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Home My WebLink AboutApplication and WC ` � � f�[�6��s � ► TOWN OF YARMOUTH BOARD OF HEALTH � � � APPLICATION FOR LICENSE/P� , I „ 2 , ,��. �� 01015 j ._ � � i �'"' * Please complete form and attach all necess ':. : � ee �b r 1 DEPT. � ' Failure to do so will result in the ret �i.�yo �:�li�ti �ac i ESTABLISHMENT NAME: TAX ID: LOCATION ADDRESS: \ TEL.#: �� MAILING ADDRESS: S ' E-MAIL ADDRESS: ` S'� " � OWNER NAME: CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: 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. i - }----- - --- --- ---- —, _ _ - � - - ---. _ - ____ _ _--- � �. — - - _ � 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. f 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. 1. 2. PERSON 1N CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. _1•�r\�_^�r��t�5�-!�--_�____ 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 fle at your establishment. 1. 2. ; i 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. 1. �[�.�c�Cs.l '�i`��CP� 2. ��, ��c�C.l� ' 3. 4. RESTAURANT SEATING: TOTAL# _ ()FF'iif F TTCF nN� � _ -- —{ 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 $110ea. ' FOOD SERVICE: , LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERM[T# LICENSE REQUIRED FEE P I # ' 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# i <50 sq.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 ( _<25,000 sq.ft. $150 _FROZEN DESSERT $40 =TOBACCO $I10 � f NAME CHANGE: $15 AMOUNT DUE _ $ 3 a•00 ' I *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** i � r • _ > i , i ADMINISTRATION � ; Under Chapter 152,Section 25C,Subsection 6,the Town of Yarmouth is now required to hold issuance or renevual of any license or permit to operate a business if a person or company does �ot have a Certificate of Worker's. Compensation Insurance. THE ATTACHED STATE WORKER'S COMP�NStiTIQN INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF 1NSURANCE ATTACHED V 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 i 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.yarmouth.ma.us under Health Deparhnent, 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 Q RE A SITE PLAN. DATE: 1\ ��I I� SIGNATURE: � PRINT NAME & TITLE: C a�.-2�t� V_��'r`C4S �- �� II Rev. 10/O1/IS � + � The Commonwealth ofMassachusetts Department of Industrial Accidents u Office of Investigations ' I Congress Street, Suite 100 Boston,MA 02II4-2017 ' www.mass gov/dia , Workers' Compensation Insurance Affidavit: General Businesses Auplicant Information Please Print Legiblv ' Business/Organization Name; �� , D �v i ds � �i s�o�a I C h��c ti Address: ��5 010l IYI a�n Sf � � " �� 6H City/State/Zip: S o� �� y�r�D ��h Phone#: 5oS 3�N Naa a Are you an employer? Check the appropriate boz: Business Type(required): 1.L"� I am a employer with��employees(full and/ 5. ❑ Reta.il , or part-time).* 6. ❑ RestaurantlBar/Eating Establishment ' _ -- ---— 2. I am a sole proprietor or partnership an�have no �� - -- " ' -- --- - ------- - 7. ❑ Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. ,-,/ , [No workers' comp. insurance required] 8• LvJ 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 warkers' comp. insurance required]* 11.0 Health Care 4.❑ We are a non-profit organization,staffed by volunteers, 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 organization should check box#1. t , ,.. f I am:an employer that is providing workers'compensation insurance for my employees. Below is the policy informafion. j Insurance Company Name: ��t��v(G h �SUfai1C.[- A�6�-P/1 C�I � r P , ' Insurer's Address: (q �G d 5�' 3� `k'' S'�"• City/State/Zip: N Q rJ y 0 f �C, (v N l D V I (o Policy#or Self-ins. Lic. # WC 76 aS q 0 D09 0 f 5 3(00 I Expiration Date: R �3��1 �o 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 � --- fine up to $1,500.00 and/or one-year imprisonment,as we as civi pen tiesin tTie�`orm�a�TOP�%OR� an m � 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. j I do hereby certify,under the pains and penalties of perjury that the information provided above is true and correct. Si�nature: �-G�,I t'�l S��iu Date: � o��e��J� Phone#: SD� 3°)N � o��o� Official use only. Do not write in this area,to be completed by city or town officiaL I City or Town: Permit/License# i 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 ...T .. A�i..l�� QATE(MMIDDtYYYl� GERTIFICATE OF LIABILITY INSURANCE October 3Q THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLOER.TH18 CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFOROED BY THE POUCIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be eodorsed.If SUBROGATION IS WAIVED,subjeCt to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate dces not confer rights to the certificate holder in lieu of such endorsement(s). RODUCER aMe: Traee Parent The Church Insurance Agency Corp oNe ' 19 East 34"'Street nrc,No,e�: 800 293-3525 Fac,rw: 800 557-1395 New York,NY 70016 �a� ORESS: � OpUCER i STOMER ID#: � INSVRER S AfFORDINO COYERAGE NAIG i � NSURED NSURER A: LlbCl'ty I17SLL1'BtlCC CO The Diocese o#Massachusetts NSURER B: 138 Tremont St NsuRER c: Boston,MA 02111-1318 NSURER F: COVERAGES CERTiFICATE NUMBER: REYISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES O�INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POI,ICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CO►dDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCIUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. TYPE OF iNSURANCE IN WVp POUCY NUMBER �M�p Y EF �P�QLp y GENE��I.n, �o LIMITS AGH OCGURRENCE $ OMMERCIAL GENERAL AMAGETORENTED REMISES Ea accunence CLAIMS-MADE�occuR � D EXP An one on � RSONAL&ADV INJURY ENER4LAGGREGATE EN'L AGGREGATE LIMIT APPLtES PER: RODUCTS-COMP/OP AG� LICY PRO-CT LOC ABILITY OMBINED SINGLE LlMIT Ea accident) Y AUTO DiLY INJURY{Per person) l OWNEO AUTOS DI�Y iNJURY(Per aCcident) HEDULED AUTOS OPERTY DAMAGE IRED AUTOS N-0WNED AUTOS MBRELLA LIAB OCCUR CH OCCURRENCB EDUCTIBLE — _ _ __ - __ _ GGREGATE _ . I CtA1MS-MApE ETENTION $ � � . --- ��. RKERS COMPENSATION WC STATU- QTH- A ND EMPLOYERS'LIqBILITY �,�N �, X WC7B2S9OOO9O153BO1 9I3O(2O1S 8/$O/2O1FJ TORY LIMITS E UTIVE�ETOR/PARTNER/EXE � .L EACH AGCIDENT �OOO OOO CCI(:CpAAF►.IRCp�yl�I 111'1Ff1� Mamfatory Yn NH) .L.DiSEASE-EA EMPLOYEE 1,000,000 i�roe rlecrrihn��nMr ESCRIPTION OF OPERATIONS below . .I.DISEASE-POLICYLIMIT $��OOO�OOO ; ESCRIPTION OP OPERATIONS/LOCATIONS/VEHiCLES(Attach ACORD 101,Additional Remarka Schedule,if more spate is reqWred) - ��, CERTIFICATE HOLDER CANCEILATiON St Qavids Episcopai Church SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 205 Old Main St THE EXPIRATION pATE THEREOF,NOTICE WILL BE DELIVEREDIN South Yarmouth,MA 02664-4529 aCCORDANCE WITH THE POLICY PROVISIONS. � � � f�� i'[:Re��lf/` J �