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HomeMy WebLinkAboutApplication and WC �* ► TOWN OF YARMOUTH BOARD��HEA�.TH ������Cs�' � � � APPLICATION FOR LICENSE/P�LitVI�T�; ` t 1 .0 ,.��( p�.� �; $ '�O�5 ``°" * Please com lete form and attach all necess � r�ocu �� � p ar�.._ � : � , �e . er IS bEPT. Failure to do so will result in the return of your application pa ket. ESTABLISHMENT NAME: C�- y TAX ID: LOCATION ADDRESS: �{ TEL.#: 5D ' - 7 7 MAILING ADDRESS: �5�-- E-MAILADDRESS: _ �,,Or� . l;I.l.(.1!Yl(�yl'�(� (1� ('_(�.J�• Y1,Q�� OWNER NAME:��� � ���- ��l ( UYYIG�YF— � � � CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: ��?�l �UYYI(fl'�' TEL.#: � ���{�j' I 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. --�:—- - --_ _ _ __ __ --- ____ _ ._-2. - -- - - - _ _ __ 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. L 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. l. � 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. l. 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. 2. 3. q,, ' RESTAURANT SEATING: TOTAL# �I n��1�'� �?��-(��I��' _ _ __ _ i LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# ' _B&B $55 CABIN $55 MOTEL $110 I� 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 PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE FERMIT# <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 _ $ !SO •OO *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** ,� �.�� -��_ ._., _�. -�----- 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 v 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. � _ , .. ;,�. .. .,,_ . , _ . , _ , . __ __� . �'OOD SER�VICE _... ._., �_.�. �. �_ , .. _ :_. �- . 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. iy 1� ' ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NE { EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUT A SITE PLAN. � SIGNATURE: '/ t.t.-`�.� DATE: �' PRINT NAME & TITLE: L��`1 UYVI(f�`T� 0�✓Y�� Rev. 10/O1/15 � The Commonwealth of Massachusetts � � _ Department of Industrial Accidents � Office of Investigations ' 1 Congress Street, Suite I00 Boston,MA 02114-2017. i www.mass.gov/dia � Workers' Compensation Insurance Affidavit: General Businesses Auplicant Information Please Print Le�iblv �- Business/Organization Name: � � . ��- Address: `� � � G ' City/State/Zip: ��� � ' �41� � Phone#: ,������" 7�S� � Ar�e y an employer? Check the appropriate boz: "- Busine Type(required): 1.U I am a employer with employees(full and/� 5. [�]Retail —�-- or part-time).* 6. ❑RestaurantlBar/Eating Establishment ; - -- — -- 2.� I am a sol�e propne�oT or pa�[r nership an�iav����-- - , 7. Q Office and/or SaCes�incT.reaI estate,auto;etc. ' employees working for me in any capacrty. [No workers' comp.insurance required] 8• �Non-profit 3.❑ We are a corporation and its o�cers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4),and we have 10.Q Manufacturing no employees. [No workers' comp. insurance required]* 11.❑ 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 i I am an employer that is providing workers'compensation insurance for my employees Below is the policy information: Insurance Company Name: Q,- � Yl� (i�- f�! Insurer's Address: � � V r�-- /��1^(�(�`� �` b( k�3 City/State/Zip: '� L(,�`' 'V1 � ��� Policy#or Self-ins. Lic. # WL�� '�v�' ��3 I 3 2 " ��-��xpira.tion Date: � Attach a copy of the workers' compensation policy declaration page(showing the policy number and zpiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a i -- �e np io$1;�(10.Of3 a��r��=y�ar�7iprsanmerr��s�vei�as-zivi�-�enalties ir t�ie farm e��STE3g WORI�4RIlER aa��fi� _ 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 covera.ge verificatiori. =' - I do hereby certify,un er the ins and penalties ofperjury that the information provided bove is true and correct. Si ature: Date: ��'oZ �� Phone#: �b E��`� ' 7��� k � Official use only. Do not wrate in this area,to be completed by city or town officiaL � City or Town: Permit/License# f 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 ; � � � WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE PO�ICY ; INFORMATION PAGE I " ` Associated Employers Insurance Company ! 54 Third Avenue, Buriington, Massachusetts 01803-0970 j (800) 876-2765 NCCI NO 40959 POIICY NO. WCC=500_5013432-2015A PRIOR NO. WCC-500-5013432-2014A ITEM 1. The Insured: Cape Cod Taffy Co lnc : : DBA: ,Cape Cod Water Taffy ' � Mailing address: 984 Route 28 FEIN;*'-**' South Yarmouth,MA 02664 , Lega!Entity Type: Corporation Other workplaces not shown above: 2. The policy period is from 05120/2015 to 05/20/2016 12:01 a.m.standard#ime at the insured's mailing address. �� 3. A. Workers Compensation insurance: Part One of the policy applies to the Workers Compensation Law of the �States listed here: MA � B. Employers'Liability Insurance: Part Two of the palicy applies to work in each state listed in item 3.A. - - � - The limits of liability under Part Two are: Bodily Injury by Accident $ 500,000 each accident Bodily Injury by Disease $ 500,000 policy limit Bodily Injury by Disease $ 500,000 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 poiicy wilt be determined by our Manuals of Rules,�lassifications,Rates and Rating Ptans. All informaiion required below is subject to verification and change by audit: • ! Classifications Premium Basis Rates . ; Code Estimated Per$100 Estimated i � No. Total Annual Of Annual I Remuneration Remuneration Premium I I , � INTRA 0157421 � � , j t . ____�TER SE CIASS CODE SCHEDULE -.--- I ' -- - _ _ ,---— � _ _ ____ :- ---- - . Minimum Premium $287 Total Estimated Annual Premium $i,g57 GOV GOV � Deposit Premium $4g5 STATE CLASS ; MA 2041 � State Assessments/Surcharges $1,433.00 x 5.8000% $gg This policy,including all endorsements,is hereby countersigned by �`����1.��"_.�. 03l17J2015 Autharized Signature Date Service Office: Commonweaith Insurance Partner 54 Third Avenue 25 Newport Ave Ext 1 st fl Burlington MA 01803 North Quincy, MA 02171 WC000001 A(7-i1) : Inciudes copyrighted material of the National Council on Compenaation insurance, used with its permission.