HomeMy WebLinkAboutApplication and WC ` Fi(LS CANCs2ECsAr-RdNA-(— i
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a ► TOWN OF YARMOUTH BOARD OF HEALTH /��� �• '
� � APPLICATION FOR LICENSE/P ,I � 0 �
�., a E��� �: �, � ' � f �015
�`"' * Please complete form and attach all necess =���ume �s y I3e e � r 1��015. '
Failure to do so will result in the retu � you��a�liCaetio�C`pac t. HEALTH DEPT.
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ESTABLISHMENT NAME: �. ►,..o„ TAX D• �
LOCATION ADDRESS:3Z.� q;,,,��t- , C�IQ bP�1 va�►,..���OG t`�vk,.�(itA TEL#• 5o8 -36a- b9'Z 7 �
MAILING ADDRESS: �c��-e oab-rs '
E-MAIL ADDRESS: e oL �-. . 0�
OWNER NAME: - � `
CORPORATION NAME (IF APPLICABLE): '
MANAGER'S NAME: �.�.�as��;\ I�. �ac�su�-. TEL.#:50�-3�2-�9 7'� �
MAILING ADDRESS: saw►�e. '
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated
Pool Operafor(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.
F�OD PROTECTION MANAGERS - CERTIFICATIONS:
All food service establishments are required to have at least one full-time employee who is certified as a Food E
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.
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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.
1. � � 2. �
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HEIMLICH CERTIFICATIONS:
All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich f
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
1. 2.
3. 4.
RESTAURANT SEATING: TOTAL#
--- - - n��r�� ires no rr�T .
LODGING: � y vy
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 P IT '
0-100 SEATS $125 _CONTINENTAL $35 �NON-PROFIT $30 � �
>100 SEATS $200 COMMON VIC. $60 WHOLESALE $80
— — —RESID.KITCHEN $80
RETAIL SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
>25,000 sq.ft. $285 VENDING-FOOD $25
_<2�,000 sq.ft. $$50 —FROZEN DESSERT $40 TOBACCO $110
NAME CHANGE: $15 AMOUNT DUE _ $ 30•OD '
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*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** �
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ADMINISTRATION I
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� i
OR �
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED !
�� Iho�.e,� ��ut�e t���.Q.�¢�. 2 —cM.�e va.l�v, '�p� 1�23�1S ct� `�-�tsz o�(.kev `��drvuc�L.. l�lZ 3 �2.a►6 4
Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES NO jJ�jT SU,��! �t„t�-
a� �.-���
MOTELS AND OTHER LODGING ESTABLISHMENTS
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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 '
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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 coumt '
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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FUOD SERVICE s
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 I
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. ,
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.
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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 QUIRE A SITE PLAN.
DATE: . � 2„ SIGNATURE: ` �, � .��L,
PR1NT NAME & TITLE: �Q�'C R l Ci R �.. �IZ�1.`( , �DM11J t ST►2�-ro R �
Rev. 10/01/15
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� ' � The Commonwealth ofMassachusetis �
Department of Industrial Accidents �
Office of Investigations �
� 1 Congress Street, Suite I00
- Boston,MA 02114-2017
� www.mass.gov/dia . , -
Workers' Compensation Insurance Aff davit: Genera��usinesses � �'-: : •� _: t ->
Applicant Information Please Print Legiblv
Business/OrganizationName: ��'SZ` �1�1GR�G�T�O__N_ftL CI�.L� � O �f�R o�T�1
Addxess: 32� �,e 6/'� o�-�- OZ(o
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City/State/Zip: Phone#: 5a�- 3�2-�.,97`�
Are you 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.urantBar/Eating Esta.blishment
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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] 8• ❑Non-profit j
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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 i
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.L� Other Cl�v�.�c�„
*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
organizadon should check box#1.
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I at�t arr e»tployer that is providing workers'compensation insurar�ce for my employees. Belaw is the palicy informdtion.
