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Home My WebLink AboutApplication and WC 5E + � ► TOWN OF YARMOUTH BOARD OF HEALT ��d��° � � APPLICATION FOR LICEN9�.?��Z�' � �� , �� t� ; � 7015 ' * Please complete form and attach a11 necessary daeument� ` llec mber 1 S 2015. Failure to do so will result in the return of your application ac1c�ALTH DEPT. ESTABLISHMENT NAME: t,i� oo�c. TAX ID: .Q�e � p�� ' LOCATIONADDRESS:Ja1�t R�' 2� 5�yr�m�rasl�V1 M1'k o2,�l0� TEL.#: �04t 3�5� 1Xyfl ' MAILINGADDRESS:�O Ur.��ud- l-�o�,ldtw�'D� L�n,vwiC� (�e� (�I�k o2_l�`i.� E-MAIL ADDRESS: S rv, orr, �' r�vtioa� w� � OWNER NAME: :v�s. '� CORPORATION NAM (IF APPLICABLE).��c�-r f-:xorc�,� 1.61.C- ' MANAGER'S NAME: TEL.#: a 3 �o"�C� ' 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. ' _ _ ._____ _ L — —-- _ _ � i Pool operatars 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. ' �, i i 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 1N CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. �. .,��C1,0.�1 �� O��,cs,r�►,�n 2. �t:�i 5�1. [� �I l 6�(1 . � j __ _ �___�.______.._- ____-- � ALLERGEN CERTIFICATIONS: �411 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' reeords. 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. � You must provide new copies and maintain a file at your place of business. i G 1. 2. 3. 4. RESTAURANT SEATiNG: TOTAL# (') � - _- - -- —� - ^T'-��ic�-�}�E QAF�,�--- ------— - ------- __-- ----! 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 P RMI #� LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �0-100 SEATS $125 (p��`'(.?i _CONTINENTAL $35 NON-PROFIT $30 _>100 SEATS $200 _COMMON VIC. $60 WHOLESALE $80 —RESID.KITCHEN $80 ' RETAIL SERVICE: i LICENSE REQUIRED FEE PERMIT# LICENSE REQU�RED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# � <50 sq.n. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 � =<25,000 sq.ft. $150 �FROZEN DESSERT $40 � _TOBACCO $110 I NAME CHANGE: $IS AMOUNT DUE _ $ /��-�j.OO � I *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** � ! I � 4 e i � 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 1NSURANCE 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. FLEASE 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. � POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected ! by the Health Department prior to openmg. Contact the Health Department to schedule xhe inspection tbree(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.varmouth.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. I 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 MA REQUIRE A SITE PLAN. � DATE:��I� SIGNATURE: ` PRINT NAME & TITLE: � I I � '� � Rev. 10/O1/15 ��X ' � ' '� � The Commonwealth ofMassachusetts Department oflndustrial Accidents Office of Investigations ��' ' l Congress Street, Suite I00 Boston,MA 02II4-2017 • www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses A licant Information Please Print Le 'bl Business/Organization Name: �1 p0 pu�( '�=� 1�-5� �-C, Address: � o�.�� -{- 2� `,J�i'C��IM.Ln��q `4 �`� --� City/State/Zip: � Phone#:�� a,�j I V�� Are ou an employer? Check the appropriate boz: Business Type(required): 1.[� I am a employer with�_employees(full and/ 5. ❑ Retail , _or�art-time).* 6._ Resta.urant/Bar/Eatin�Establishment 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] g• ❑Non-profit 3.❑ We are a corporation and tts 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]* 1 l.� Health Care ' 4.❑ We are a non-profit organiza.tion,staffed by volunteers, ; with no employees. �1�To workers' comp.insurance req.] 12•� Other *Any applicant that checks box#1 must atso 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 ' oxganization should check box#L I � I am arr employer that is providing workets'compensation insurance for my employees. Below is the policy information. ' Insurance Company Name: � ►r'C�LJ.��.�Ca(� ,� . �,• Q ' �t��5-i Y..LY4� �, Insurer's Address:C�� h w� ��,, l,� ,,,�-� City/Sta.te/Zip: �C��ra �rt' ('�(� � $3 Policy#or Self-ins.Lic.