HomeMy WebLinkAboutApplication and WC �. � p " " ' •Y I
� � TOWN OF YARMOUTH BOARD OF HEALTH [�DD ''
� � APPLICATION FOR LICENSE/� '
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* Please complete form and attach all necess .efl s�ITec ''ber 1 S 2013. ,
' Failure to do so will result in the retur�tif q� 1&catipn "ck '
Y �.� �.,. 4�EALTH DEPT.
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ESTABLISHMENT NAME: % �-� TAX ID: '
LOGATION ADDRESS:�_�,�,�,�s -A T�✓ TEL.#:.s'68-,�5y-,.r/o a
MAILING ADDRESS: �� �ou .s`7�s �16.✓�r-.��.�T 8z�.s�c�r. /�J.� o zs��` �
E-MAIL ADDRESS: ��c c,q.e�,��ti�.Pi�a��✓�T �
OWNERNAME: c�r� �t�C,.�z�rr�� �
CORPORATIONNAME (IFAPPLICABLE�,,,�frf���T Cd- ?��' - �
MANAGER'S NAME: i',;S.a �vSc �5/o�•; �o L� .n'1��� TEL.#:So�3-�5'S�'-�i�� �
NTAILING ADDRESS: ,�'cs 23cs� �?o �'a.�.�.,�z-..r� ��',r,r� .��,t� rs z,r.s� �
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.
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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. j
You must provide new copies and maintain a file at your establishment. �
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1. r'C.S/d�L� � .��ar'✓�� 2. r G��' � ,s4' �i�/ �
P�RSON 1N CHARGE:
�ach food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
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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. '
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1. i C��C,� t-�.��c..Tis' 2. v�71 �f c� �"' i
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HEIMLICH CERTIFICATIONS: j
All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich j
Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and I
attach copies of employee certifications to this form. The Health Department will not use past years' records. f
You must provide new copies and maintain a file at your place of business. ,�
1. �/�/d' 2. '
3. 4.
RESTAURANT SEATING: TOTAL# � �
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_-- ---�E�-�u�
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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. '
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FOOD SERVICE:
LICENSE REQUIRED FEE P RMIT LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
( 0-100 SEATS $125 =�E� —CONTINENTAL $35 NON-PROFIT $30
>100 SEATS $200 _COMMON VIC. $60 —WHOLESALE $80 !
—RESID.KITCHEN $80 ;
RETAIL SERVICE:
LICENSfi REQUIRED FEE PERM[T# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# i
<50 sq.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 i
_<25,000 sq.ft. $150 _FROZEN DESSERT $40 _TOBACCO $110 i
NAME CHANGE: $15 AMOUNT DUE _ $ /25 .00
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*****
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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 ;
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 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.
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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 j
inspected and opened. '
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POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count
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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
obtained at the Health Department,or from the Town's website at www.yarmouth.ma.us under Health Department,
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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.
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OUTSIDE CAFES: '
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. I
OUTDOOR COOHING:
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 i
THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 15, 2015. I
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 RE UIRE A SITE PLAN.
DATE:��- �-'/�� SIGNATU `� c.�'
PRINT NAME& TITLE: rz U� ,�� � -�-NS �c��
Rev. 10/O1/15
' ' � The Commonwealth of Massachusetts
Department of Industrial Accidents '
� Office of Investigations
` 1 Congress Street, Suite I00 ',
Boston,MA 02114-2017 ,
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x�ww.ma�s: ov/dia ,
Workers' Compensation I��urance`Affidavit: General Bus�nesses . ;
Anplicant Information _ Please Print Legiblv �
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Business/Organization NameF �,,,,��r ��,.� �. �;,�- J?.v ��" ,� N� f,.�� �
-�E �A� �/N � I
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Address: O S�6 a,���'.� !�o � s�,'� �r .vT � ,,,s��;"� ;
az 3 _
City/State/Zip: Phone#: �S'�sS �y-3��b
Are ypu an employer? Check th�appropriate boz: Busine Type(required):
1.� I am a employer with v employees(full and/ 5. Retail
r __ -a�.rix�.* 6. ❑ RestaurantBar/EatingEsta.blishment I
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2.❑ I am a sole proprietor or partnership and have no �, � Office and/or Sales(incl.real estate,auto,etc.) �
employees working for me in any capacity.