Insurance Company Name:����,.a.� ��Su4cs.�,.ct �c�.�.�-, , f
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Insurer's Address: 3pOc5 �uc �� � �
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City/State/Zip: -e, i �
i :a7-7 2-369
Policy#or Self-ins.Lic.# v1-L� � O�0 2 �lxpiration Date: 2.
At�h a copy of the workers' compensation policy declaration page(showing the policy number an 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 f
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fine up to $1,500.00 and/or one-year imprisonment,as�we�as civil pena-Tties m the�rm o�a-�T`6��kK 6ff73E�arid a tine 4
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 her certify,under the pains and penalties ofperjury that the information provided above is true and correct. ,
Si ature: Ct,�. t�,• Date: �.
Phone# Sb4 ' 3�02 �0 9��I
Official use only. Do not write in this area,to be completed by city or town officiaL
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,,<City or Town: Permit/License# - �
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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
STATE OF NBW YORK
WORKERS'COMPEAISATION BOARD
CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COV�RAGE
Ia. Legal Name&Address of insured(Use street address only) 1b. Business Teleplionc Number of Insured
FIRST CONGREGATIONAL (S08)-362-6977
CHURCH OF YARMOUTH
329 ROUTE 6A
YAR1�40UTHPORT,MA 02675-1817 lc. NYS Unemployment Insuraace Emptoyer
Registratiov Number of Insured
Work Location of Insured(O��ly reqrrlred ljrnrernge/sspec�cnli,� ld. Federal Employer ldentificatlon Number of Insured
(lmlled io certnl�t localloiu tii New York Slele,l.e.a Wrnp-Up Polfc}) or Social Securlty Number
04-6.��av4o
2. Name and Adclress of the Entity Requesting Proof of 3a. Name of Insurance Carrier
Coverage(Entity Being Listed as tht Certiticate Holsl�r) ---
CHURCH MUTUAL INSURANCE C0111PANY
TOif'N OF YARMOUTH
HLALTHDEPARTMENT
I146 ROUTE 18 3b. Policy Number of entity listed in box"la"
SOUTH YAR�l10UTH,1tiA 02664
0187606-07-�42369
3c. Policy effective period
la/Z3/19 to 1.2/,23/IS
3d. T6e Proprletor,Partners or Executive Ofticers are
❑ inetuded. (Only chec3:box if all plrtners/offieers inciuded) '
� all egcluded or certAin partuers/offecers excluded.
This certffies that tlie insurance carrier indicated above in box "3" insures the business referenced above in box "la" for�vorkers'
compensation under tue Ne�v York State Workers'Compensation Law. (To use t�is form,New York(NY) must be listed under
I em 3A ov tlie INFORMATION PAGE of the workers' compeasatlon lnsurance poltcy). The Insac�nce Carrier or its licensed
agent will send this Certificate of Ins�u�ance to the entity listed above as the certificate holder in bos"2".
Tfre I►fsura►rce Carrier will also�tol�tlte above certffrcate Itolder withfn 10 days IF�policy is canceled due to nonpayment ofprentituns
or wfthin 30�lays IF there are reasons olher tl�mt�ro�rper}�neirt of premiums tl:at ca�rcel�/re policy o��elin�i�tate the i�rstu•ed jro�fi t{re
coverage it�dicated w�tlris Certtftcat� (filtese notfces may be sej�t by regulcrr mall.) 011�erwlse,tlrJs Cert�ca/e Is wrlld for o�re year
nfter tl��Is jo�nr ls e�rprove�l bp tlre�itsurn�rce carrler nr!ts llcei�sed age�it, or Wirtt!tl�e pollc����plrotPo�t date Nsted!ir bar "3c';
wlriclrever is earller.
Please Note: Upon flie cauceliation of the workers'compensxtion policy indicated on th�s form,if tlie uusiness continucs to 6e
n�med on a peruiit,license or contract issued by a certificate hoider,the business must providc that certIffcate holder with a
new Certificate of Workers' Compensation Coverage or other authorized proof tLat the busiuess is complying witli the
mandatory coverage requirements of the New York State Workers'Compensation Law.