# Z E113-t A31 O`1 O -1�1 -1 S Expiration Date: O`7� c>ti'�p Atfach 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 well as civil penalties in the form of a STOP WORK ORDER and a fine � of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwaxded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify,under the pains and penalties of perjury that the information provided above is true and correc� � Si ature: � Date: � � � I � Phone#: oZ. O � Official use only. Do not write in this area,to be completed by city or town official � i City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Iiealth 2.Building Department 3. City/Town Clerk 4.Licensing Board 5. Selectmen's Office 6.Other Contact Person: Phone#• i �www.mass.gov/dia TRAVELERS�, WORKERS COMPENSATION ` ONE TOWER SQUARE AND HARTFORD, cT obiss ' EMPLOYERS LIABILITY POLICY TYPE V INFORMATION PAGE WC 00 00 01 ( A) i � , POLICY NUMBER: (IEUB-1 A37070-A-15) RENEWAL OF (IEUB-1 A37070-A-14) ' INSURER: THE TRAVELERS INDEMNITY COMPANY OF CONNECTICUT 1. NCCI CO CODE: 12637 INSURED: ' PRODUCER: POLAR EXPRESS LLC EDWARD F SULLIVAN INS 10 HARVEST HOLLOW DRI VE _ __ ___---.-_ 507- NIGl-! ST _ _ __ _- ---- ' HARWICH PORT MA 02646 DEDHAM MA 02026 (nsured is A LIMITED LIABILITY COMPANY Other work places and identification numbers are shown in the schedule(s) attached. I 2. The policy period is from 07-01-15 t0 07-oi-�6 12:01 A.M. at the insured's mailing address. 3. A. WORKERS COMPENSATIOPI INSURANCE: Part One of the policy applies to the Workers Compensation Law of the state(s) listed here: MA ._ � , ��r--- = 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: ' � Bodily Injury by Accident: $ 10000o Each Accident � � Bodily Injury by Disease: � 50000o policy Limit � Bodily Injury by Disease: � 10000o Each �mployee — C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any,.listed here: � � AL AR AZ CA CO CT DC DE F L GA HI I A I D I L I N KS KY LA MD ME MI N�V ! o� __ _ _ = MO MS MT NC NE NH NJ NM NV NY OK OR PA RI SC SD TN TX UT VA VT WI ; � w� h�� = D. This policy inciudes these endorsements and schedules: � �_ a� SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE a� � � 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating �= Plans. All required information is subject to verification and change by audft to be made ANNUALLY. � � ..� � DATE OF ISSUE: 05-21 -15 GB I � OFFICE: HUDSON/BOSTON 126 DIRECT BILL � PRODUCER: EDWARD F SULLIVAN INS CRFB'7 � i 001826 ' i f I ! i ! TRAVELERSI�� WORKERS COMPEN SATION ONE TOWER SQUARE AND HARTFORD, cT ob�a3 EMPLOYERS LIABILITY POLICY TYPE V INFORMATION PAGE WC 00 00 01 ( A) POLICY NUMBER: (IEUB-1 A37070=A-15) CLASSIFICATION SCHEDULE: PREMIUAA BASIS ESTIMATED RATES ESTIMATED TOTAL ANNUAL PER $100 OF ANNUAL . CLASSIFICATIONS CODE NO REMUNERATION REMUNERATION pREMIUM SEE EXTENSION OF INFORMATION PAGE - SCHEDULE(5) SIGCODE: 5451 NAICS: 445299 ------------------------------------------------------- STANDARD - TOTAL ESTIMATED ANNUAL STANDARD PREMIUM $ 216 LOSS CONSTANT 20 PREMIUM DISCOUIVT NONE 0900-20 EXPENSE CONSTANT 250 TERRORISM g TOTAL ESTIMATED PREMIUM 492 TAXES AND SURCHARGES 13 DEPOSIT AMOUNT DUE 505 ; � _ _ _ __- � Minimum Premium: $ 219 DATE OF ISSUE: 05-21-15 GB ' OFFICE: HUDSON/BOSTON 126 - ' PRODUCER: EDWARD F SU�LIVAN INS CRF87 COUNTERSIGNED-AGENT i , TRAVELERS�, WORKERS COMPENSATION AND oNe ToweR seuaRe EMPLOYERS LIABlLIIY POLICY HARTFORD, CT 06183 EXTENSION OF INFO PAGE-SCHEDULE WC 00 00 01 ( A) POLICY NUMBER: (IEUB-1 A37070-A-15)� INSURER: THE TRAVELERS INDEMNITY COMPANY OF CONNECTICUT 12637-MA INSURED'S NAME : POLAR EXPRESS LLC PREMIUM BASIS ESTIMATED RATES ESTIMATED TOTAL ANNUAL PER $100 OF ANNUAL CLASSI-EIGAT�ON _ ______ __, _. COQE__ REMU(�RQTION REMUNERATION PREMIUM LOCATION 001 01 FEIN 260314991 ENTITY CD 001 POLAR EXPRE55 LLC 1279 RT 28 SOUTH YARMOUTH, MA 02664 - --" SIC CODE : 5451 NAICS: 445299 RESTAURANT NOC 9079 18764 1 .15 216 � .`� � � � ' �— � � � � o� i o� o� � � m�� I o� _ _ --____ _ --- -�_ _ _ . � o� „� MA MANUAL PREMIUM $ 216 o� _�- ------------------------------------------------------------------------------------ o� EXPERIENCE MODIFICATION: NONE MODIFIED PREMIUM $ NONE o� TOTAL ESTIMATED ANNUAL STANDARD PREMIUM 216 , .,�. LOSS CONSTANT (0032) 20 ,� EXPENSE CONSTANT(0900) 250 � TERRORISM (9740) 6 �� MA WC SPECIAL FUND AND TRUST FUND 13 i TOTAL ESTIMATED PREMIUM 505 � DEPOSIT AMOUNT DUE 505 ; i DATE OF ISSUE: 05-21 -15 GB SCHEDULE NO: 1 OF LAST oo,e2