HomeMy WebLinkAboutApplication and WC il t � �S
� �* � TOWN OF YARMOUTH BOARD OF HEALTH G3C�C�C�UNIL�D°
� � APPLICATION FOR LICENSE/PEI� ; 6 -
�e � �j] NQV 12U15
* Please complete form and attach all necessary do�.iine,� c�"mb :15 201�.
' Failure to do so will result in the return o��e,ur�pkcation p�ac . HEqLTH DEPT.
E�TABLISHMENT NAME: � e e�w �`�`�5 TAX ID: ��- �
LOCATION ADDRESS:`35� ov�� Z-8 TEL.#: So8 -�9$ -Z t Sq
NIAILINGADDRESS:�.:c.e+�s':.c� 0eek - `2o �x t5ao S�r:rnq �Ql�.�o�.o �55d1
E-MAILADDRESS:r�.�1�•0���ee�wa,.r. �a�
OWNER NAME:��ee��4-� LL —
CORPORATION NAME (IF APPLICABLE):
MANAGER'SNAME:�v�4`�:atassac - S�o�e Mn.n0.4�c' TEL.#: 50$-398� 2\59
MAILINGADDRESS: `1353 �o�+�� �� Soo��. `�o�r+.�o.���. ,M� 02toi�►y�-45o�
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated
P4o1 Operator(s) and attach a copy of the certification to this form.
1. _ _ _._ _ 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.
1. 2.
3. 4.
Ffl(�Tl PR(ITF,CTI��A/IANAGF.��-;._(�E�ZTIFI�l�TI�N�_— �re-_PK�. S+r�ci�Ks
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.
l. ��o.''C'o����o� �o.sso� 2.
PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
1. ��a�-c����cX �-assoc 2. M�c.4�we� N� cl+o�S
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. ��o.�t-c���; a_ �as S o c- 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#
___._______�._ - ---------
_ OFFICE USE ONLY
LUD(GING:
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 COMMON VIC. $60 WHOLESALE $80
—RESID.KITCHEN $80
RETAIL SERVICE:
LICENSE REQUIRED FEE PERM[T# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
Z<2� q >25,000 sq.ft. $285 VENDING-FOOD $25
,000 sq.ft. $150 �� _FROZEN DESSERT $40 �TOBACCO $110 T /�Z
NAMECHANGE: $15 AMOUNTDUE _ $ ZC�O.00
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*****
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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
APPROPRIATELY IF PAID: �
� YfiS � 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.
POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of
closing. �
FOOD SERVICE
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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.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: �
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
EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY REQUT A SITE PLAN.
DATE: �� � 'l� SIGNATURE: +
PRINT NAME& TITLE: �-o�.a�\� L , E�.r•.:S�c��n ,�ccasu�-e c- ,Sp�e�wes. �
Rev. 10/O1/15 ���� �
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' � � The Commonwealth of Massachusetts
Department of Industrial Accidents
-� - Office of Investigations
� 1 Congress Street, Suite I00
Boston,MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legiblv f
Business/Organization Name:��ee�.wav �-L �- ��b�Q �������� � �`�4 S j
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Address: �3'S 3 �a�� e Z 8
City/State/Zip:���� �Q�ma���,�'� °2�'�y_ Phone#: S o8 - 3`�$ - 2i S q
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. ❑RestaurantBaz/Eating Esta.blishment �
2.❑ I am a sole ro netor or artnershi and have no � �• � �
P P � P P 7. Office and/or Sales mcl.real estate,auto,etc. �
employees working for me m any capacrty. i
[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 required]* 11.0 Health Care '
4.❑ We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp. insurance req.J 12.0 Other ,--`- C
*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
i
__ . . �#►eckbe�#�1.-_ _ - ------ --- - _ __ - -- _ _ �
!
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. ;
Insurance Company Name: P`�4s e s e� a�� o���-.e� i
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 egpiration date).
Failure to secure coverage as required 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 WORK ORD�R and a fine '
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 certify,under the pains and penalties of perjury that the information provided above is true and correct.
; Date• '" J
Sisnature �� �%���� l/�~�
Phone#: `�3'1 - 8� 3 - � 3 2, Z
� Officia[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
�
t� Contact Person• Phone#•
�
j www.mass.gov/dia
�
A�a� GERTIFlCATE OF LlABiLITY INSUF�ANCE pATE4MFRlODIYYYY�
6122/2 15
THI& CERTIFICA7E IS tSSUEp AS A MATTER OF lNP4RMAT{ON t?NLY AND CQNFERS NO RIC3H7S UPON THE CERTI�lGATE HOLRER. TNIS
CERTIHCATE ppES NUT APFIRMA7IVELY QR MEGATIVELY AMEND, EXTENO OR ALTER THE COVERAGE AFFORDED 8Y T#iE PQUCIES ,
BELQW. TNtS CERTIFICATE OF INSURANC� DOES NOT CpNS71TUTE A C�NTRACT BETWEEN 7FlE lSSUING INSUR£R(S), AUTHOFtiZED
REPRESENTA7IVE OE2 PRODUCER,AAid THE CERTIFlCATE HQLDER.
IMPORTANT: if the certificate hotder is an ADOITiONAL tN3URE0,the policy(aes)must 6e endorsad. if SUBROGATION IS wAiVED,subject to
; the tsrms and conditiorss of tho policy,certain policiss may require an¢ndorsement. A statement on this certificate doos not canter rights ta Lho
'; csrtfflcate Ytoldsr ln tieu of such endorsemeo s. .
� PRODUCER .NAMEL._.._._.�'..Il$5r�_LQ.Y�..._.....�__...._._._..._..............................._..._.._._.�._...._....._.._.._..Y___......._.._.._�---_ �
, Hylant Group-Gleveland PHONE !FA%
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INSURER C
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TNIS IS TO CERTIf Y THAT THE POL1C{GS OF INSURAN�[L15TER BELQW HAVE BEEN ISSUED TO 1'NE 1NSURED NAM[D RBtJV��OR THE PQUCY pERt00
INDIC:ATE.O. NOTVSflTh1STANAING ANY REQISI#2EMENT,TERM Qft CONOI710N OF ANY CONTRACF OR OTHER �OCUMENT WITti RESPECT ip WHfCN THIS
CERTIFtCATE PAAY BE IS5U[D OR NWY PER7NN, THE INSURANCE AfFORl�ED BY 7HE POLtCIES �E5CRf6ED HEREiN �S SUBJECT 'r0 ALL THE TERMS,
EXCI_US10NS AND CONDITiONS UF SUCH POLiC1ES.�tMiTS SHQNJN MAY HAVE LiEEN REDUCEn ElY PAIU CLAIMS.
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DESCRipTtOff OF OPERa710NS;LOCATiONS l YEMICLE5�Attech AGORD 101,Additlanat Ramarks Scheduta,II mor�space Is requitetl� �.
CER7IFICATE HOLDER CAtJCELLATiQN
SHOULD ANY pF 7FlE ABOVE dESCRIBEO POLICIES BE CANCELLED BEFORE
7HE EXPIfiA710N OA'fE tHEREOF, NOTfGE W1LL 8E DELIVERED IM '
Evidence of Insurance-Speedway ACCORpANCE iMTH T}iE pOLICY PROVI8lONS.
� ' ' " AUTHOREZED REPRESENTATIVE �
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O 1988-2010 ACORD CORPORATiON. Alt rfghts reserved.
ACpRD 25(2010105) Tfie ACORD name and 4ago are registered marks of ACORD