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Home My WebLink AboutApplication and WC� �, , n�,� �r � �► TOWN OF YARMOUTH BOARD OF HEALTH ' [�C(�C0�1C�� . . APPLICATION FOR LICENS ' �015 �,. (� % "`° * Please complete form and attach all neces � � t „s � �� er t"��Ol S. ' Failure to do so will result in the ret `of `` �a ` ac et. HEALTH DEPT. E�TABLISHMENT NAME: S TAX ID: '� LOCATION ADDRESS: S • 0 TEL.#: � MAILING ADDRESS: � � E-MAIL ADDRESS: �-S r'�" f� fYt • 8�i' OWNER NAME: �-- '' �� CORPORATION NAME (IF APPLICABLE): S Y� �.t � MANAGER'S NAME: r TEL.#: 8 62 �j- M�AILING ADDRESS: � PbOL 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. , !S - `j�V tC�1., - _ - - _ _ _--__ _ Pool operators must list a mirumum 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 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' Iv � 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. ---_ 1_,�-_--� ____._.�_� _ _ rv �.� -- �.��r�_;.�,.�_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 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�le at your place of business. 1. � � 2. 3. 4. � � , ; RESTAURANT SEATING: TOTAL# ; _ — --____$�Fiir!� irc� n�vr v --- _ LODGING: 1 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE P MIT# B&B $55 CABIN $55 / MOTEL $110 —6 Z _INN $55 CAMP $55 1 SWIMMING POOL$110ea. �o _LODGE $55 _TRAILER PARK $105 �WHIRLPOOL $110ea. � FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 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 _ $ 3 30•00 *****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 OR WORKER'S COMP. AFFIDAVIT SIGNED A1�TD ATTACHED Town of Yarmouth taxes and liens must be paid prior o renewal or issuance of your permits. PLEASE 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 sha11 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 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. _ _ _ _ ___��_��n� _.._- �., ___, _ _ _ _:,.. ----- 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 atthe Health Department,or from the Town's website at www.varmouth.ma.us under Health Departrnent, 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 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 RESFONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATfON(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 COMMENCE ENT. RENOVATIONS MAY QUIRE A SI LAN. r�/, DATE: � � •J SIGNATURE: " (1 PRINT NAME&TITLE: � �— �� ` �' Rev. 10/O1/IS ;� , � � The Commonwealth ofMassachusetts _ Department of Industrial Accidents � - Office of Investigations ' 1 Congress Street, Suite 100 Boston, MA 02I14-2017 = www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses � Applicant Information Please Print Legiblv Business/Orga.nization Name: � ��'{� �S6 1,� � Address: . . .. _ .��y_�'S�� . . City/State/Zip: �j► V�� ` {�c Phone#: h(�S �� 7�� Are you employer? Check the appropriate boz: Business Type(required): f 1. I am a employer with�_employees(full and/ 5. ❑ Retail _ -�- or�art-iirne).*____ __ _ _--- –__ _____– 6. Q RestaurantBaz/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 right of exemption per c. 152, §1(4),and we have 10.� Manufacturing no employees. [No workers' comp.insurance required]* 11.� Health Care 4.❑ We are a non-profit organizaxion, stafFed by volunteers, with no employees. [No workers' comp. insurance req.] 12.❑ Other * ' w rkers'com nsation oli information. � 1 the section below showin their o Any applicant that checks box#1 must aiso fil out g pe p �Y **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 am an employer that is providing orkers'compensation insurance for my employees Below is th�policy information. 1� � ��- C� ' Insurance Company Name:� '�'' r t�lr\ �VT1.�li�f C� ��(� , . Insurer s Address: � S �� P�� Ci /State/Zi � �� tY P� Policy#or Self-ins.Lic. # v`� 1� � ,� `�� Expiration Date: �- At�tach a copy of the workers' compensation policy declaration page(showing the policy number and e iration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalries of a _ ----- ----- fine up to$1,500.00 and/or one-year imprisonment,as well as civil pen ties in e orm o�a�'�6�C7I�K�EI�and a m�e— 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. G I do hereby c under the ins enal ' s of perjury that the information provided above is true knd correct. Si ature: Date: �r^ �� Phone#• '�'/� �-1� �� Official use only. Do not write an this area,to be completed by city or town offaciat City or Town: PermitlLicense# 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#: Iwww.mass.gov/dia WORKERS COMPENSATION AND EMPLOYERS'LIABILTY I INSURANCE POLICY----INFORMATION PAGE iNSURER: POLICY NO: Wg114835A NORFOLR & DSDHAM MUTUAL FIR13 INSURANCS COMPANY 222 AMES STRSST BNDORSEMENT SFF 05/18f2015 DSDHAM, MA 0 2 0 2 6 NCCI Company No: 210 5 9 Account No: FEIN: � � j ITEM 1. NAMED INSURED AND MAILING ADDRESS: AGENT NAME AND ADDRESS: PARRLRS RIVER RSSORT LLC � ROGERS & GRAY INS. - � ; 759 MAIN STREET AGSNCY, INC SOIITH DENNIS SdUTH YARMOUT�I MA Q2fi64 � OFFICS 434 ROUTS 134 � SOIITS DBNNIS, MA 02660 AGENT NO.: 20577 LEGAL ENTITY: LIMITBD LIABILITY COMPANY (LLC) OTHER WORKPLACES NOT SHOWN ABOVE: (See Workers Compensation Classfication Schedule) tTEM 2. POLICY PERIOD: From: 0 5/18/2 O 15 To= 0 5/18/2 016 Effective 12:01 A.M. Standarc!Time at the insured's mailing address. ITEM 3. COVERAGE: � A. Workers Compensation Insurance: Part One of the palicy appiies 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{imits ( of liabitity under Part Two are: � � Bodily Injury by Accident: $ � 5 0 0,0 0 0 eac�accident _ � Bodily injury by Disease: $ 500.000 P��Y limit _ _ Bodily Injury by bisease: � 5 0 0,Q 0 4 ��employee C. Other States Insurance: Part Thfi�ee of the policy appiies to the states,if any,listed here: SS8 ENDORSSMENT inlC 2 0 Q 3 0 6 B D. This Policy includes these Endorsements and Schedules: See Schedule of Forms and Endorsements. E tTEM 4. PREMIUM:The premium for�this Policy witi be determined by our Manuals of Rutes,Classfications, Rates and I Rating Pians. All information reguired on the Workers Com�nsation Ciass'�"ication Schedule is subject to ', verfication and change by audit. _ - Totai Estimated� Minimum Premium: $ 2 3 4 Annual Premium: $ 1,6 2 8 i Audit Period:��, Additionai/Retum Premium: $' 804 ADDITIONAL Comments: CHANGE PAYROLL P$R AUDIT Issued At � Date: 07 j 15 j 2 O 15 Countersigned by � � I . f � - ^ � WC 00 00 01 A Copyright 1987 National Councii on Compensation insurance , i C �Nsu�o co�r � F