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HomeMy WebLinkAboutApplication and WC �"� � �LJL�1'..l VOS• � � TOWN OF YARMOUTH BOARD OF HEALTH ���6��d�� � � APPLICATION FOR LICENSE/P�1�TIT=2016 a,,, �f� NOV i � 2015 * Please complete form and attach all necessarSi�cur�ents l��'Decen er 1 S 201 S. ' Failure to do so will result in the return�yotx�ap�i�c�fiori�� et.HEALTH DEPT. ` ESTABLISHMENT NAME: TAX ID: � �— � LOCATION ADDRESS: HOUQAYVI�A�i�i NC TEL.#: - � L� MAILING ADDRESS: • E-MAIL ADDRESS: WEST YARMOUTH, • � a c,Gc� OWNER NAME: V� C�S �'L CORPORATION NAME (IF APPLICABLE): � 1VIANAGER'S NAME: �vC T�vst-�e s SGC4 Ve-l�tl e EL.#:��-�7�j 'O� ) MAILING ADDRESS: �,�Q � i POOL CERTIFICATIONS: ; The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Poo Operator(s) and attach a copy of the certification to this form. � —��� _— ----- ---- —2 - � Pqol 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 bu 'ness. 1. �e O 2. Gl.t�� 3. 4. 'K�'��'�o�''I)�t' �Y�� 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 IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. � �.�.— 2. —_ __ _--— _ --- — _ ____ _ __ _ _ ___ _- _ I - - � 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.'�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# �_ --- _--- n�Tr v 1' `liL /J �-�j�/��- . _. ___."'_. ' LODGING: ; LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# L CENSE REQUIRED FEE PERMIT# _B&B $55 CABIN $55 � MOTEL $110 6�0 —I� $55 CAMP $55 �SWIMMING POOL$110ea��s�j� _LODGE $55 =TRAILER PARK $105 �WHIRLPOOL $1 IOea.� FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �1 O�SEATS $200 —CONTINENTAL $35 NON-PROFIT $30 — _COMMON VIC. $60 �WHOLESALE $80 RETAIL SERVICE: —RESID.KITCHEN $80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.8. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 � _<25,000 sq.ft. $150 _FROZEN DESSERT $40 _TOBACCO $110 NAME CHANGE: $ts AMOUNT DUE _ $ ��O.00 ! *****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 MUS�'BE COMPLETED�ND SIGNED, OR - ; � � � CERT: OF INSL�RANCE ATTACI��D� ' 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, �nd 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 � obtamed 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 j 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 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 ESTAB SHME T, MOTEL OR POOL (i.e., PAINTING, NEW j EQUIPMENT,ETC.), MUST BE REPORTED T AND APP OVED BY E BOARD OF HEALTH PRIOR � TO COMMENCEMENT. RENOVATIONS M Y QUIRE ITE PL DATE: � "7 � SIGNATU : � PRINT NAME&TITLE: ' Rev. 10/01/I S L � i�� 4 � � - •-s . ' � � The Commonwealth of Massachusetts �, � Department of Industrial Accidents Office of Investigations ' I Congress Street, Suite 100 Boston,MA 02114-2017 ivww.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses` Applicant Information Please Print Legiblv , , Business/Organization Name: � �l ���� Address: �l�.L�V.�L L� City/State/Zip: (.l� �(� � �o e - �'j - � Are you an employer? Check the appropriate boz: Business Type(required): 1.[�I am a employer with 1 employees(full and/ 5. ❑ Retail or part-time).* 6. ❑ RestaurantBar/Eating Establishment _ —_ _— - — - — --- -- _ __ _ ------ - - 2. I am a sole proprietor or partnership and have no �. � Office and/or Sales(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. ❑Entertainxnent their right of exemption per c. 152, §1(4), and we have 10.� Manufacturing no employees. [No workers' comp. insurance required]* 11.❑ Health Care 4.❑ We are a non-profit organization,stafFed by volunteers, with no employees. [No workers' 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 o�cers 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 prbv' ing wor ers'compensation insurance for my lo ees. Bel w is the policy information. Insurance Company Name: } ��`.) � �� Insurer's Address: �� - tZ�� � �� City/State/Zip:��,<0 � � �X.X [� , �C� v���� '� � �- Jl � Policy#ar Self-ins.Lic. # �_�Ln�, (�l�`_��Q����-C� '/�� Expiration Date: I�'I«�Ck.