Loading...
HomeMy WebLinkAboutApplication and WC � � � � TOWN OF YARMOUTH BOARD OF HEALTH ' � � � APPLICATION FOR LICENSE/PE k�T� ��+� � �� �� �: ��y � � ���5 ``"'� * Please complete form and attach all necessary docume� y, .e erttbe IS 2015. Failure to do so will result in the return of yot�r a�plication packe . HEALTH DEPT. ESTABLISHMENT NAME: .d�11�-� 72-�-� TAX ID: - / �.� LOCATION ADDRESS: 5 C.on� n1 � S u � arr�-cvvf� TEL.#: s'�J� 3 �/?�Z MAILING ADDRESS: Sd� �14 ( U c�./��fc �S �h�-. A �33�-z� E-MAIL ADDRESS: � ,`c� I � t L�2 �C < � O WNER NAME: �D t(�-T .S�"e�-S ...��� CORPORATION NAME (IF APPLICABLE): !�o f 1a.1�-_ 2��- .S�l�-s ZN � MANAGER'S NAME: h� l 1 �`� /��1�i EL.#: So£� �-�,�=7? y MAILING ADDRESS:5`�� t/�1✓o �� C��/��.ak� /�4- o�3s'2--c� POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operatar(s) an attach a copy of the certification to this form. ]:_ _ -- �v � __ 2_ �I� - 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. Yo must provide new copies and maintain a file at your place f business. l. /v 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 maint in a file at your establishment. �� 1. ' �---- 2. � PERSON IN CHARGE: �ach food establishment must have at 1 ast one Person In Charge (PIC) on site uring 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 applicatio . The Health Department will not use past years' records. You must provide new copies and maintai a le at your establishment. 1. 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 certifcations to this form. The Health Department will not use past years' records. You must provide new copie and maintain a file at your place of business. 1. 2. 3. 4, RESTAURANT SEATING: TOTAL# ---__---- --- __ nFFICE USE Q1YLY_ -- -- - _--- _ _- ------- IN : __ _ 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 RETAIL SERVICE: —RESID.KITCHEN $80 LICENSE REQUIRED FEE PERM[T# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# r.�<2�,000 sq.ft. $150 �r =FROZEN DESSERT$$40 =OBAn CO FOOD$$10 — NAME CHANGE: $15 AMOUNT DUE _ $ /,SO.QO *x***PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** ADMINISTRATION c ' 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 1NSURANCE ATTACHED �f 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. 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 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: 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 APP OVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY QUT A SIT�PLA . DATE: �I��/ � I3 �D 1 S�f SIGNATURE: PR1NT NAME & TITLE: ���Q � t � 5tor� Lic. Coordinator Rev. 10/01/15 � The Commonwealth of Massachusetts � _ __ . Department of Industrial Accidents Office of Investigations " 1 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: Dollar Tr�e Stares, InC. Address:�� �-f�n1 �hl YL- o��� j �� 7� 2. City/State/Zip:,s J�.�/`�- Phone#: Cs.