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Home My WebLink AboutApplication and WCr . � f'� 7 � � TOWN OF YARMOUTH BOARD OF HEALTH c� ° � � APPLICATION FOR LICENSE/PERMIT-20 6 b4� J�4� 2 8 2016 '"' * Please complete form and attach all necessar��doc�inen s y ecemb r 1 S 201 S. Failure to do so will result in the return o�y.our�app�ication pack t. HEALTH DEPT. _� ESTABLISHMENT NAME: e�a�S � Q� TAX ID: LOCATIONADDRESS: �I`I � Ya-aV � � '�� TEL.#: � �I� 42 S6 1VIAILING ADDRESS: �'�Gi.rn E-MAIL ADDRESS: 1�$k�A K��cYl(�C.�� .�� OWNER NAME:�i�lr� �2��v� CORPORATION NAME (IF APPLICABLE): 1VTANAGER'S NAME: Ke��t� K,e�� -rEL.#:�� "Z M�AILING ADDRESS: `�vY� (�� G±�U`e 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. _ �___ __ _ 1 _ __ __ -- - . _ _ __ _ � _______ __ ---- - �; i ' � 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 y�ars' 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 l�ast 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.�� 1 �P�..�� `--��1� 2.�C�.:�� 1��✓ PERSON IN CHARGE: Ea.ch food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. �� I��`J ��1�'� �_ 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.�`j�►'��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. 2. 3. 4. RESTAURANT SEATING: TOTAL# I I _ ' I� — -��z cT��9�1�,�' _ -- _–; LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $1l0 _INN $55 CAMP $55 SWIMMING POOL$110ea. _LODGE $55 _TRAILER PARK $105 WHIRLPOOL $110ea. ' • FOOD SERVICE: LICENSE REQUIRED FEE P MIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# ' �0-100 SEATS $125 /(o—��%� 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 _ $ �g�� *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** f ! �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 CO PENSATION 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 p or to renewal or issuance of your permits. PLEASE CHECK � APPROPRIATELY IF PAID: j YES NO . � MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: Far purposes of the limitations of Motel or Hotel use,Transient occupancy sha11 be � limited to the temporary and short term occupancy,ordmarily and customarily associated with motel and hotel use. ! Transient occupants must have and be able to demonstrate that they maintain a prineipal 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 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 PQOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. _ __ ___�___ _.�; FOOD SERVICE � i 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. i CATERING POLICY: r 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.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. 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. . _ _. .1 I 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 RE UT A ITE PLAN. � DATE: � �' �� SIGNATURE: ,� �� , � PRINT NAME & TITLE: ��/�� "� �n �� Rev. 10/OU15 � � � � :" ' � � The Commonwealth ofMassachusetts Department of Industrial Accidents � Office of Investigations ' I Congress Street, Suite 100 Boston,MA OZll4-20Z 7 { www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Apulicant Information Please Print Legiblv . � Business/Organization Name: ► I�l,�' 1�l Address: � � Z , � A i City/State/Zip:_ C,�2�(�� Phone#: �� 28� � Are you an employer? Check the appropriate boz: Business Type(required): 1.� I am a employer with�'�employees(full and/ 5. ❑ Retail � ^''^a,-r_r;,"-�-* - 6.�'R�staurantlBar/Eatin�Establishment , 2.❑ I am a sole proprietor or partnership and have no �, � Office and/or Sa1es(incl.real estate,auto, etc.) i employees working for me in any capacity. [No workers' comp. insurance required] g• ❑Non-profit j 3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment i their right of exemption per c. 152, §1(4),and we have 10.0 Manufacturing ' no employees. [No workers' comp. insurance required]* 11.