HomeMy WebLinkAboutApplication and WC a �c��D
�* ► TOWN OF YARMOUTH BOARD OF HEALTH ��� -� t� ZO�S
� � APPLICATION FOR LICENSE/PERMIT' ,�� ,
""' * Please complete form and attach all necessary docur�ents y c�cem' er 1 DEPT.
' Failure to do so will result in the return of you`r app�ic�tiori pac .
ESTABLISHMENT NAME: � .• TAX ID: �-
LOCATION ADDRESS: .g 1 , �� �6 . y ,r�. il � TEL.#: 5�$' 7�'0-$Sob
MAILING ADDRESS:311 �.} �1$• U °��,-r�ov��.- /�/\.a, p Z� 7 3
E-MAIL ADDRESS: (��,���o„�,�.,C G►�oLG6� a,�►�+-r��1 . �e�,
OWNERNAME:���t , L Mo��..v.,
CORPORATION NAME (IF APPLICABLE):
MANAGER'S NAME: 3�i�L Wt a��v. TEL.#: �� ) • ?�� �1 I`�S
MAILING ADDRESS: �.C�I N 1Keu+� S�l 5. l�a..rw�ov-��- /u0... O�L� l�'y
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.
__ -T. _ _ - - ___ � -- - --_ __ _ _ ---__
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.
You must provide new copies and maintain a file at your establishment.
1. Jv l,� /��l v ��,,,.� 2.
PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
1 -#�t-►-�_�__�—L"._��'���P�...._ _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.
1. ��1,;� /�c�rc�,✓�, 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.
1. 2.
3. 4.
RESTAURANT SEATING: TOTAL# I p
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- -- II ... _.__.-------- --- __ _.... ._ ,.
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 $1 l0ea.
FOOD SERVICE:
LICENSE REQUIRED FEE EJ�MIT LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
�0-100SEATS $125 �({o—(�� CONTINENTAL $35 NON-PROFIT $30
_>100 SEATS $200 �COMMON VIC. $60 �,D =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
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NAME CHANGE: $15 AMOUNT DUE _ $ �g�'j.00
*****PLEASE TURN OVER A � PLETE'(�'I���llE 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 >C
Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK I
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. �:
�
POOLS
POOL OPElYING: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.
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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,
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.
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
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 SITE PLAN.
DATE: 1�/IU��S SIGNATURE• / ��
PRINT NAME& TITLE: /����� (-� /�or��..�; t�r��w�d-� D��:-�c.�"
Rev. 10/O1/15
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NOTICE - � �: NOTICE
� TO
TO "
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EMPLO�EES �t El��IPLOYEES
��_ ��••
The Commonwealth of Massachusetts
DEPARTI�'IENT OF I1�DUST�CIAL ACCIDENTS
1 Congress Street, Suite 100, Boston, Massachusetts 02114-2017
617-727-4900
As required by Massachusetts General Law, Chapter 152, Sections 21, 22, 8� 30,this will give yon
notice that I(we)have provided payment to our injured employees under the above mentioned
chapter by inswnng with:
A.I.M.Mutuallnsura�ce ComP�Y
NAME OF INSURANCE COMPANY
P.O.Box 4070 Burlington,MA 01803-fl970
ADDRESS OF INSURANCE COMPANY
VWC-100-6015935-2015A 07/30i2015-07/30/2016
POLICY NUMBER EFFECTIVE DATES
396 Main Street ���59
Marshaif K Lovelette Ins Agcy West Yarmouth,MA 02673 � �
NAME OF INSURANCE AGENT ADDRESS PHONE
Bageis&Beyond LLC 311 Main St West Yarmouth,MA 02673
EMPLOYER ADDRESS
_ _ _ _ _. - _ -- - 08/05/20'15 _
DATE
MEDICAL TREATMENT
The above named insurer is required in cases of personal injnrie.s arising out of and in the course of
employment to furnish adequate and reasonable h�pital and medical services in accordan with t1ie.
provisions of the Workers Compensation Act A copy of the�rst Report of In,jury must be �en to the
injured employce. T6e employee may select his or her own physician.The reasonable cost of t�e serv�ces.
provided by the treating physician will be paid by the insurer, if t6e treatment is n and
reasonably connected to the work related injury. In c�ses reqniring hospital attention, emp yees are
hereby notified that the insnrer has arranged for such attentiofl at the
NEAREST AND BEST MEDICAL FACILITY I
HOSPITAL ADDRESS
, ., ,.��
TO BE P�STED BY EMPi.O � ����`
.�.__ _...___.�
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� The Commonwealth ofMassachusetts
; _ Department of Ittdustrial Accidents
Office of Investigations
' ' 1 Congress Street, Suite I00
Boston,MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legiblv
Business/Organization Name: Q•�.c,c��s c.�,.�.� ��,�o ow�
Address: 31� d��.E� ;Z� _ �'nr�
City/State/Zip: �el�. ,�u,,��-�Ir [��„ f�?�67 3 Phone#: 508 - �qo- �SSo 0
Are you an employer? Check the appropriate boz: Business Type(required):
1.� I am a employer with 5 employees(full and/ 5. ❑Retail
_ o�art-time).* 6. �RestaurantlBar/Eating Esta.blishment
2.❑- - - _ _ _ _ _ _ _ _----- ___—__--- _
I am a sole proprietor or partnership and have no �_ � 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 ri t of exem tion er c. 152 1 4 and we have
� P P � § � )� 10.� Manufacturing
no employees. [No workers' comp. insurance required]*
4.❑ We aze a non-profit organization,staffed by volunteers, 11.� Health Care
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 �
organization should check box#1. i
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I am an employer that is providing workers'compensation insurance for my employees Below is the policy information. '
Insurance Company Name: A. �, �_ ���r,,e�..� �►�.s��o.,v��-c, �o,r�.r�aw y
Insurer's Address: 6"• O• +,�p x �� 7 0 '
City/State/Zip: �U�' (�,n.�,-�o v�. , � �_. G��'a� ' O Q 7 C�
Policy#or Self-ins. Lic. # UGUG -100 -6015q 3S � 2015A Expira.tion Date: 07�3o/Zo16
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
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fine up to$1,500.00 and/or one-year imprisonment,�as civii penalties iri t�ie form o�a �, �c�a�� '
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. '
I do hereby certify,under the pains and penalties ofperjury that the information provided above is true and correct.
Signature����--"— Date: %Z�iv/iS '
Phone#: �G�- 7"O� �SO O .
Officdal 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.Selectme�s�Cl�� i
6.Other `"'�
��.- . ,� =�;� i
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Contact Person: Phone#: ____�-------
www.mass.gov/dia