Under peualty of perjury,I certify that I asn an authorized representativc or licensed agent of the insurnnce carrier refereuced
above and that tl�e named insared has thc coverage as depicted on ti�is form.
Approved Chrfstopher A. Tetzlojf
by:
(Print nwnc of autharized represrn[ative or licrnscd ngent of insuronce carrier)
APproved . FebrlrRry 18,2QI5
by:
(Signaturc) (D�te}
Title: Servlce Represenlnti►+e
Telephone Number of authorized representative or licensed agent of insurance carrier: (800)-554-2642
Plense Note: Oj�ly insurmice cm•rie�s nnd tlteir liceirsed age�rls are au�lra•ized!o issue For�1r C-l05.2. liism•mrce broke�s are NOT
aulho��iz�cl to isst�e it.
C-105.2(4-07} �v�vw.wcb.state.ny.us
Workei•s' Compensation Law
Section 57. Restrlcfion a�Issue of permits and the entcring into contracts un[ess compensatiou is secured.
1. The head of a state or munioipal deparW�ent,board,commission or office authorizcd or required by la�v to issue any pernut for or in
connection �vith any �vork involving the employment of employees in a hazardous employment defined by this chapter, a�id
notwithstauding any general or special statute requiring or authorizing the issue of such permits,shall not issue such permit anless proof
duly subscribed by an insurance carrier is produced in a form satisfactory to the chair, that coinpensation for all employees has been
secured as provided by this chapter.Nothing hereut,ho�vever,shaIl be construed as creating any liability on the part of such state or
municipal department,board,commission or office to pay any compensation to any such emptoyee if so empIoyed.
2. The head of a state or mu�ucipal deparhnent,board,commission or office aathorized or required by law to enter into any contract for
or iu connection with any work invoIving the employment of employees in a hazardous employment defined by this chapter,
not�vithstanding any_gener�l or special statute_requiring or auihorizing any sucli contraet,shall vot enter u►t�a�ty such�tfntracti�ntess ;
proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair,tliat compensation for a(l employe�s has
bee;i secured as provided by this chapter.
C-105.2(9-07)Reverse
STATE OF NEW YORK
WORKERS'COMPENSATION BOARD
CERTIFICATE OF NYS WORK�RS' COMPENSATIDN INSURANCE COVERAGE
la. Legal Nartte&Address of Insurcd(Use street address only) lb. Business Telephone Number of Insured
FIRST CONGREGATIONAL CHURCH OF YAR1110UTH (S08)362-6977
329 ROUTE 6A
YARd�OUTHPORT�lA 02675-1817
lc. NYS Unem�loymeut Insurnnce Employer
Reglstration Number of Insured
Work Location of Insured(OnJp reqa►red ljcovernge Js spec�ca/l�� ld. Federal Emptoyer ldentification Number of Insured
tJml�e�l to cerlalu locallo�tsl�t New YorkSinle,l.e.a Wrep-Up Pollca) or Social Security Number
04-611004U
2. Name and Address of the Entity Requesting Proot'of 3a. Name ot Insurance Carriec
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overage(Entity Be_!ng Listed as th�C�rtiffcateI�eldex}- - --- -- -- - -
CHURCH AIUTUAL INSDRAR'CE CO1t1PANY
3000 SCHUSTER LANB
AiERRILL I�'154452
TO{f'N DF YAR1110UTH
HEfiLTH DEPARTNIENT
1146 ROUTE 28
SOUTH YARBIDUTHAIA 02664
3b. Policy Number of entity listed in box"la"
0187606-0�842244
3c. Policy effective period
12/13/1 S to 12/23/16
3d. The Pro�rietor,Parf��ers or Esecutive Officers are
❑ iucluded. (O�ily chcck box if aU partners/a8lcers included)
� All excluded or certain partners/office�•s exciuded.