❑ Health Care � 4.❑ We are a non-profit organiza.tion,staffed by volunteers, � with no employees. [No workers' comp.insurance req.] 12.❑ Other i � •An a hcant that checks box#i must also fill out the section below showin their workers'com Y PP� g pensation policy information. i **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#L I am an employer that is providin work rs'co,mpe�n insurance fo my empl y ees. Below is the policy information. Insurance Company Name: 7 Insurer's Address: � � �'� i City/Sta.te/Zip: / �� . . Policy#or Self-ins.Lic.# � A 7 Expiration Date: � � �ttach 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;��.06 arid/or one-yeai imprisonment,as we as civil pen ti�th-�orni of a STOP WORK ORDER and a fine of up to $250.00 a da.y 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 cert' ,under t pai and enalties ofperjury that the information provided a ove is true and correc� Si ature: � Date: � �v� � Phone#: �� '01'l02,� 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 Office 6.Other Contact Person• Phone#• www.mass.gov/dia , Date Prepared: 03/19/15 a ;, DIRECT BILL � � ; WORKERS' COMPENSATION AND EMPLOYER'S LIABILITY INSURANCE POLICY = MERCHANTS MUTUAL IfdSURANCE COMPANY BUFFALO, NY 14202 NCCI COMPANY NUMBER: 15652 INFORMATION PAGE � POLICY NUMBER: 1MCA9097799 TRANSACTION TYPE: RENEWAL AGENCY/BROKER: S�U11�1EASTERN i NSURANCE AQCY RENEWAL OF Nt�ER: Y�A9097799 AGENT CODE: 66814/NER06/033 BUSINESS TYPE: IND i V IDUAL ; 1. THE KEITH KESTEN INTERSTATE/INTRASTATE RISK ID: INSURED DBA KE I LAR'S BAKERY BOARD FILE NUMBER: MAILING � CYGNET ROAD ADDRESS w Y��m' � 02673-3609 FEDERAL EMPLOYER IDENTIFICATfON NUMBER: 285496129 � OTHER WORKPLACES NOT SHOWN ABOVE: (ADDRESS,CITY, STATE,ZIP CODE) , _ _ _ ____ __ _ 2. POLICY PERIOD is from 04/15/15 to 04/15/16 12:01 AM standard time at the insured's mailing address. { 3. A. Workers' Compensation insurance: Part One of the policy appiies to the Workers' Compensation Law of the states listed here: �p 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 i � 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: I ; D. This policy includes these endorsements and schedules: MS IU 05 11 99 MU 06 3J 10 14 WC 00 00 00 C WC 00 00 01 A WC 00 04 21 C WC 00 04 22 B WC 20 03 Q1 WC 20 03 02 A WC 20 03 03 D t� 20 04 01 Y�C 2D 04 04 WC 20 06 01 A I I 4. The premium for this policy witt be determined by avr Nlanuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Code Premium Basis Rates Per Estimated Annual Classifications No. Total Estimated Annual $100 of Premium Remuneration Remuneration SEE EXTENSION 4F INFORMATION PAGE MINIMUM PREMIUM $ 2�2 DEPOSIT PREMIUM $ 1 ,560 TOTAL EST I MATED MAVUAL PREM I ll�t $ 1 ,560 Interim adjustments of premiums shall be made: ANNUAL Countersigned by: �. � Authoriz representativ Date COPYRIGHT 1987 NATIONAL COUNCIL ON COMPENSATION INSURANCE WC 00 00 01 A INSURED COPY T MERCHANTS MUTUAL INSURANCE COMPANY WORKERS' COMPENSATION EXTENSION OF INFORMATION PAGE POLICY NUMBER: WCA9097795 THE KEITH KESTEN tNSURED DBA KE 1 LAR'S BAKERY MRtLING 1 CYGNET ROAD ADDRESS � Y��H, MA a2673-3603 Premium Basis Tatal Estimated Rates Per Estimate Classifications Code Annual $100 of Annual No. Remuneration Remune�ation Premiurr � _ -- — - _ - - ____ LOGATION 001 1 CYGNE� R4AD W YARMOUT'H, MA 02673-3609 BAKERY & DRIVERS, ROUTE SUPERV 2003 35,000 3.2400 1 ,13� INCREASED LIMiTS EMPLOYERS' LIABILITY 9812 2.Q000 �'0 7f MERIT RATING 9885 .0500- 6( TOTAL ESTIMATED STANDARD PREMIUM 1 ,14� j MASS DIA 9999 1 ,077 .0580 6� ' EXPENSE CONSTANT 0900 33F i TERRORISM RISK INSURANCE ACT - NIA 9740 .0300 11 TOTAL ESTIMATED ANNUAL PREMII�N 1 ,56C MINiMUM PREMIUM 272 DEPOSIT PREMIUM 1 ,560 COPYRIGHT 1987 NATlONAL COUNCIL ON COMPENSATION INSURANCE WC 00 00 01 A