HomeMy WebLinkAboutApplication and WC �.
� � � � TOWN OF YARMOUTH BOARD OF HEALTH . r �
� � APPLICATION FOR LICENSE/PERMIT -2016 � ��� NOV Z 3 Z015
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* Please complete form and attach all necessary doc�r�f�by �cenzbe ''1 S 201 S.
Failure to do so will result in the return of your a�iplication pack . HEALTH DEPT.
ESTABLISHMENT NAME: +r �✓ i r T X ID:
LOCATION ADDRESS: / v Y'h t�r�• •� D 26�STEL.#: g'�`f`��S 4��
MAILINGADDRESS: � vnov Z�� S
E-MAIL ADDRESS: re S e►-�va-fra� ' fcv� co�
OWNER NAME: ✓�
CORPORATION NAME F APPLICABLE): �/�t-
1VIANAGER'S NAME: � ,�r � t.� TEL.#: b'"'�y ��S�6
1VfAILING ADDRESS: �u 6,/F �.✓m� `fZc o ,/v(/P- O 2!0 ,�
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. �_ _ __ �
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�'ool 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 i
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. l� ...�lv� � 2.
PERSON IN CHARGE: 'I
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. i
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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 ew copies nd maintain a �le at your establishment. f
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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. � F ��-- 2, i
3. 4. '
RESTAURANT SEATING: TOTAL#
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LODGING:
LICENSE REQUIRED FEE P IT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
�B&B $55 -��3 —CABIN $55 _MOTEL $110
INN $55 CAMP $55 SWIMMING POOL$110ea.
LODGE $55 TRAILER PARK $105 WHIRLPOOL $110ea.
FOOD SERVICE:
LICENSE REQUIRED FEE P ��IT LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
�0-100 SEATS $125 ���`o�—`.'-kI CONTINENTAL $35 NON-PROFIT $30
>100 SEATS $200 ZCOMMON VIC. $60 .�py _WHOLESALE $80 '
—RESID.KITCHEN $80
RETAIL SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_<25q >25,000 sq.ft. $285 VENDING-FOOD $25
,000 sq.ft. $150 _FROZEN DESSERT $40 _TOBACCO $110
NAME CHANGE: $15 AMOUNT DUE _ $ 240.00
*****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 CO PENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR
CERT. OF INSURANCE ATTACHED
OR f
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED �
Town of Yarmouth taxes and liens must be paid prio to renewal or issuance of your pertnits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES NO
-- ., MOTEL�:AND OTHER LODGING ESTABLISHMENTS ,
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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 thirly(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.
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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 j
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, j
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,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 December 31. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 15, 2015.
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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 UIRE ITE PLAN. '
DATE: lj�19�I,� SIGNATURE: , ��
PRINT NAME & TITLE: �0 L 4� �'1�--�� - �j�NC lZ �So L E P�D P R�ETo�-
Rev. 10/O1/IS
� The Commonwealth oflVfassachusetts
� Department of Industrial Accidents ,
Office of Investigations
� I Congress Street, Suite 100
Boston, MA 02I14-2017
www.mass.gov/dia '�
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legiblv
Business/Organization Name: ��� i3�us�-1N�-6 ys T�� ��"� �- 1�E l«.>¢-� �1�- ;
Address: ��9 p l�D(�7� �/}'
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City/State/Zip: y��nU�1��� �1� Phone#: �d�' �'f`����
Ar�e y an employer? Check the appropriate boz: Business Type(required):
1.LI I am a e loyer with y employees(full and/ 5. ❑Retail
o art-tim .* _____ - .---; - � =t;= 6: -��Zesfaurai���Establishm�nt- _ - i
2.❑ I am a so e proprietor or partnership and have no �, � Office and/or Sa1es(incl.real estate,auto,etc.)
employees working for me in any capacity.
I [No workers' comp.insurance required] 8• ❑Non-profit
3.❑ We are a co r poration and its officers have exercised 9. ❑Entertainment
their right of exemption per c. 152, §1(4),and we have 10.�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.] 12.[�Other�ja�, a�d��C��S{— .;
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. I
**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 informataon.
Insurance Company Name: /�'�.U' .� .S'
Insurer's Address: ��� � (6 ���' � ,co �D(��� _ Sv�� �l b
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City/State/Zip: � C ��I O � �`� � '
Policy#or Self-ins. Lic. # � ��� Expira.tion Date: J�
Attach a copy of the workers' compensation policy declaration page(showing the policy number and ezpiration date). �
�_____ FailurE_to se�ure covera�e as zec�uired 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 the form of a STOP WORK ORDER and a fine ;
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of �
Investigations of the DIA for insurance covera.ge verification.
I do hereby cert' ,under t ains and penalties of perjury that the information provided above is true and correct.
Si ature: Date: /'� 1� 1 i
Phone#: ���` ��'����
Officdal use only. Do not write in this area,to be completed by city or town officiaL
;
;
City or Town: PermitlLicense# �
Issuing Authority(circle one): ;
1.Board of Health 2. Building Department 3. City/Town Clerk 4.Licensing Board 5. Selectmen's Office
6.Other
Contact Person: Phone#:
www.mass.gov/dia
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T�A1I��E#'�S� WORKERS COMPENSATION
ONB TOWER SQUARE AND
HARTFORD, CT 06183 EMPLOYERS LIABILITY POLICY
' TYPE V INFORMATION PAGE WC 00 00 01 ( A)
I
� POLICY NUMBER: (IEUB-7F61180-1-15)
NEW-15
INSURER: THE TRAVELERS INDBI�iITY COMPANY OF CONNECTICUT
+ � NCCI CO CODE: 12637
I -- - _ _�— - —
' INSURED: PRODUCER:
SILVA, HOLLY THE BLUSHING AUTOMATIC DATA PROC INS
OYSTER BED & BREARFAST 1 ADP BLVD MS 325
168 RT 6A ROS$LAND NJ 07068
� YARMOUTH PORT MA 02675
I
I Insured is AN INDIVIDUAL
Other work places and identification numbers are shown in the schedule(s)attached.
2. The policy period is from 04-05-15 to 04-05-16 12:01 A.M. at the insured's mailing address.
3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers
Compensation Law of the state(s)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 our liability under Part Two are:
Bodily Injury by Accident: $ 100000 Each Accident
Bodily Injury by Disease: $ 500000 policy Limit
Bodily Injury by Disease: $ 100000 Each Employee
___ C. QTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here:
AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN RS KY LA NID ME MI l�T
MO MS MT NC NE NH NJ NM NV NY OK OR PA RI SC SD TN TX UT VA VT WI
D1V
D. This policy includes these endorsements and schedules:
SSB LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGS
4. The premium for this policy will be determined by our Manuals of Rules,Classifications, Rates and Rating
Plans. All required information is subject to verification and change by audit to be made ANNiTALLY.
DATE OF ISSUE: 04-03-15 KC
OFFICE: PAYROLL 70A DIRECT BILL
PRODUCER: AUTOMATIC DATA PROC INS XV770