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Home My WebLink AboutApplication and WC � ► TOWN OF YARMOUTH BOARD OF HEALTH ,.--, r.. � � ��`v��-�° %- � '� � APPLICATION FOR LICENSE/PER1�4�'F��f � *� �A� Z � �Q�� ``"" * Please complete form and attach all necessary dodufii�nt ;��b ee�nr�"e 1 S 201 S. ' Failure to do so will result in the return of y�;ap�i�ation packe HEALTH DEPT. ESTABLISHMENT NAME: �-/,i�� C.L��-ld�.–' TAX ID: �;- LOCATION ADDRESS: �� t!f�o,�✓ �T— �� %/,�/t��TEL.#: SD�''� 7�5'�2�r 3� MAILING ADDRESS:�S' �g�r� �T- !�� ?`�2�e�r� l'�2� D2673 E-MAIL ADDRESS:��„ ,q �`�� l��lZox� �U�r" OWNER NAME: -��✓ ��-�� CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: ��at.�-sc-� �'�t2l��'"�– TEL.#: •`�g• ��'r• �13�-- MAILING ADDRESS: 7 �0'1-��1v�vdo � G�/ Y/�/Z�?dc7� �4 m26 � POOL CERTIFICATIONS: ��o l., W>�.1-- vG'G� i�e' �,1��av�' 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. __ 1 ____� -- _ 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. 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 IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1 ___ - —- _________________ __—_ ___ _ – ___ _____.________—____ ____ L ----1-- . ALLERGEN CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who has Allergen certification, as'de�ined 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: 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 e�nployees 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# LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE P IT B&B $55 CABIN $55 MOTEL $110 ��J�� _INN $55 CAMP $55 �SWIMMING POOL$110ea. ( —p _LODGE $55 _TRAILER PARK $105 WHIRLPOOL $i l0ea. 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: 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. $I50 _FROZEN,DESSERT $49 TOBACCO $110 NAME CHANGE: $i s AMOUNT DUE _ $ Z�-�a *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** f � ADMINISTRATION � > - s 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 sha11 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 i Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient. POOLS POOL OPENING:Alt 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. i ; POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standaxd plate count j 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. k FOOD SERVICE SEASONAL FOOD SERVICE OPENING: All food service establishments must be inspected by the Health Department prior to opening. Please conta�th� 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. ' 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 REQUIRE A SITE PLAN. DATE: SIGNATURE: PR1NT NAME & TITLE: Rev. 10/O1/15 .��' � The Commonwealth ofMassachusetts Department of Industrial Accidents : � � Office of Investigations ' � ' 1 Congress Streei, Suite I00 _ Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses '" Auplicant Information Please Print Legiblv Business/Organization Name: ��,4!�"z-� i�i��6 9`��L— � Address: �TS' ��'� �T City/Sta.te/Zip: Tit�. ��9-2�/1�v�f— � Phone#: ��• 7�� 3 Are yo an employer? Check the appropriate bog: Business Type(required): 1. I am a employer with 3 employees(full and/ 5. ❑Retail __ or part-time).* 6. ❑RestaurantJBaz/Eating Esta.blishment ' 2. I am a sole proprietor or partners ip an ave no 7. ❑ Office and/or Sales(incl.real estate,auto,etc.) ' employees working for me in any capacity. , 8. Non- rofit [No workers comp. insurance required] ❑ P 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.❑ ealth Care ' 4. We are a non- rofit or anization,staffed by volunteers, ❑ P g ,r�j rGsl� 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 I organizaUon should check box#L i I am an employer thatis providing workers'compensation insurance for my employees. Be[ow is the policy information. ' Insurance Company Name: � Z � 47��'"l� GJV�� D � Insurer's Address: b�,� �/}�/2� /4�� 9D ��x 4�0 7� City/Sta.te/Zip: U yNG � D I�d 3 - O "�Z� Policy#or Self-ins. Lic.# � a�1 Lv e ~ �t> '� ��23 / 2-.