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Home My WebLink AboutApplication and WC � TOWN OF YARMOUTH BOARD OF HEALTH ��C�L��MLSDD � r�s t.�. � � � APPLICATION FOR LICENSE/PERI�� `e �S �,�� ., ` � Uk�: < � 'lf)15 �'°' * Please complete form and attach all necessary docu�rent�'t�,• ' y It �'1 2015. ' Failure to do so will result in the return of y�u;t�ap�i � o ac cet. HEALTH DEPT. ESTABLISHMENT NAME u GD U C � TAX ID: LOCATION ADDRESS: `��3 �%✓S T �sf y�491 M o��f�' TEL.#:;3�� '77�D g�// MAILING ADDRESS: � g 3 NV�'�N �,'f', GllST `//1�M Ou�ft YYI fi 4a 6 73 x E-MAIL ADDRESS: �JYCG N ec.- h'1-S�� OWNER NAME: /i�l�sT" Y/ �� o �1`� �vN�, c/f-x/�cif CORPORATION NAME (IF APPLICAB E): 1��5(` �l,,4-2h��TN G�� • G��-�� ,. - MANAGER'S NAME: 'S1�'� �G i�r TEL.#: ?��?vS d c� { MAILING ADDRESS: PbOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated P4o1 Operator(s) and a tach a copy of the certification to this form. _ -- 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 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. �C B��r'�5�Q M-.� (� 2. P�RSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. _ �y,� �--� � i �, �-�-� -_ __ _–– ^ - - --—_ __ __. ALLERGEN CERTIFICATIONS: � AlI 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. � 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. �e `c 2. 730�..�� - �vs Q. ,"a - LJ��- 3. "—'' 4. � RESTAURANT SEATING: TOTAL# � � 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 $l l0ea. ; � FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# L CENSE REQUIRED FEE �/ 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# <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 _ $ 30• O b *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** . " _ _ ,, 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 i OR � � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED � il ; 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 � I _ _ -- -__,__ _�_ _I TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy sha11 be !� limited to the temporary and short term occupancy,ordinarily and customarily associated with motel and hotel use. I 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 I'� � I 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) I 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 I', 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 I 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, 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. NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETIJRN 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 Y THE BOARD OF HEALTH PRIOR TO COMMENCEME T. RENOVATIONS MA UIRE A S E PL N. DATE: / � SIGNATURE: — r PRINT NAME& TITLE: ' -� Rev. 10/O1/IS � / � � � � ��Q��`-' ,�--r 68 (Policy Provisions: WC 00 00 00 B) ' 59 ''�.E � INFORMATION PAGE �� WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY INSURER: �'N1IN CITY FIRE INSURANCE COMPANY ONE HARTFORD PLAZA, HARTFORD, CONNECTICUT 06155 NCCI Company Number: 14974 THE company Code: � HARTF�RD M ' � O �i N $U�X � LARS RENEWAL � POLICY NUMBER: 08 WEC NN5968 10 m Previous Policy Number: 08 WEC NN5968 � HOLT�ING CODE: DW "z' 1. Named Insured and Mailing Address: �ST YARMOUTH CONGREC-ATIONAL ,� (No., Street, Town, State, Zip Code) CHiJRCH 0 N � 3 83 �MAIN STREET � FEIN Number: WEST Y1�RMOUTH, r�x 02673 � � State Identification Number(s): � UIN: — The Named Insured is: NON-PROFIT ORGANIZATION = Business of Named Insured: CHURCHES AND OTHER HOUSES OF W — Other workplaces not shown above: 3 83 MAIN STREET � WEST YARMOUTH MA 02673 — 2. Policy Period: From 10/01/15 To 10/01/16 — 12:01 a.m., Standard time at the insured's mailing address. Producer's Name: FITTS INSURANCE AGENCY, INC/PHS � 301 WOODS PARK DRIVE � CLINTON, NY 13323 = Producer's Code: 088027 � = Issuing Office: THE HARTFORD - � � 301 WOODS PARK DRIVE ' � CLINTON NY 13323 � (866) 467-8730 — Total Estimated Annual Premium: $1,046 = Deposit Premium: = Policy Minimum Premium: $350 MA (INCLUDES INCREASED LIMIT MIN. PREM. ) — Audit Period: �JAL Installment Term: — The policy is not binding unless countersigned by our authorized representative. Countersigned by ��'�'� ��`�`��' 0 8/17/15 Authorized Representative Date Form WC 00 00 01 A (1) Printed in U.S.A. Page 1 (Continued on next page) Process Date: 0 8/17/15 Policy Expiration Date: 10/01/16 ORIGINAL t INFORMATION PAGE (Continued) Policy Number: os raEc NN5968 � t� 3.A. Workers Compensation Insurance: Part one of the policy applies to the Workers Compensation Law of the states listed here: MA 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 $1, 000, 000 each accident Bodily injury by Disease $1, 000, 000 policy limit Bodily injury by Disease $1, 000, 000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any , listed here: ALL STATES EXCEPT ND, OH, WA, WY, US TERRITORIES, AND S'FATES DESIGNATED IN ITEM 3.A. OF THE INFORMATION PAGE. � .`, D. This policy includes these endorsements and schedule: J � WC 00 04 22B WC 20 03 03D WC 20 06 02 WC 00 04 14 WC 20 03 01 ' WC 20 03 02A WC 20 04 01 WC 20 04 05 WC 20 06 01A 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. • Premium Basis Classifications Total Estimated Rates Per Estimated Code Number and Annual $100 of Annual� Description Remuneration Remuneration Premium 8868 105,100 .67 704 RELIGIOUS ORGANIZATION PROFESSIONAL EMPLOYEES & CLERICAL INCREASED LIMITS PART TWO (9812) 2.00 PERCEN'I' 14 TO EQUAL INCREASED LIMITS MINIMUM PREMIUM (9848) 61 TOTAL PREMIUM SUBJECT TO EXPERIENCE MODIFICATION 764 MA - MERIT RATING CREDIT (9885) .950 PREMIUM ADJUSTED BY APPLICATION OF EXPERIENCE MODIFICATION 726 SMALL DEDUCTIBLE 500 (9663) 2 .20 PERCENI' -15 TOTAL ESTIMATED ANNUAL STANDARD PREMIUM 726 EXPENSE CONSTANT (0900) 250 MASSACHUSETTS DIA ASSESSMIIVT 5.750 PERCIIVr!' 38 TERRORISM (9740) 105,100 .030 32 TOTAL ESTIMATED ANNUAL PREMIUM 1,046 Total Estimated Annual Premium: $1, 046 Deposit Premium: Policy Minimum Premium: $350 MA (INCLUDES INCREASED LIMIT MIN. PREM. ) Interstate/Intrastate Identification Number: / 000017863 NAICS: Labor Contractors Policy Number: SIC: 8661 UIN: N0. OF EMP: 000003 Form WC 00 00 01 A (1) Printed in U.S.A. Page 2 , Process Date: 0 8/17/15 Policy Expiration Date: 10/01/16 ', • i