�f1 ��/`f -/ Are yoy,an employer? Chec the appropriate boz: Business Type(required): 1.I� 1 am a employer with�employees(full and/ 5. [��-Re�tail or part-time).* 6. ❑ RestaurantlBaz/Eating Esta.blishment _ _ - -- - 2.LJ �am a sole proprietor or partnership and have no �7, � Office and/or Sa1es (incl.real estate,auto, etc.) employees working for me in any capacrty. [No workers' comp. insurance required] g• ❑ 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.� Manufacturing no employees. [No workers' comp. insurance required]* 11.❑ Health Care 4.❑ We are a non-profit organization, sta.ffed 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 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 empl ees Below is the policy information. Insurance Company Name: y� tJ rG2'-�� �,c..i✓ Insurer's Address: � �� ��=/�� �1��-�' . �� � City/State/Zip: � }�� j9�� Policy#or Self-ins. Lic. # � �� Z� Expiration Date: g l 2�� Attach a copy of the workers' compensation policy declaration page(showing the policy numbe a d 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 impnsonment�as weil as civii penaifies in tne�orm o�a S'i'QP�0���'v����.� of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the O�ce of Investigations of the DIA for insurance coverage verification. I do hereby ce ' , und he pa' s and ena 'es ofperjury that the information provided above is true and correct. Si ature: ` Date: '13'zo/.S`� Phone#: C��7���� `�' � C� Official use only. Do not write in this area,to be completed 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 -�--. �� !_"C_�!r!� f��1����1��Cr1�C �� ���O�L� 1 �� �I��J���1��44= � _r:,� J l� / I t I,i�(il I/r�/� � ��.G I '��5 CcRTIFIrAfF_ �� �;;�UED;�;i A !dAiTER OF I`IF�R:V1AT10N O�`ILY AVD CGNFERS NO RIGHTS UPaN fHF CER7IFICATE HOLD E R. T f�I S :�R71FiCAi E D O E S N O T .1 F F I R M A T IV E LY �J R �I E G A i i V E L Y a M E N D, E Y T E A I D O R A�i�R THE COVERAGE AFFORDED BY THE POLIClES •� �ELOW. THiS CERTIFICdTE OF INSURANCE DOES �OT CONSTITUTE A CONTRACT BETNEEN THE ISSUING INSURERIS), ;�UTHORIZED '_PRESENTATIVF OR PRODUCER.AND THE CERT1FiCATE HO�DER. :� I,�1PdRTANT: If the cemticate holder is an ADDIT1aNAL INSURED, the oolicy�ies) must he endor�ed. If SUBROGATION IS WAIVED, subjpct to �he terms and conditions�f the poilcy,certain oolicies may require an endorsement A statement on this certificate does not co�fer riqhts to the ' �crt�ficate holder ia lieu of such endorsementls►. j�=ROOUC'cR �1 iACT �� �.10t1 NISk 1e?fVlf05 C@flLfdl, C11C. � � � ���F� I - � H�ra ;;b6) z�3-71?Z i '�x z � r�ind aarlid5 rnI Otfir_e � � c ,�aexq: ��00-363-o1p5 �lO LOt115 �CfP_8L i�!'N �.�C.No.: � �� . . � r_�dAll � 7 I .00RESS: � - 1 �J1'B �'.t)n � � � � � � ;rrand aapids r.ti l')SD3 u5A � y � . � .� �'-^1SURERt3)AFFQRDINO COVERAGE,. . . I vA1C X JSURED �� ��,��suReAn: �>rcn [nsurance Comoany � ���11i0 i eo I 1.Zr �ree. [nc.: !r;�uaeR e: <L �peci a 1 ty Lnsurance Co ' all..ir r'ree Stores. tnc. i;7385 i°_ �.utl volvo ParkwaY ; r:suaenc: Ciiesapeake vq t3320 i�5.