[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 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 e�nployees,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: ���.T�'� . ` �
Insurer's Address: �C�� /ir/6b� P�'/Lf� ��/�1�� �
City/State/Zip: L� [r%N T Z� � /✓�! � �3 ��j , . . �
Policy#or Self-ins.Lic. #,�, - �J,E� �� 4,3,3��' Expiration Date: � • � " �!� ,
Attach a copy of the workers' compensaHon policy declaration page(showing the policy number and ezpiration date). '
Failure to secure covera�e as re uired under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a __i
fine up to $1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK O E an a�ine
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 '
Inv�stigations of the DIA for insurance coverage verification. '
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I do hereby certify,under the pains and penalties of perjury that the information provided above is true and correct. �
Si ature: � �% Date: �� + ���� �
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Phone#: �d ' '" �� !
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Official use only. Do not write in this area,to be completed by city or town official
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
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32 (Policy Provisions: wC o 0 0 0 0 o s)
03
LF INFORMATION PAGE i
�C WORKERS COMPENSATION AND EMPLOYERS LIQBILITY POLICY (
INSURER• �TFORD ACCIDENT AND INDSNINITY COMPANY i
ONE HARTFORD PLAZA, HARTFORD, CONNSCTICUT 06155 �
''('' I
� NCCI Company Number: io448 1HE (
Company Code; 5 HARTFORD ;
s�X
LARS RENEWAL
POUCY NUMBER: 08 WEC LF0332 �—[— 05
Previous Policy Number: os wEc LF0332
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IRG _ E i SB . _
1. Named insured and Mailing Address: SUNSET FRUIT CO. , INC.
(No.,Street,Town,State,Zip Code)
PO BOX 570
FEIN Number• MONUMENT BEACH, MA 02553 I
State Identffication Number(s): II
The Named Insured is: CORPORATION '
Business of Named Insured: GIFT BASKETS - RETAIL �
Other workplaces not shown above: SEE ATTACHED SCHEDULES ;
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2. Policy Period: From 05/O1/15 ' T� 05/o1/i5 (
12:01 a.m.,Standard time at the insured's rnailing address. i
Produce�'s Name: O�BRIEN & GiBBONS iN5 AGENCY INC �
52 HIGHLAND STREET
WORCESTER, MA 01609
Pi'OduCB�''S COde: 061629
Issuing Office: THE HARTFORD ''
301 WOODS PARK DRIVE `
CLINTON NY 13323
(800) 962-6170
Total Estimated Mnual Premium: S3,744
Deposit Premfum:
Policy Minimum Premium� $280 MA �INCLUDES INCREASED LiMIT MIN. PREM.)
Audit Pe�iod: �U� InstaUment Term:
The policy is not binding uniess countersigned by our authorized representative.
��'�� C � 03/14/15
Countersigned by .
Authorized Representative Date
Form WC 00 00 01 A (1) Printed in U.S.A. Page 1 (Co�inued on next page)
Process Date: 03/14/�5 Policy Expiration Date: 05/O1/16
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INFORMATIUN PAGE (Continued) ; Poiicy Number. os wEc LFo33a '
3.A. Workers Compensation insurance: Part one of the policy applies to the Wo�lcers Compensation Law of the
states listed here:� �
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B. Employers Liability Insurance: Part Two of the policy applies to woric in each state listed in Item 3.A. !
The limits of our liability under Part Twq are: �
Bodity injury by Accident S 5 0 0,o 0 o each accident �
Bodily injury by Disiease $soo,o0o policy limit '''
Bodily fnjury by Dis;ease $500,o0o each employee ,
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C. Other States Insurance: Part Three af the policy applies to the states,if any, listed here:
ALL STATES EXCEPT ND, OH, WA;, WY, US TERRITORIES, AND
STATES DESIGNATED IN ITEM 3.A. OF THE INFORMATION PAGE.
