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Home My WebLink AboutApplication and WC i � � TOWN OF YARMOUTH BOARD OF HEAL H ` � � t� �,� '' � � APPLICATION FOR LICENSE/PE�VI�- � p�(; ;.: $ j�jj5 , � t � 1�� "°' * Please complete form and attach all necessary dt�cume�ts by erembe 1 S 2015. Failure to do so will result in the return of your application pack . H DEPT. ESTABLISHMENT NAME: ��1 L T M f�1 CV i�1 N� TAX ID• LOCATIONADDRESS: 5�� Ro�TF 2� W�S'� �qi�MoUTI� , MA TEL#• �O�-��jo�- IqS�- MAILING ADDRESS: �q� (2�v2 � 2 Ss UU Ec?�rQl`_,,_ Mocrr�-ITN1 �j o26�-3 , E-MAIL ADDRESS:�q��A bo ��f oTt?Al� . (;oM OWNER NAME: P2Q P�A SoM !�r�/�A teo�N CORPORATION NAME (IF APPLICABLE): ' MANAGER'S NAME: A t10/ZN �H 0 N G'f D N("� TEL#• �O�-- Z�S o-e�43� MAILING ADDRESS: 5q� Rocr'��2� w�S7 �p1� M ov�f� ., M� 02��-3 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. _ �_� _ -- _- - —- __ _. .__-- --- `--; �. 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 pr,emises 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. �. �i �l DRN pON� 7DI�i � 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. �_t"�P t�N �oN� 7�01�� 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 application. The Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment. �. PRI��N ,� S-o M k I7 �-A- fzo��/ 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. l. pRA-�NR SbM kr'r"�A �o��l 2. �o I�R �AT� S�DTA�ASv,v�T�F�v 3. 4. RESTAURANT SEATING: TOTAL# � �' ---- -- ----- 8�'F�I� TTr-v��-^v�L-� LODGING: 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 $I l0ea. FOOD SERVICE: LICENSE REQUIRED FEE PE IT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# I 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 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: $�s AMOUNT DUE _ $ /SS•OQ *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** ' ADMINISTRATION u � " 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 I 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: 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 , 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 tl�e 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 APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: � Z— ��" �� SIGNATURE: ,��5 j � PRINT NAME& TITLE: �TZ�� (�- S'0 P') �-1 I �i�� C?�N' Rev. 10/O1/15 1 ! ; The Commonwealth of Massachusetts i : � De artment o Industrial Accidents . P .f Office of Investigations ' 1 Congress Street, Suite I00 i Boston,MA 02114-2017 ; � www.mass.gov/dia , Workers' Compensation Insurance Affidavit: General Businesses ' � Applicant Information Please Print Le�iblv ': Business/Organization Name: �A S I 1.`��-1�1 CU 1 5 i N � _ Address: ��F �n U T� 2� 026�3 City/State/Zip: UU �S`� 0(1T Phone#: �d� " ��" �� Are you an employer? Check the appropriate boz: Business Type(required): 1.� I am a employer with 3 employees(full andl 5. ❑ Reta.il or part-time).* 6. ❑RestaurantJBar/Eating Establishment , . am a so e propne or or p r i 7. Office and/or Sa�es inc�I.reaTestate�auto,etc. employees working for me in any capacrty. ---II-_ � [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.� Manufacturing . no employees. [No workers' comp. insurance requiredJ* 11.0 Health Care 4.❑ We are a non-profit organization,staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.0 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 employees Below is the policy information. Insurance Company Name: A L' �9 U I��N S U (L A hJ C'_6 ('�O�'1 ��It/ y/ Insurer's Address: p_O_ �0 k ��1 f�� _ : City/State/Zip: �1 f�!1U�'A PO��S . 'N( N ��Lf �°r Policy#or Self-ins. Lic. # �/'C°� 20 -20 - O O 5�2^�I Expira.tion Date: D�-—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 ----- =-- ---- ----- . . . . . -- nnr�r.n _� .. �_ i �e up t�.l��and7or one-year impnson�ii-e�as � � �t��s u'� -�nr�� 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 cert�,under the pains and penalties of perjury that the information provided above is true and correc� ' o! Si�nature• ST� Date: j Z� �- 2 S Phone#• �t�� - �"�14 - � Gl s�' Official use only. Do not write in this area,to be completed by city or town officia� 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 NOTICE NOTICE TO a : TO EMPLOYEES EMPLOYEES � The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 1 Congress Street, Suite 100, Boston, Massachusetts 02114-2017 617-727-4900 — http://www.state.ma.us/dia As required by Massachusetts General Law,Chapter 152, Sections 21,22&30,this will give you notice that I(we)have provided for payment to our injured employees under the above-mentioned chapter by insuring with: Acadia lnsurance Company NAME OF INSURANCE COMPANY P.O.Box 59143,Minneapolis,MN 55459-0143 ADDRESS OF INSURANCE COMPANY WC-20-20-005412-01 07/31/2015 POLICY NUMBER EFFECTIVE DATES Kerry Insurance Agency Inc PO Box 1945, North Eastham,MA 02651 (508)255-8000 NAME OF iNSURANCE AGENT ADDRESS PHONE# PRACHA SOMKITCHARON 594 MAIN STREET,WEST YARMOUTH,MA 02673 EMPLOYER ADDRESS 5/27/2015 EMPLOYER'S WORKERS' COMPENSATION OFFICER(IF ANY) DATE MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the ser- vices provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the NAME OF HOSPITAL ADDRESS TO BE POSTED BY EMPLOYER