•�f" � 2, wj�p 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 -- --_ ------- fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in tFie form of a S'TOP W�1�K�ffGER an3 a fne - - of up to$25,. day against the violator. Be advised that a copy of this sta.tement may be forwarded to the Office of Investig 'ons of e DIA for in ance coverage verification. � I do h reby certi under th p 'ns and penalties of perjury that the information provided above is true and correct. � ' �$i a e: Date: i Phone#: Official use only. Do not write in this area,to be comp[eted by city or town officiaL 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 � ��ghtFax C3-1 10/1/2015 6:41 : 39 AM PAGE 2/002 Fax Server �._ � i :=�'''"'� .:. I � CERTIFICATE OF LIABILITY INSURANCE DATE(MMlDD/YYYI� T. IFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFlCATE DOES NOT AFFIRMATIVELY OR NEGATIVEIY AMEND,EXTEND OR ALTER THE COVERAGE AFFdRDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE ACONTRACT BETWEEN THE ISSUING INSURER(S),AUTH�RI2ED REPRESENTA77VE IMPORTANT:If the certificate holder ls an ADDITIONAL INSURED,the policy(fes)must be endorsed. If SUBROGATION IS WAIVED,subject to he terms and conditions of the policy,certain policies may require and endorsement A statement on this certificate does not confer rights to he certificate holder in lieu of such endorsemen s. � PRODUCER CONTACT NAME: AMITY INS AGENCY INC PNONE FAX 500 V[CTORY RD (A/C,No,Ert): (NC,No): MARINA BAY NOR1'H QUINCY,MA 021'71 A DRESS: �?w2C INSURER(S)AFFORDING COYERAGE NAIC X INSURED INSURER A: ACH AMII2iCAN tNSURANCS COMPANY HOLIDAY VACATION CONDOMINIUMS INSURER B: IfJ.SURER C: � INSURER D: PO BOX 940 INSURER E: � SOUTH YARMOUTH,MA 02664 INSURER F: COYERAGES CER7'�ICATE NIAIABER: REVIS�N NUMBER: HAT HE POLIGES OF NSURANCE USTED BELOW HAVE BEEN 6St1ED TO THE NSURE�NAMED ABOYE FOR THE POLICY PERIOD INDICATED. NOTWRHSTANDNG ANY REQUIREMENT,TERM OR CONDRION OF ANY CONTpACT OR OIHBi DOq1UAENT WRH RESPECT TO WHICH 7HIS CEHTIFICATE IAAY BE ISSUED OR MAV PEHTAN.THE MISUHANCE AFFOHDED BY THE POLIGES DESCRIBED HEFiEN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS IIND CONORIONS OF SLICH POLIqES.L�11T6 SHOWN MAY HAVE BEEN REDUCED BY PAD CLNIAS. NSR ADQ B POLICV EFF DATE POLICV EI(P DATE LTR TVPEOFNSUHANCE L R POLICYNUMBEH (NAIOWYYYY) (MMDD\VY`/tl} LMARS GENERAL LIABILITY ACH OCCURRENCE $ COMMERCIAL GENERAL 11ABiLITY DAMAGE TO RENTED $ CLAIMS MADE �OCCUR. REMISES(Ea occunence) � ED EXP(Any one person) $ ERSONAL d ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: ENERAL AGGREGATE $ POLICY a PRQIECT❑LOC RQDUCTS-COMPlOP AGG $ AUTOMOBILE LIABILITY CON�NVED SINGLE $ ANY AUTO LIMIT(Ea accident) ALl OWNED AUTOS 80DILY INJURY S SCHEDULE AUTOS (Per person) HIRED AUTOS 80DILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE � (Per accidentj UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CIAIMSauIRDE AGGREGATE $ DED UCTI B LE $ RETENTION $ a A EMPLOYER S�ABINS�YATION AND Y!N UB d494P9o0-15 03lD2Pto15 03l02/2016 X WMI SAMDRY OrHEA ANY PAOPEFITORJPARTNER/EXECUTIVE � �A E.L.EACH ACCIOENT $ 500,000 OFFIC£FiIMEMBER EXCLUDED? (AAandatay in NH) E.L.DISEASE-EA EMPIOYEE f 5p0,D00 II yes,desaibe under DESCAIP71otv oF oPeaaTloNs be�ow E.l.DISEASE-POLICY LIMIT $ 500,000 DESCRiPT'ION OF OPERATIONS(LOCATIONSNEHICLESIRESTRIC710NS/SPECIAL ITEMS TIiIS REPLACBS ANY PRIOR C&RT[FICATE ISSU&D TO THE CERT[FICATE AOIAER AFF&CI1NG WORKERS COMP COV&RAGE. CERTIFICATE HOLDER CANCELLATION TO WN OF YARMOUTH SHOULD ANY OF THE ABOYE DESCRIBED POLICIES BE CAWCELLED 1 14G RT 28 BEFORETME EXPIRA710N DATE 7FIEREOF,N0710E WI��B DELIV IPI ACCORDANCE 1MTN TFIE POLICY PRO AUTHORI2ED REPRESENTAl1VE 5 YARMOUTH,MA 02664 ACORD 25(201Q/05) The ACORD name and loga are registered marks of ACORD 1988-2010 ACORD CORP R . r g ts reserved.