D. This policy includes these endo�senients and schedule:
WC 99 00 05 WC 00 03 08 WC� 00 04 21C WC Od Q4 22A WC 20 O1 01
_ -- - ---
SEE ENDT
4. The premium for this policy will be de�ermined by our Manuals of Rules, Ciassifications, Rates and Rating
Plans. All information reyuired below is subject to verification and change by audit.
Premium Basis
Classifications i Totai Estimated Rates Per Estimated ',
Code Number and i Annual �100 of Annual ;
Description i Remuneration Remuneration Premium
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(SEE ATTACHED SCHEDULES)
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MA RATE DEVIATION PREMZUM CREDIT'� (.20) (9037) -803 �
INCREASED LIMITS PART TWO (9807� 1..00 PERCENT 32 �
TO EQUAL INCREASED LIMITS MINIMUM PREMIUM (9848) 18
TOTAL PREMIUM SUBJECT TO EXPBRIEAiCE MODIFICATION 3,264 '
MA - MERIT RATING CREDIT (9885} .950 �
PREMIUM ADJUSTED BY APPLICATION OF EXPERIENCE MODIFICATION 3,101 I
TOTAL ESTIMATED ANNUAL STANDARD PREMIUM 3,101
EXPENSE CONSTANT (0900? 338
MASSACHiJSETTS DIA ASSESSMEPTT 5.800 PERCENT 221
TERRORISM (9740) 279,200 .030 84
TOTAL ESTIMATED ANNUAL PREMIUM I 3,744
i
Total Estimated Annual Premtum: S3,�44 '
Deposit Premium:
Policy Mtnimum Premium: $2g� � tiNCLUDES INCREASED L2MiT MiN. PREM.)
Interstate/Intrastate Identiflcatlon Number: / 0004s45s5 ';
NAICS: �
�
Labor Contractors Policy Number. SIC: 5947 '
Form WC 00 00 01 A (1) Printed in U.S.A. Page 2
Process Date: 03/�.4/15 Policy Expiration Date: 05/01/16
SCHEDULE OF OPERATIONS
This Schedule of Operations forms a part of the policy effective on the inception date of the policy unless another date is
indicated below:
INSURER: �RTFORD ACCIDENiT AND INDSMNITY COMPANY
Company Code: 5
Policy Number: 08 taEc LF0332 Schedule Number: oi-2o-o4
Effective Date: 05/O1/15 Effective hour is the same as stated on the Information Page of the policy.
Named Insured and Location Address of operations covered by this schedule:
SUNSET FRUIT CO. , INC.
12 STEEPLE STREET
MASHPEE MA 02649
NAZCS:
_ .FEIN: ._---IITN' ------- Gr�'- 5947 _ n�n nF RMpL• nnnn__
4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating
Plans. AU information required below is subject to verificatlon and change by audit.
Premium Basis
Classlflcations Total Estimated Rates Per Estimated
Code Number and Annual 3100 of Annual
Description Remuneration Remuneration Premium
sool ii3,�oo i.6o i,ai9
FLORIST - STORE - & DRIVERS
TOTAL CLASS PREMIUM 4,017
MA RATE DEVIATION PREMIUM CRfsDIT (.20) (9037) -803
INCREASED LIMITS PART TWO (9807) 1.00 PERCENT 32
TO EQUAL INCREASSD LIMITS MINIMUAR PREMIUM (9848) 18
TOTAL PREMIUM SUBJECT TO EXPERIENCE MODIFICATION 3,264
MA - MERIT RATING CREDIT (9885) .950
PREMIUM ADJUSTED BY APPLICATION OF EXPFsRIENCE MODIFICATION 3,101
TOTAL ESTIMATED ANNUAL STANDARD PREMIUM 3,101
EXPENSE CONSTANT (0900) 338
MASSACHUSETTS DIA ASSESSMENT 5.800 PERCENT 221
TERRORISM (9740) 2?9,200 .030 84
_ �OTAL ES�IiKATED �NN�P� gR��7Ni __ ----3'744
Countersigr�ed by
; Authorized Representative
Form WC 99 00 05 (1) Printed in U.S.A. i OS/O1/16
Process Date: 03/14/15 Policy Expiration Date: