� �O�I'C�DD M�r.
a • TOWN OF YARMOUTH BOARD OF HEALT
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� APPLICATION FOR LICENS�H�3ZM�' ��1 '' � ,
"`°` * Please complete form and attach all necessary doc m nts y D�e ber 1 S 201 S.
Failure to do so will result in the return of your application ck�EqLTH DEPT.
ESTABLISHMENT NAME: d Q TAX ID:
LOCATION ADDRESS: �tr/, md TEL.#• 4 — ,.����
MAILING ADDRESS: a 3
E-MAIL ADDRESS: `
OWNER NAME: aR,t� _�tL �rS,��R/C
CORFORATION NAME (IF APPLICABLE):
MANAGER'S NAME: 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 certification to this form.
Pool operators must list a minimum of two employees currently cer•tified 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. 2.
PERSON 1N CHARGE:
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
_ 1. _ -- — _ 2. - — ___ _
ALLERGEN 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. .
l. 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. �
RESTAURANT SEATING: TOTAL#
----- ----- —___-- _..t}�FI�T--i.z���T�T
_ _ — —____.;
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
B&B $55 CAB[N $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 _COMMON VIC. $60 WHOLESALE $80
—RESID.KITCHEN $80
RETAIL SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMI'C#
<50 sq.fr. $50 _>25,000 sq.ft. $285 VEND[NG-FOOD $25
=<25,000 sq.ft. $150 ��� _FROZEN DESSERT $40 TOBACCO $I10
NAMF.CffA�IGE: $�s AMOUNT DUE _ $ �SO • 00
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORIVI***** �
�
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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, OR �
'
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. PLEASE CHECK "1
APPROPRIATELY IF PAID: I
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. I
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 ,
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 i
SEASONAL FOOD SERVICE OPENING: !
All food service establishments must be inspected by the Health Department prior to opening. Please contact�e _
Health Department to schedule the inspection three (3) days prior to opening.
CATERING POLICY: II
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 I,
obtained at the Health Department,or from the Town's website at www.yarmouth.ma.us under Health Department, �
Downloadable Forms. i
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: I
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 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 i
EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR ,
TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
DATE: �� /`f /:S� SIGNATURE: i���l/�/
PRINT NAME&TITLE: �t r `'� v�'� ��-s�'r �'`
Rev. 10/O1/IS
I
� The Commonwealth ofMassachusetts
% � �' _ Department of Industrial Accidents
' Office of Investigations
' 1 Congress Street, Suite 100 '
_ Boston,MA 02114-2017 ;
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses '
Aunlicant Information Please Print Legiblv
Business/Organization Name:
Address:
City/State/Zip: Phone#:
Are you an employer? Check the appropriate boz: Business Type(required):
1.❑ I am a employer with employees(full andl 5. ❑Retail
_ or art-time}.* 6. ❑RestaurantlBar/Eating Establishment '
2. I am a sole proprietor or partnership an ave no - -�
__ — _ _-
. 7. Office and/or Sa1es(incl.real estate,auto,etc.)
employees working for me in any capacrty. �
[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 a 152, §1(4),and we have 10.� Manufacturing '
no employees. [No workers' comp. insurance required]* 11.�Health Care I
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
organizadon should check box#1. '
I am an employer that is providing workers'compensation insurance for my emp[oyees Below ds the policy information.
j
Insurance Company Name:
'
Insurer's Address:
City/State/Zip:
Policy#or Self-ins. Lic. # Expiration Date:
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 j
� --- - - - - �
fine up to$1,500.00 and/or one-year imprisonment,as we�as civiIpenalties ui t�e�orm of aSTOP aVORK OR�ER an-3 a�ine �
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
�
I do hereby certify,under the pains and penalties ofperjury that the information provided above is true and correct. j
�, � �/� / �
x Si�,nature: ��''`�v'" i�� Date: // S
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Phone#:
I
Official use only. Do not write in this area,to be completed by city or town official
I
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#:
wwwmass.gov/dia ;
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� Nov, 3. 2015 1Q: 22AM Brigar Express Stns 518-438-0224 No. 8134 P. 1
�'��-'� CERTIFIC�iTE OF LIABILITY INSURANC� °",�`"�'°°'""",
12f02/2014
THIS CERTIFICAT� !S tSSUED AS A MATTER PF INFORi4fATtON bNLY AND GONFERS NO RIC3HTs UPON THE CBRTIFICATE HOLDER.7HtS
- CERTiFICATE DOES NOT AF�IRI4IATIVEIY OR NEGATfVE1.Y AMEND, EXT�NP OR ALTER THE COVERAOE AFF� bED BY T E P
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BELOW. THIS C�12TiFICATE OF (NSURANCE po�S NOT CoN6TiTUTE A CONTRACT BETW�EN THE 16SUING INSURER(8), AU7HORIz�O
REPRES�NTATIVE OR PRODUCER,AND THE C�R7IKICATE HOLDER.
IMPOa7ANT: If the certiticale holdet is an ADI]ITtONAI INSURED, lhe policy{ies)rnusf be endarsed. tf SUBROQATION IS WANEU,sub)ecf to
the fe►ms and conditions of fhe poficy,eerlaln pollsles may require an endorsemenl. A statemenl on Ihfs certificate does not eonfer righls lo lhs
cerlificate holder in Ifeu of sucb endorsement{s}.
PROOUCEit
Assoclalbn Benefits Insurance Ageney �noNe Fax
298 Baflardvale Sl,Suite 1 �-MnI� c M°'
Wilminglon,MA 01887
IHSURERfS}AFFdRD]NO COVEfiAOE NAIC d
INSURERA; MA Reiall Merchanls WC Grou Ine. ^
INbURED INSURER B:
Cape Codder Seaiood MarKel,L�C iNsuaEnc�
679 Main Sl.
Wes!Yarmoulh,MA 0z673 fNSURER D:
INSUFEfi E:
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COVERACyES CERTIPICATE NUMB�R: 00001 REViSlON NUMBER: 00000
THfS IB TO CERi1FY THAT THE POLICI�S AF INSURANCE LI&TEO BELOW HAVE BEEN lSSUED TO 7H�IfVSUREO NAMEp ABOVE FOR 7HE P�LICY P�RIOD
INDICATED. NOTWITHSTANDINfi ANY REQUIREMENT,TERM Of2 CONDITION OF ANY CO(VTftACT OR OTHER OOCUMENi'W1TH RESPECT 7Q WFUCH THIS
CERTIF�CATE MAY BE ISSUED�R MAY P�RTAIN, Tl-!E IPFSURANCE AFFORDEG BY THE POLJCl�S pESCR19ED HEREIN IS SUB,IECT FO ALL 7Fi� T�RMS,
EXCLUSIOHS AND GONDITI�NS OF SUCH PpI�CIES.UM1T6 SHOWN MAY HAVE BEEN REOUCED BY PAID CLAfMS.
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CERTfFICATE HOLDER CANCEILATfON
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