HomeMy WebLinkAboutApplication and WC r,
- �, °� r� TOWN OF YARMOUTH BO _ , i ���" l� _. '� °
APPLICATION FOR LICENS i ~� ,�1 , � �; � a � ,- ,;.� '�
�• �� �� *?� .�.� 7 ����' � �� �.���
* Please complete form and attach all necessary documents by Decemb 1 S 201 D.
Failure to do so will result in the return of your application pack t. �D��•
ESTABLISHMENT NAME: Kw� 6�T ��, � '� TAX ID: �
LOCATION ADDRESS: 33 VNa:�. . � v�. TEL.#: � � — pb
MAILING ADDRESS: 1'
OVVNER NAME:�_ 'I�.j a.r•�1 �v�.•� J �v a�v�
CORPORATION NAME ( APYLICAB E): ( 'v� �;�� � � �Q �
MANAGER'S NAME: �k ��rr� TEL.#: -
MAILING ADDRESS: S'�v��.
POOL CERTffICATIONS: ',
The pool supervisor must be certified as a Pool Operator,as required by State latv. Please list the desi�nated '
Pool Operator(s) and attach a copy of the certification to tl�is form. ;
1• 2. . _
Pool operators must list a minunum of two em loyees cun ently certified in basic water safety,standard Fust Aid aud
Community Cardiopulmonaiy Resuscitation(�PR). Please list these employees below and attach copies ofemployee
certifications to this foi�n. The Health Department will not use past years' records. You must provide ne���
copies and maintain a file at your place of business.
1. 2.
3. 4.
FOOD PROTECTION MANAGERS - CERTIFICATIONS:
All food service establislunents 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 Seivice Establishmeuts, 105 CMR 590.000.
Please attach copies of certification to this application. The Health Department�vill nat use past years'records.
You mus rovide new copies and maintain a file at your establishment.
l. tn � ��v�ot 1.t 2.
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PERSON IN CHARGE:
— - -
�ac ood establislunent must�ave at�Ieast one Person In Charge (PIC on site dui{uig hours of operation.
1. C��,\� S�1�J��� 2. ���, �. o� ���.
HEIMLICH CERTIFICATIONS:
All food service establishments with 25 seats or more must have at least one employee trained ui tlie Heimlicli
Maneuver on the premises at all tunes. Please list your employees trauied 'ui anti-chokui�procedures below and
attach copies of employee certifications to this foi�nl. The Health Department�vill not use past years' records.
You must provide new copies and maintain a �le at pour place of business.
1. 2.
3. 4.
RESTAURANT SEATING: TOTAL #
OFFICE USE O1V'LY
LODGL\G:
LICENSE REQUIRED FEE PERMII'?� LICENSE REQUIRED FEE PERVIIT� LICENSE REQUIRED FEE PERVIIT�
_B&B S55 _CABIN S5� _MOTEL S»
—�'T S�� —C�� S» _S4'V'� � ING POOL S80ea.
_LODGE S�5 �IRAILERPARK 5105 ���V�iIRLPOOL S80ea.
FOOD SER��ICE:
LICENSE REQUIRED FEE PER�VIIT# LICENSE REQUIRED FEE PER��IIT� LICENSE REQUIRED FEE PERMII'�
I 0-100 SEATS S8� ��� _CONTINENTAL S3� NON-PROFIT S30
>100 SEATS 5160 _COMMON VIC. S60 �'�'HOLESALE S80 4
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RETr1II.SERZ'ICE: —RESID.KITCHEN S80 i
LICENSE REQUIRED FEE PER.�IIT� LICENSE REQUIRED FEE PER��IIT� LICENSE REQUIRED FEE PER�vIIT#
_<50 sq.R. S50 _>25,000 sq.2t. S225 VENDING-FOOD S?5
�<25,000 sq.ft. S80 �(���o _FROZEN DESSERT S40 ! TOBACCO S» � ��D��
���zE c�`cE: sis AMOUNT DUE _ $ �Zo�pp
**"**PLEASE TtiR\O�'ER A\D CO�IPLETE OI'HER SIDE OF FOR�I*****
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. 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 �OMPENSATION INSURANCE
AFFIDAVIT MUST BE CUMPLETED AND SIGNED, OR
CERT. OF INSURANCE ATTACHED �
OR .
