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HomeMy WebLinkAboutApplication and WC . . ` �� ► TOWN OF YARMOUTH BOARD OF HEALTA �"����� � � � APPLICATION FOR LICENSE/P�RM�T� � A�' ��(; !� � 2Q15 �"°" * Please complete form and attach all necessary doc :��� r 1 20 . , ' Failure to do so will result in the return of your app�ication pac t. DEPT. E�TABLISHMENT NAME: v 7� TAX ID: LOCATION ADDRESS: � ` TEL.#: - 5` . MAILING ADDRESS: E-MAIL ADDRESS: �P�f j-LGGi � �1l1,1'fCn�z� ��''oTGr��J OWNER NAME: C(ORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: !3(LI A-N PETYLt)C�t TEL.#: MAILING ADDRESS: 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. — - - - ___- ---- -- _ __ __ _- ---- ------_ --�— g.___ - ----- Pool operators must ist 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 Heatth Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. � /1,5 2. ��tr° ' 3. .` �` Y 4. . , UGC 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. ; L 2. PERSON 1N CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. I ; � 1 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. 2. ; HEIMLICH CERTIFICATIONS: j 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 f 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 � — ---- -----_ - —i -- - _ _ __- -- LOUGING: , 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.-��] j _LODGE $55 _TRAILER PARK $105 WHIRLPOOL $I IOea. 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 I LICENSB REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 ' <25,000 sq.ft. $150 _FROZEN DESSERT $40 _TOBACCO $110 NAME CHANGE: $t s AMOUNT DUE _ $ /!0 •O� ; *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** i { . f F � ^ • � f 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 pri 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 tertn 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(3U)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 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 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: I Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. �I� OUTDOOR COOHING: 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. j 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 REQUIRE A SITE PLAN. ' DATE: ��',� '�d�.j SIGNATURE: ,, � PRINT NAME&TITLE: " �'✓��i �+�►� r� Rev. 10/01/15 ! ' �Y �� � The Commonwealth of Massachusetts � _ Department of Industrial Accidents - Office of Investigations ' l Congress Street,Suite 100 Boston,MA 02II4-20I7 _ , www.mass.gov/dia : _, Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Le�iblv Business/Organization Name: j` �U Address: ` C� City/State/Zip: � o� �hone#: �D �'�c3�a 'c�5� Are ou an employer? Check the appropriate boz: Business Type(required): 1� I am a employer with employees(full and/ 5. ❑ Retail — °-_-r L��e)•* - — — -- -- ---- - 6_[] RestaurantlBar/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. ❑ Entertainment their right of exemption per c. 152, §1(4),and we ha.ve 10.❑ Manufacturing no employees. [No workers' comp. insurance required]* 11.� Health Care ' 4.❑ We are a non-profit organizaxion, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 1 . ther *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#L I am an employer that is providing workers'compensation insurance for m employees. Below is the policy information. Insurance Company Name: L> >GL 7 � � s Insurer's Address:�/s l�j�� �iy��j��A?"�D17� .NL �� a9q���-�/i/�,L'D�___,7, City/Sta.te/Zip: /,/�/i'1'��j�t��77� ///r7 0���� Policy#or Self-ins.Lic.# LU� s c3�� �o�5��n�� Expiration Date: L'S=�3��I/,�_ 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 ' �irie up�o$1,500.00 an�or one-year imprisorimen�,as�vell as civil periat�ies in the form ofa STOP W6Kt�a�13ER an3-a fine - � of up to $250.00 a day against the violator. Be advised that a copy of this sta.tement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. ' I do hereby certify,under the pains and penalties of perjury that the information provided above is true and correc� Si ature. /YJuhu ��r ct Date: 1�c311,$� Phone#: �v� � 3���3f3� Ojficial 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 i �� CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYIn IFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)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 dces not confer rights to he certificate holder in lieu of such endorsemen s. PRODUCER CONTACT NAME: HUB INTERNATIONAL NEW PHONE FAX 299 BALLARDVALE ST (ac,No,Ext): �ac,No�: E-MAIL WII.,MINGTON,MA O1887 ADDRESS: 2939R INSURER(S)AFPORDING COVERAGE NAIC# INSURED INSURER A: TRAVELERS INDEMNTI'Y COMPANY OF AMERICA KINGS WAY CONDOMINIUM TRUST INSURER B: INSURER C: INSURER D: C/O PROPERTY MANAGEMENT AT 64 KINGS CIltCUIT INSURER E: YARMOUTH PORT,MA 02675 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: H I CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE POR THE POLICY PERIOD WDICATED. NOTNRTHSTANDING ANY RECUIREMENT,TERM OR CONDRION OF ANY CONTRACT OR OTHER DOCUMENT 1MTH RESPECT TO WHICH THIS CERTIFICATE MAY BE 1&SUED OR MAY PERTAIN.THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN I$SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDRIONS OF SUCH POLIC�S. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CL/1�AS. INSR ADD SUB POLICY EFF DATE POL�CY D(P DATE LTR TYPE OF INSURANCE L R POUCY NUMBER (MMIDDIYYYY) (MMIDDIYYYY) LIMRS GENERAL LIABILRY CH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY � AMAGE TO RENTED $ CLAIMS MADE �OCCUR. REMISES(Ea occurrence) ED EXP(Arry one person) $ ERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: ENERAL AGGREGATE $ POLICY �PROJECT Q LOC RODUCTS-COMP/OP AGG $ AUTOMOBILE LIABILITY OMBINED SINGLE $ ANY AUTO IMIT(Ea accident) ALL OWNED AUTOS ODILY INJURY $ SCHEDULE AUTOS Per person) HIRED AUTOS ODILY INJURY $ Per accidern) NON-OWNED AUTOS ROPERTY DAMAGE $ Per acciderk) UMBRELLA LIAB OCCUR CH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE GGREGATE $ DEDUCTIBLE $ RETENTION $ $ A WORKER'S COMPENSATION AND X WC STA7UTORY OTHER EMPLOYER'S LIABILITY Y/N UB-0175N69&15 02/26/2015 02/26/2016 LIMI7S ANY PROPERITOR/PARTNER/EXECUTIVE a N/A � E.L.EACH ACCIDENT g 500,ppp ����� OFFICERIMEMBER EXCLUDED? '�� (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 ''�... H yes,describe under DESCwPriON oF o�rtn7loNs beiow E.L.DISEASE-POLICY LIMIT $ 500,000 ', DESCRIP710N OF OPERATIONSILOCATIONSNEHICLESIRESTRICTIONS/SPECIAL ITEMS TI�DS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE. CERTIFICATE HOLDER CANCELLATION TOWN OF YARMOLTTH SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED HEALT'H DEPART'MENT BEFORE THE EXPIRATION DATE TMEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 1146 ROUTE 28 AUTHORI�D REPRESENT E � � SOUTH YARMOUTH,MA 02664 ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD 1988-2010 ACORD CORPORATION. All rights reserved.