This certifies that the insurance carrier indicated above in box "3" insures the busiuess referenced above iu box "ta" for workers'
compensation under the New York State Workers'Compensation Law. (To use this form,New York(N�must be listed under Item 3A
on the INFORMATTON PAGE ot the workers'eanpeusation f�tsuranee pol[cy). The Insurance Carrier or its licensed agent�vill send
this Ccrtificate of Insurance W the entity listed above as tl�e certificate holder ni box"2".
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The L�surmice Carrier will also rtot�tlie crbove cerliflcate!to/der wilhi�r 10 da}�s IF a po/icy is canceled dtre to uwipayme�tt ofpremimns
or►t�itlri�i 30 da}�s IF I{rere are r�asons otlier thasi nonp�r}�me�rt of premlums tfral cancel the policy or e/inri�rate the�nsured fi•onr the
coverage i»dicated o�r tlr3s Certificale. (T/iese r�ot�ces may be sent by regular mail.) Otlter►v�se,llris Cerl�cate Is vnHd for ose yenr Rfl'er
I/r3s forn�ls npproved by t/�eli�st�rnitce carrler or fls/fceusedage�ti,or nnif/f/repo!!cy��pirnifo��r/n1e JJsledl�t box"3c';►nlilc/rever Js
errrller.
Please Note: Upon t[�e cancellatlon of tl�e workers'compens�tion policy indicated on this form,if the business continues to be
named on a permit,license or contract issued by a certificate holder,tlie business uiast provide that certificate holder H�ifh a new
Certificate of Workers'Compensatton Covernge or other autliorized proof that the business is complying with the mandatory
covcragc requiremeuts of the New York State jVorkers'Comnensation La�v.
Under peuatty of perJury,l certity fhat I am an authorized representative or licensed agent of ti►e insurance carrfer referenced
above And that tl�e named insured has the coverage as depicted on tl�is form.
Approved by: Ke!!y St.Lortfs
. (Print name of nuthaized represenfatiti�e or itcensed agent oCinsurance esrrier)
.
Approved by: Decetn8er 14 201 S
(signxture) (Date)
Titte: Servlce Represe»tath+e
Telephone Number of authorized re}xesentative or licensed agent of insurance carrier: (800)-SS4-264Z
Ple�se Note: Only insura�►ce carriers a�ad tHeir/icensed agenls are autlrorized to 3ssue Foren GIOS.2. l�lsura�rce broke►s are NOT
nuthorized to issue It.
G105.2{9-07) �v�v�v.�vcb.state.ny.us
Workers' Compensation Law
Section 57. Restrlctlon on issue oP permits and ttie entering into contracts ualess compensation is secured.
i. The head of a state or ttiunicipal dep�rtment,board,comuussion or office authorized or reyuired by la�v to issue any permit for or in
connection with any tivork involving tl�e empIoyment of employees in a haxardous employment defined by tlus chapter,and nohvithstanding
any general or special statute requiring or authorizing the issue of such pernuts,shall not issue sucli permit unless proof duly subscribed by
au insurance carrier is produced in a form satisfactory to the chair,that compensatiou for all employees bas been secured as provided by this
chapter.Nothing herein,however,shall be construed as creating any Iiability on the part of such state or municipal department,board, '
commission or office to pay any compensation to any such empIoyee if so employed. �
2. The head of a state or cnunicipal department,board,commission or o#�ice authorized or required by Iaw to enter into any contract for or ;
in connection�vith any work involving the employment of employees in a l�azardous employment defined by this cl�apter,not�vithstanding
Any general or special statute requiring or authorizing any such contract,shall not enter into any suc�contract vnless proof duly subscribed
by an insurance canier is produced in a fonn satisfactory to the chair,tliat compensation for all employees has been secured as provided by
tivs chapter.
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j C-105.2(9-07)Revers$
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