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED '
Town of Yannouth 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
TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shaU 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 sha11 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, sha11 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
pnor to opening.PLEASE NOTE:People are NOT allowed to srt m 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('Tj days of
closing.
FO�D SERVICE
SEASONAL FOOD SERVICE OPENING:
All food service establishments must be ins�ected 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.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:
_Qutci . . f.c��.�,�tdQor se�Ying�ith��it�r/waitress service),must have prior approval from the Board ofHealth.
OUTDOOR COOKING:
Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohi6ited.
NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBII.TTY TO RETLJRN II'
THE COMPLETED RENEWAL APPLICATION(S) AND REQIJIlZED FEE(S)BY DECEMBER 15, 2010.
ALL RENOVATIONS TO ANY FOOD ESTABLI NT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIl'MENT,ETC.), MUST BE REPORTED TO APPROVED BY TI�BOARD OF HEALTH PRIOR
TO COMMEN EME T. RENOVATIONS MAY IRE A SITE PLAN.
DATE: . l �-o � SIGNATURE:
PRINT NAME&TITLE: t °v �. Vl ►
10j06�10
• � �
The Commonwealtt�o,f'Massachusetts
Departneen!of Industrial Accidents
NrfriNiw� .
600 Washingtnn Street, 7'"'Floor
' �.Boston,Mas� 02111
Workers'CompeesaHos I�aneee p}fldavih Baildiog/Plam�ie�Electrics!Contnctor3 , , .
n��I a�' �� �- � 1v�Q � d� .� o� ��nw•� �n o��- V• � �t,� ,
ad�s�: 0 111/�o�c v� 1Z�- �p If� '
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site locatioo(fiill addnss)•
LJ I am a 6omeowner perforrmng all work myself. ` Pro ect T j
❑ 1 a sole proprietor and have no one workin tn an � J ype: ❑New Construction QRemodel �
g Y P�i�'• ❑Building Addition
I am an employer providing worke�s'compensati�for my employees wodcic�g�t6is job.
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ad�rcss:
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❑ I am a sole pcoprietor,ge■enl coetractor,or iiomeowner(circte oni)and have hit+ed the contractocs li�d below who bave
the following workers'compensation polices:
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address:
city
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A1rel� i����� +k
Fail�re b sams u reqeirsd��dQ SeetlN 2SA�[MGL 132 cu Ind t�tre���fvi�iul . .
�Y�n'� �eat a�weY as dH PmMb�f a fi�e�b f1,3N�M aadl�r
pe�aHia h tre firi eta 3TOl WORK ORDER a�d a Ane Kt1A�.0i a dap s�ai�t ie. 1 a�das4�d t6at a
np�y�t fYh�ta vy be ferwarded b tee OAke�!ImMIpW�s.f t�e DIA tor cwense verlAeatln.
