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Home My WebLink AboutApplication and WC I ' # � � TOWN OF YARMOUTH BOARD OF HEALTH � � � , , APPLICATION FOR LICENSE/P�I�11�`� A � 0�� . ` �1� (�tG �� i ..�• � �:; "' * Please com lete form and attach all necess � doc "" ents by�rnb 1 S 201 S. P �', ' Failure to do so will result in the return o�yo�a��lic�tion pack t. HEALTH DEPT. ESTABLISHMENT NAME: � TAX ID: - � LOCATION ADDRESS: o�� Ir Q��'EL.#: D �? �'6 �S MAILING ADDRESS: � � E-MAIL ADDRESS: OWNER NAME: l C- � CCORPORATION NAME (IF APPLICABLE): � _ { M�ANAGER'S NAME: C � (,� TEL.#: O • oZ - 77�9s � MAILING ADDRESS: AI (N '►nl , l�•l�l'�f S7 d�'S ;�1 l.c�.�r��A D�Lr6 Z PdOL CERTIFICATIONS: /J /� The pool supervisor must be certi ied 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 --__ -- -- -- - - _ . �- _ _ _ ;---- 1 ----- -- - 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 a11 times. Please list the eri�ployees 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: 'v � i All food service establishments are required to have at least one 11-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 IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. 2. � ALLERGEN CERTIFICATIONS: � � . Altfood service establishments are requi ed 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 2 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. 2. 3. 4. RESTAURANT SEATiNG: TOTAL# OFFiC�; TT�F (l1Ni,�' _ 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 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 P RMIT# 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 _ $_`^'JO.00 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** � M,� .♦ ADMINISTRATION � r ., 5 � � 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 v NO MOTELS AND OTHER LODGING ESTABLISHMENTS �. . . : ._ . _ . _ - -= __ __�-��.�_,_._.�.,�__� _ � 4 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 thirly(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. � i 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.Xarmouth.ma.us under Health Departrnent, { 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 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 RETLJRN I 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 SI E PLAN. ' DATE: � I� SIGNATURE: � 1' PRINT NAME&TITLE: L • L�v� �� Rev.10/O1/15 , , '. r � The Commonwealih of Massachusetts - Department of Industrial Accidents 3 j Office of Investigations ` 1 Congress Street, Suite I DO Boston,MA 02I14-2017. www.�rcass gov�dia Workers' Compensation Insurance Affidavit: General�Businesses Auplicant Information Please Print Le�iblv j Business/Organization Name: �,L� ��(�L'� (J� �/k�� C'D?� � ��7 �o u i� �$ Address: City/State/Zip: �jt� . ��/�i�� NI� Q�7J� Phone#:_ �a��l'�p�$ C! Are ybu 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 am a so e propne or or p e p an ave no -- - -- --- 7. ❑ Office and/or Sa1es(incl.real estate,auto,etc.) employees working for me in any capacity. [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 a 152, §1(4),and we have 10.❑ Manufacturing j no employees. [No workers' 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•0 Other *Any applicant that checks box#1 must aiso fill out the section below showing their warkers'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 providin workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: �� /\( /V Insurer's Address: p�y�d �A � /l�� .� U� . S�� City/State/Zip: L � Q D ��. �O~0�� Policy#or Self-ins. Lic.#_��'u�' 'rJ �3��s"�� Expiration Date: � 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 I ume up to$1;�� an or one-year impnsonment,as we i as ctvi pen es in o a �� - - 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 coverage verification. I do hereby certify,under th pains and penalties of perjury that the information provided above is true and correct. Si ature. Z �(� /j Date: i �7 Phone#: .�� " ! 7 l' �D�� 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 Of�ice 6.Other Contact Person: Phone#: www.mass.gov/dia ! � . , TRAVELERSJ� � WORKERS COMPENSATION ` AND EMPLOYERS LIABILITY POLICY TYPE AR 1NFORMATION PAGE WC 00 00 01 ( A) ' POLICY NUMBER: (6HU6-5637385-3-15) RENEWAL OF (6HU6-5B37385-3-14) INSURER: THE TRAVELERS INDEMNITY COMPANY OF AMERICA � 1. NCCI CO CODE: 13439 � INSURED: PRODUCER: � ` WILBUR, NANCY OCEANSIDE INS GROUP i DBA A TOUCH OF CAPE COD 52 WEST MAIN ST j 327 ROUTE 28 HYANNIS MA ,02601 , � WEST YARMOUTH MA 02673 i � � Insured is AN INDIVIDUAL , Other work places and identification numbers are shown in the schedule(s) attached. ; 2. The policy period is from 07-28-15 to 07-28-16 12:01 A.M. at the insured's mailing address. i ' 3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers Cornpensation Law of the state(s) listed here: MA _ �,_ . m— B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed in �— item 3.A. The limits of our liability under Part Two are: �_ o " Bodily Injury by Accident: $ 10000o Each Accident o_ � Bodily Injury by Disease: $ 500000 Policy Limit _ Bodily Injury by Disease: � 10000o Each Employee ^� C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here: � COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06B � _ . . . �� ^ D, This policy includes these endorsements and schedules: � i o�� SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE i . i o - 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating m— Plans. All required information is subject to verification and change by audit to be made ANNUALLY. .� DATE OF ISSUE: 08-03-15 WC ST ASSIGN: MA OFFICE: ORLANDO INDUS AFF 161 PRODUCER: OCEANSIDE INS GROUP 28GD5 004383