HomeMy WebLinkAboutApplication and WC �0�.n �,-�
:- � ►� TOWN OF YARMOUTH BOARD OF HEALTH
� APPLICATION FOR LICENS� ` � ��, NOV � O ZO�5
•,..• �"' ���� � � �`'
* Please complete form and attach all neces��o�tr�ien �, � ec,� er EPT.
Failure to do so will result in the ret�of�r�;�ppl�c�€o�pa .
ESTABLISHMENT NAME:�t�l�wt� ��-rnc�rH-. TAX ID:
LOCATIONADDRESS: 5�1 S�sa�-:cx, v-e�n.,-�i. F `�{�cn�c„3t�l�►A TEL.#:(SU�.�3C1`1-°L�Z.1
1VIAILING ADDRES S: $bO Sc�� 5�, ,.�e S�Y�����t-�ha��'�(!- r�4 S�
E-MAIL ADDRESS: ������s���;�,��P Gv.cQs�-,
OWNER NAME: C��,-\c�1�a\ �"\ar��e �10 ('��rp�
C(�RPORATION NAME (IF APPLICABLE): t8 �, Nlcmke�\G Frcr�.,e C,arO.
MANAGER'S NAME: �{�,��,-� �r� TEL.#: 5C>��3qr-1-�82.�
NIAILING ADDRESS:�Z CX� -��•. 4t�-PQ,� , �,,i,�te. S(`l�J, lS.��-�n•,. M(� C�Z4 5�
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.
_ _ _ - _ _
}. - - - - -�_ 2._ _ __ _
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.
L 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'reeords.
You must provide new copies and maintain a file at your establishment.
1. �"`�t� (�r�rn�o c� 2.
PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
,
__1,��?�n�� ��� 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.
1. �a'c1�1,eu�n �rnr�.. 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 wi11 not use past years' reeords.
You must provide new copies and maintain a file at your place of business.
1. 2.
3. 4.
RESTAURANT SEATING: TOTAL# '
�
�
-- ------- - OFFI�C��J-S�ON�L�'- �
_ ___ -- _ _ _ ___ _____ ,
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
B&B $55 CABIN $55 MOTEL $110 '
_INN $55 CAMP $55 SWIMMING POOL$i l0ea.
_LODGE $55 _TRAILER PARK $105 WHIRLPOOL $110ea.
FOOD SERVICE: ',
LICENSE REQUIRED FEE P RMI LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
�0-100 SEATS $125 (����6 _CONTINENTAL $35 NON-PROFIT $30 r
_>100 SEATS $200 _COMMON VIC. $60 WHOLESALE $80 '
RETAIL SERVICE:
—RESID.KITCHEN $80
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
<SO sq.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 �
�<25,000 sq.ft. $150 �O =FROZEN DESSERT $40 �TOBACCO $110
1
NAME CHANGE: $IS AMOUNT DUE _ $�85roo �
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** !
I
�
�
�
I
ADMINISTRATION ` � j
�
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
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
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.
,x
POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of
closing.
_ _ -, FUOD 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 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:
Outdoar cooking,preparation,or display of any food product by a retail or food service establishment is prohibited.
� ___ ------- _ _ _ _-_
i
NOTICE:Permits run annually from January 1 to Decem er 31. IT I YOUR RESPONSIBILITY TO RETURN
THE COMPLETED RENEWAL APPLICATION(S) A D REQUI D FEE(S) BY DECEMBER 15, 2015.
� ALL RENOVATIONS TO ANY FOOD ESTABLI HMENT, MO EL OR POOL (i.e., PAINTING, NEW
� EQUIPMENT,ETC.), MUST BE REPORTED TO A D PPROVED Y THE BOARD OF HEALTH PRIOR
� TO COMMENCEMENT. RENOVATIONS MAY RE A SITE LAN. � �
l�i �'�I1� � C
DATE: �� �1 n f t� SIGNAT
—�
PRINT NAME & TITLE: ; �e{ �:c�`S
Rev. 10/O1/15
i
�
�
The Cottimanwealth af 1Ylassuchusetts
Depart�rae�t af Indusftircl Accidents
� 1 Cnrzgress S'treet,Suite 1(14
Bvstan,MA t�2114-2Q17
�vww.ntass g�avfdia
Workers'Compensation-Insurance Af£davi#:General Businesses.
TO BE FILED WITH THE PERMTTTING AUTI-I4RITY.
Apulicant Information Please Print Le�iblv
Business/flrganization Name:���bal Man#elfa Group Corp.
A�����;800 Sou#h Street
City/StatelZip:�a(tham,MA 01453 Phone##:781-8J3-8800
Are you an emplvyer?Gheck the appropri�te box: Business Type(r�quired);
1.[]✓ I am a employer with 270d employees(fiili and/ S, �Retaii
ar part-time).* 6. �RestaurantBarlEating Establisl�ment
2.❑ I am a sole proprietor or partnership and have na �. �p�'fice andlor Sales(incl.real astate;auto,ete.)
employees working for ine in any capacity,
[No workers'comp, insurance required] g• ❑Non-profit
3.❑ We are a corporation and its offc�rs have exereised 9. ❑Entertainment
ttleir right of exemption per c, 1�2,§I(4),and we have �p,Q Manufaeturin�
no employees. [Na warkers'camp.insurance rsquired]* 11.0 Health C�re
4.� We sre a nan-profit organization,staffed by voltanteers,
with no empIoyees. [No workers'comp.insurance req] 1�.�0���
*Any applicant that�hecks�krpx#1 mnst also t51[out the section befa�v sho�ving their w�rlcers'compenxaricrn polisy infar�taYit�p.
**If the corporate officers have exempted themsetves,but thc carparation has other employees,a warkers'compensation policy is ret�uired and sueh an
organization shoi�ld check box#i.
I attr a�a emplvyer th�t is prvvitlirzg wnrker�s'corrtpeitsadion in.sa�runce far my employces. Below is tlte pofrcy infarncatiotx.
Tnsuranca Company Narne:Liberfy Mutual Insurance�ompany
Insurer's Address:175 Berkeley Street I
City/State/Zip: �oston, MA 02117
Policy#or Self-ins.Lic.#��7-6�L't-460066-015 �xpiratian Date:10/�112018 '
Attach a copy of the workers'compensation policy declaratian page(showing the pol[cy nutnber and e�piration date).
Failure to secure coverage as required under Sectio�i 25A of NIGL a I SZ can lead to the irnpositian of eriminai 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 WQRK QRDER and a fine
of up to$250.QQ a day against the vialator. Be advised that a copy of this statement rnay be forwardecl to the Offics of
Investigations of the D1A for i�lsurance covera�e verifiea#iQn.
I do hereby certi ,r�rrder ttie�rr�iris and r�lties-vf�rerjury tiiut tlie ifaformatevri pravirlerl abave is true anrl cvrrec� '
�
Si nature: Date: L} t ,� �
Phone#: i'� � �"_. ,� i
Offrciat use only, Do�xat write in tf�is area,tv be contpleled by eSty or tawr�offici�cG �
City or Town: PerrnittLicense# � I
Issuing A»#hority(circle dne): � ,
1.Board af Health 2.Building Department 3,City/Town Gierk 4.Licensin�;Board S.Selectmen's Of�ice �
6.Other
�
Cantack Persan: ��p��#. �
,
�vwrv;mass.gov/dia �
�
�
�
1
�
' WORKERS COMPENSATION AND EMPLOYERS LIABiLlTY
INSURAfVCE POLICY Liberty Mutual.
i
; iNF4RMAT10N PAGE 175 Barkeley SN eu so on,MA 42116
i Issued by Liberty fnsurance Corparation (a stock company} 21814
' Policy Number WA7-69D-460066-015 (ssuing Office Lewiston, ME
� Renewal Of WA7-69D-460068-014 Issue Date 1Q/15/2015
Accounf Number 9-460066 Sub Account 0040
1. Insured and Mailing Address FEIN
Global Partners, LP NJ TIN 141924242000
800 South Street,Suite 500 Risk(D 811385333
PQ Box 9161
WALTHAM MA 02453
Status Lirnited Partnershlp
Other workplaces not shown above:See Item 4. Premium-Extension of lnformation Page
2. Poiicy Period: The policy period is from 90J09/2015 to 10/01/2016 12:01 A.M. standard time at the Insured's
mailing address.
3. Coverage :
A. Workers Compensation lnsurance: Part One of the policy applies to the Workers Compensatifln Law of the '
stateS li5tetf here: CT FL GA tA ME MD MA MT NH NJ NY NC OR PA RI TX VT
VA i
'
B. Emplayers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The
limits of our liability under Part Two ac-e: I
Bociily Injury by Accident $ 1,000,000 each accident
Bodily lnjury by Disease $ 1,000,000 policy limit i
Bodi(y Injury by Disease $ 1,00�,000 each employee i
C. Other States Insurance: Part Three of the pollcy appl3es to the states, if any, listed here:
All States except thase listed in ftem 3.A and the States of:
ND OH WA WY
D. This policy includes these endorsements and schedules: See Item 3. Goverage D-Extension vf
Information Page �
4. Premium, The premium for this policy witl be determined by our Manuals of Rules, Classfflcations, Rates and '
Rating Plans. Ali information required below is subject to verification and change by audit.
Classifications Code Premium Basis Tota! Rate per$100 Estimated Annuat ,
Number Estimated Annuai Remuneration of Remunera#ion Premium
See Extens�on of Information Page '
Minimum Premium $1,771 (PA) Total Estimated Annual Premium $ 1,047,289 '
Premium will be billed Annual Deposit Premium $ 1,047,289
Deposit Tax/Surcharge/Assessment $ 106,089
Producer 0002 000499 Countersigned by Authorized Rep. (FL)
LOCKTON COMPANIES LLC(DALLAS SERiES)
2100 RaSS AVE STE 1400 A ,�,
DALLAS TX 752016706 S��,c
Producer MASTERS $828 �
Irving,TX �
i
I
i
I
i
�
WC 00 OU 01 A CO 1987 Nationat Council on Compensation Insurance,lnc. WC 00 00 01 B (CA)
Ed.07/01/2011 All Rights Reserved Page 1 of 1 