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Home My WebLink AboutApplication and WC ' :� - � � TOWN OF YARMOUTH BOARD OF HEALTH G°3L�C�LSOML�D � � � APPLICATION FOR LICENSE/PE�'.N�I- ' � ��ll15 * r � � : �� r �� ""°' Please complete form and attach all necessary idocu r ts y - yzL r 1 Ol� Failure to do so will result in the return of your ppfica°ti�n`�ac et. HEALTH DEPT. ESTABLISHMENT NAME: r ' TAX ID: / LOCATION ADDRESS: �9 �».°.e�Q� �� /qp�,n..rtn �if TEL.#: �0�3 -�fi'.5-C)Si9� MAILiNG ADDRESS: �s.,,,,. E-MAIL ADDRESS: OWNER NAME: CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: ,o,Qa.,� p� ��i i ��.�.,�...�t TEL.#: �,��g t3g',�-9 y9� MAILING ADDRESS: POOL CERTIFICATIONS: •Ir W;// P/'e y��C/� ir� �3'°PR%�' The pool supervisor musf tie 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. �o�t� s-�-sa�. _ 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. , i. .�I� 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. _ _ --- - - - �, _ _ _ --— - -_ '' 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: 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. I You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# - - -- - 1 __ __ _ E LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERM[T# B&B $55 CABIN $55 MOTEL $110 _INN $55 -CAMP $55 =SWIMMING POOL$110ea�� _LODGE $55 TRAILER PARK $105 �WHIRLPOOL $1 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: 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: $15 AMOUNT DUE _ $ Z2CU•00 ; � *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** r � � _ �c 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 j WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED i 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 � __ _ . ..� _ I 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. f 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 contactthe --- ; 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 I obtamed at the Health Department,or from the Town's website at www.yarmouth.ma.us under Health Department, � Downloadable Forms. i 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: II, 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 ESTABLIS MENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO A PROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY � A SITE PLAN. DATE: �Z g/S� SIGNATURE: PRINT NAME& TITLE: � or� U��Pt�� µ�'� �� Rev. 10/O1/15 � i � � The Commonwealth ofMassachusetts Department of Ittdustrial Accidents ; � Office of Investigations � ` I Congpess Street, Suite 100 i _ Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Auplicant Information Please Print Legibl� : Business/Organization Name: ,��,'� �/','ll �n o �d e, � Address: a�9 7'I'),`r,`.o f, �✓'• I � vzc.TS City/State/Zip: �� h o�t.h'J Phone#: ,,�� ,�8� Are you an employer? Check the appropriate boz: Business Type(required): 1.❑ I am a employer with employees (full and/ 5. ❑Retail or part_time).*_ 6. ❑RestaurantlBar/Eating Establishment ._ _ - — __ ; - - _ --- 2. I am a sole proprietor or partnership ancl have no �, � 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, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.[�Other �O/9 *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. **If the coiporate officers have exempted themselves,but the corporation has other employees,a workers'compensadon 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: �'N A �`„i 5 v�a,�vte Insurer's Address: � d. � �9�5 City/State/Zip: O r'l�.�d�v.oa FC 3,�fj'a Z��oS ' Policy#or Self-ins. Lic. # 5��7 �r'7 p /9=y-l� Expiration Date: 7��/��G� Attach a copy of the workers' compensation policy declaration page(showing the policy number and egpiration date). ' Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a --- _ iine up to$I 3Q y p -- .U`�i an or one- ear im nsonmen as e 1 of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwazded to the Office of Investigation f DIA for insurance coverage verification. I do hereby under the pains and penalties ofperjury that the information provided above is true and correct. Si ature: �v � ' Date: Z Phone#: 8- � 9 t Official use only. Do not write in this area,to be co�npleted by city or town officiaL ; i City or Town: PermitlLicense# 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#• ii www.mass.gov/dia l � , . : � ` • VDAC a • �HA WORKEHS COMPENSATION AND � EflAPL.OYERS LIABILITY POLIGY , TYPE AR INFORMATION PAGE WC 00 00 Ot { A) POLICYNUMBER: (6S59UB-4747P19-4-15) RENEWAL OF (6559UB-4747Pi9-4-14) 1NSURER: COM'INENTAL CASUALTY COMPANY i 1, NCCI CO CODE: 10243 1 ' I INSURED: PRODUCER: ; - --- ------__ -- - -- _-__ DEBS HILL CONDOMINIUM RQC�RS & GRAY INS AGGY T � ASSOCIATION 434 RTE 134 29 MIRIAH DRZVH SOUTH DENNIS MA 02660 • YARMOUTH PORT MA 02675 � � Insured is TRUST OR E5TATE � Other work places and Identtflcation numbers are shown tn the schedule{s} attached. 2. The policy period is from 07-13-15 t0 07-13-16 12:fl1 A.M. at the fnsured's mailing address. 3. A. WORKERS COMPENSATtON INSi1RANCE: Part Qne of the policy appfies to the Workers Compensation L.aw of the state(s)listed here: Ma .� � � B. EMPLOYERS LIABILtTY INSURANCE: Part Two of the poficy applies to work in sach state Iisted ln � item 3.A. The limits of our Ilability under Part Two are: �� Bodtly Injury by Acctdent: $ 50000o Each Acctdent _ Bodity InJury.by D[sease: $ 5aooao policy l.imh � Bodily InJury by Disease: � 50000o Each Empfoyee o= � C. OTHER STATES INStfRANCE: Part 7hree of the policy appfies to the states, iP atny,listed here: � COVERAGE REPLACED BY ENDORSEMENI' tilC 20 03 U6B - � �� '� � �� '� D. This pollcy includes these endo�seme►�ts and schedutes: „� � SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFQ PAGE � c.� � 4. The premium for this policy wili be determined by our Manuals of Rules,Classifications, Rates and Ratfng � Ptans. Ail required Information Is subject to veriFication and ohange by audit to be made AwvuA�.�Y. � .� DATE OF ISSUE: 06-29-i 5 WC ST ASSIGt�t: MA OFF{CE: CNA o4� PRODUCER: R�RS & GRAY It�IS AGCY I 26D4J oo4s28