�- E��rat on Date: -7 i� %� Attach a copy of the workers' compensation policy declaration page(showing the policy number and ezpiration date). ___ Failure to secure covera�e as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a i — __- - fine up to$1,500.00 andlor one-year imprisonment,as well as civil penalties in the form of a STOP WURK ORDER an a n-�--- -' 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,u ,. 'the pains ndpenalties ofpetjury that the information provtded above is ue and corred. Si ature: ��`^- /� �� Date: � � /� Phone : � - � ' Of a aal 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. CitylTown Clerk 4.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: ' www.mass.gov/dia �""""" WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE A.I.M. Mutuai insurance Company 54 Third Avenue, Buriington, Massachusetts 01803-0970 (80�)876-2765 NCCI NO 26158 POLICY NO. AWC-400-7023125-2015A PRIOR NO. AWC-400-7023125-2014A ITEM 1. The Insured: John Barker � DBA: Yankee Viliage Motel . Mailing address: 275 Main S#reet FEIN:*=*** West Yarmouth, MA�2673 Legal Entity Type: Sole Proprietor Other workplaces not shown above: __, __, _ ___-_ ..-�_.____-_�..__..____....�_.__�W__...._W_. 2. The policy period is from 07/18/2015 to 07/18/2016 12:01 a. .standard time at the insured's mailing addre�s. 3. A. Workers Comperas�tjQII lnsuranc_�e:Part One of the poli lies to the Workers Compensation Law of the states fisted 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 liability under Part Two are: Bodily Injury by Accident $ 100,000 each accident Bodily Injury by Disease $ 500,000 policy limit Bodily Injury by Disease $ 100,000 each employee C. Other States Insurance: Coverage Replaced by Endorsement WC 20 03 06 B � D. This Policy includes these Endorsements and Schedules: SEE SCHEDULE 4. The premium for this policy wiil be determined by our Manuais of Rules,Ciassifications,Rates and Rating Plans. All information required below is subject to verification and change by audit. Ciassifications Premium Basis Rates ! Code Estimated Per$100 Estimated No. Tota!Annuai Of Annual Remuneration Remuneration Premium INTRA 87394 j INTER SE CLASS CODE SCHEDU E Minimum Premium $234 Total Estimated Annual Premium $620 GOV GOV Deposit Premium $640 STATE CLASS MA 9052 State Assessments/Surcharges $343.00 x 5.8000°!0 $2p This policy,inciuding all endorsements,is hereby countersigned by �� 06/26i2015 Authorized Signature Date Service Of6ce: Benson Young&Downs Ins Agency Inc 54 Third Avenue P O Box 158 Buriington MA 01803 Harwich Port,MA 02646 WC 00 00 01 A{7-11) Includes copyrighted material of the National Council on Compensation Insurance, used wtth its permission. ; /�.� �. _ �y�� A.I.M. Mutual Insurance Company /�'l �. Massachusetts Empioyers Insurance Company New Hampshire Employers Insurance Company � tIdSURANCE COMPANIES Assaciated Empioyers Insurance Company RENEWAL PROPOSAL WORKERS'COMPENSATION TEL.# (800}876-2765 PLEASE MAKE REMITTANCE TO DBte 06/02/2015 � A•�.M.Mutual insurance Co' P.O.Box 4070 � Burlington,MA 01803-0970 Yankee Village Motei tMPORTANT: COVERAGE WILL NOT BECOME John Barker EFFECTIVE UNTIL YOUR POLICY EFFECTIVE 275 Main Street DATE. West Yarmouth,MA 02673 • . _ RI.EASE PfltY THE Tf}T�tt�l�- _ =W-._ .-: DUE SHOWN BELOW NO LATER THAN: INSURED June 28,2015 Benson Young&Downs ins Agency Inc payment of the deposit premium will constitute P O Box 158 the empio�rer's acceptance of and agreement to Harwich Port,MA 02648 the terms and conditions of the policy. PRODUCER OF RECORD Current Policy F�cpiretlon Date 07/18/2015 Renewal Policy Effective Date 07/18/2015 I Renewal Policy Number AWC-400-7023125-2015A CODE Estimated Total �j�� Estimated Annual Premiums NO Annual Remun- Subject to Remuneration e�tion Mod�cation AllOther SEE EXTEIdSION OF INFORMATION PAGE TOTAL ESTtMATED ANNUAL PREMIUM 620.00 TOTAL MA ASSESSMENT 343.00 x 5.8°k 20.00 DEPOSIT PREMIUM 640.00 DEPOSIT ASSESSMENT TOTAL AMOUNT DUE 640.00 FOR COMPANY USE ONI.Y NET AMOUNT OF CHECK Piacing Uffice: 400-113-2 Initial&Date AP 4921 (9-69) 54 Third Avenue•P.O. Box 4070•Burlington, MA 01803-0970•Tei: 781.221.1600/800.876.2765•FaX;781.270.5599 BRIDGEWATER•BURLINGTON•CONCORD,NH•HOLYOKE•MARLBOROUGH spor�sored byAssociated Industries of Massachusetts