� i i!tlSUREA D: � 1 � ���NSUiiER E: , ;^JSURER F• :OVERAGES �:�RTiFiCATE NUMBER: 57C059160909 ZEVISION NUMBER• � i iiiS IS TO GcRTIFY THAT TNE POLIGES OF iPJSURANCE LISTED BELCW HAVE BEEN ISSUED TO THE INSURED MAbIED A80VE FOR THE P(JLlCY PERIOD iP101CATED. NOTbVITHSTANDING ANY REQUIREMENT.TERM OR CONOITION OF ANY CONTRACT OR OTHER DOCUMENT WITN RESPECT TO WHICH THIS �;cRT�FICATE PAAY BE iSSUED OR i1MY PERTAIN. THE INSURANCE AFFORDED BY THE POLICiES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. ? " POLICIES.L;MITS SHOWN MAY HAVE BEEN REDUCEII BY PAID CLAlPAS: Limit3 shown are as requested '_'� SAND�ONDI�IQCE OF SUCH iSQ WVO �nUCYNUMBER i.ytM/ODlY`/YY � � ..1 � S1MlOD/YYYV :_:,^-AITS i �C � COMMERCIAIGENEAAlL7ABILITY I i � LGPP I�%'��� � � �� � �rHOCCURRENCE I i,�OO,00Q � ��� ��L��MSMACE �occua � ��IR applies per poticy terfis & condi�ions ' � , ���n� . c . � i � � � � � f�=F_EMISES Eaoccuvenee �1,G00,000 ��'—� � I � i � i`�,-D EXP iAnv ans oereon� cxc 1 ud2d �� � � I � �°RSONAL 8 ADV INJURY rn I I I I I i1.000,Q00 � ciJ l AGGREGATE L!y11T APPI_IES FER' ! �cPiERAL AGGREGATE I 515,060.000 0 I � �< � PfJLICY I I cCT I_1���''� ' ( i I ' ^ 1 --f � I �PRODUCTS•CGMPIOPAGG $Z,OOO,OOO � 'T`'�R � i ' � ,� � a ! aUiOMO81LELLtBW��'/ j i �11U64954007 ;ii9/Ol/201509/Ol/2016.'CGPABINEDSINGLELIMR �n 1 ' � �a0S I ' Ea acGa�nn 5 2,000.000 � � �Nr AU70 I I 41CA,84954107 �09/Ol/2015109/OL/ZO16�BOOILY IN;IURV(Pxoenonl � �� I .�ILGWNED �CHEDULED ''�/1 . . � .a001 � � � Z ��UTOS � .1UT05 . . . . . . . . . . . . .. ; . IYINJURY(peraepCant . � �I I:-+�RED AUTOS I ���uN-GWNED I �•�f?pcRTY DAMAGE 9 �----} AUTOS I I;Pw acuderttl �� I j '[� I . . I . . + � g �� uMeRElu uae �� ocCua � �u�000662 1LZ15B �09/O1/2015 09/O1/2016 F I �� I ( . ' ACH GCCURRENCE i 7,OOO,OCO V � EXCE53UAB I CL4iMS-MADE � �'C'G�EG,iTE . . - � �5,000,000 � � � ��,:E� �RETENT!ON ! A I �vORKERSCOMPENSA710NAND i �d1wCI495420 �U9/Ol%20 ��O /0 /20 6 X pER �T�.� cMPLOYERS'LIA81lITY y�,y I'NC-AOS EXC� TX I �TATUTE �r :,yy oqqpo�ETOR/PPRTFIER/EXECUTPIE I ;FFICER/MEMBEA F�(CLUOEDt '� � N I A �.. i 3 L,v1CM ACCIDENT , � S 1,GOO,OOO �Mandatory m NM) I 't�ies,aesenbs unax � I � ;EL DISEASE-EA EMPlOYEE I S1,000,000 � �E>CRIPTICN GF OPERATIOpl3 balow i ��-.i_.DISEiSEPQUCY LMIT �1,OOO,000� I � i I I i � ESCPIPTION OF OPERA�iIONS I LOCAilON91 VEHICIES(ACORD 701,AdtlAbnal Remarks Sch�duN,may u�atlactwp if mor�l I i �� �Evidence of Coverage. � svsc��s recwne) . , '� i� '� �:-- �T� CERTIFICATE HOIDER CANCELLATION .�� �! �.iHOULp ANY OF THE ABOVE OESCRIBEp POL1ClE3 BE CANCFI(,Ep BEFOtiB THE ;1� cYPINATION OATE THEREOF, PIOTICE WILL BE OEUVEAEp IN ACCORDANCE WITH THE �_+�-� POUCY 7ROVISION3, Dolla� Tree Stores, Inc. ;� ��0 VO�VO PdI'kWdy aUTHOR1ZEpREpqE5EN7ATiVE �_hesaoeake v4 [3320 u5A ;� �-xi4�► i�%e:a4r6 eJsG�led �G��✓ ,r:r' ��a '� � aCORD 25�2014l01) rhe ACORD name and logo are registered ma�ks�otACORpRD CORPORATION.All rights reserved.