/10 hu+ebl'K e pries awd peneltles of p�rjary t/kar rl�e ls
fonwmion prevldel abope fs d+re awd cornrx
Signatoce ' t 1 ,1-�
Datt �
Print name h'�n �V U Phone M '� �, '�� �
efBeial use osty do eat wTke�thil r+ea to be ceopleted DY�Y��wo oBkial
dty or towo•
• P�ensc� QHaidiea Departmeet
❑cheek if Immedi�le respeex h rcqdred ��s�R Baard
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�/1/A �5�,
�.�� STANDARD WORKERS COMPENSATION
AND �IPLOYERS LIABILITY POLICY
ZNFORMATION FAGE - RENEWAL OF WC 4 17599053
p�� From p�pariod to . Caverage b Prarid9d By A9�y
WC 4 17599053 07/16/10 0?/16l11 NATL FIRE Il+1S. CO. OF HARTFORD 02625612d
N�ned lt�a�ed Md�lddress a9�
SULLNAN`S VILLAGE STOR� OGERS & C:RAY INSIIRANCE AGENCY INC
330 Route 6a 34 ROt�TB 134
i YARMOIITIi PORT, MA O BO% 1601
OIITH DENNIS MA 82660
I� 026?5
** S C H E D II L E O F. O P E R A T I 0 N S ** SCAEI3QLE
STATE: MASSACHQS$TTS PAGE 1
4. ,
LOC CLASS CLASSIFTCATION OF OPBRATIONS EST TOTAL RATL PER EST ANNI3AL
NQ. CODE ANN REMUN $100 REMUN PR�IIttM
001 8006 GROCERY, TEA OR COFFEE DEALER-RETAIL 105.000 1.38 1,449
SUBTOTAL FOR LOCATION 001 $1,449
9$07 E�lPLOYERS LIABILITY INCREASED LIMITS .0100 14
9848 INC. LTM. BALANCE TO MINIMUM PRI�fIt�t 36
TOTAL PRffi�IIIIM SIIBJECT T'U E%PERILNTCE MODIFICATIOAT 1,499
9885 MERIT RATING MOD. , EFF 09/16/10, IISING FACTOR .0500 75- '
TOTAL EST�MATED ST.ANDARD PR�IIIM $Z•�24 �
0900 E%PENSE CONSTANT NCCI REVISED PROGRRM 338
9740 TBRRORISM PR�lIUM 105,000 .0300 32
TOTAL ESTIMATED PRF.�IIIIM $1,794 ;
� Q988 MASSACHIISETTS ASSESSMENT 6_80� 94 '
� TOTAL ESTIlKATI3D COST $1•8 8 g �
�
,►*,ir** POLICY TOTALS ***** i
ESTIMATED CLASS PREMIOM $1,449 k
ESTIMATID STANDARD PRF�IIUM 51,��4 �
� PREMI[IM DSSCOUNT $� '
EXPEN58 CONSTANT $338
'" TERRORISM PRI�IIt7Ir! , $3 2
E3TIMATED PRII�iIt3M $1,794
� STATE TAXES/ASSESSMEi3TS/SURCHAR6ES $9�
� ESTIMATED COST $1f$8$ '�
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� DATE OF ISS'UE: d7/16/10 's
� POLICY TSSUING OFFICE: NEW ENGLAND M
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� WC000001 P-33398-E (ED. 6/87) �
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t�o,INl�wb�OB0�4 STAI+TDARD WORKERS COMPENSATION''
AND EMPLOYERS LIABILITY POLZCY
INFORMATION PAGE - RENEWAL ,
��p�� F ����� Cavarage Is Prcwided BY A9s�Y
WC 4 17599 3 07/16/10 07116/11 NA FIRE INS_ CO. OF HARTFORD 026256120
Irnw�ed Md Addreas w�
ITEM SULLIVAN 'S OGERS & GRAY INSIIRANCE AGENCY IATC
1. 330 Route 6a 34 ROIITE 134
YARMOUTH PORT, MA O BOR 1601
OIITH DENNIS MA 02660
02675
i FEIN NUMBER: NCCI CAR.RIER CODE NO: 12238 '
pTHER WORR PLACES 1dOT SHOWN ABOVS: SEE ATTACHED SCHEDIILS(S)
YOU ARE A - CORPORATION/S
2. POLICY PERIOD- 07J16110 TO 07/16l11 12:01 AM STANDARD TIME AT THE
INSUREDS MAILING ADDRESS. �
3A. PART ONE OF TIiIS POLICY APPLISS TO THE i�iORKERS COMPENSATION LAW AND ANY
OCCUPATIONAL DISRASE LAW QF EACH OF THE STATES LISTEQ HSRE:
MA.
3B. PART TWO OF THIS POLICY APPLIES TO �FLOYERS LIABILITY INSURANCE FOR WORR
IN EAGH STATE LISTED IN ITEM 3A: THE LIMITS OF LIABILITY ARE:
BODILY INJ[3RY BY ACCIDBI�'P $5QO,OQO BACH ACCIDLNT
BODILY INJURY BY DISEASE $50Q,000 POLICY LIMIT
BODII,Y INJURY BY DISEASE $500,000 EACH II+IPLOYEE
3C. PART THREE OF THIS POLICY AFPLIES TO O'i'HER STATES, IF ANY, LIST$D HERE:
ALL STATES E%CEPT AR, 13D, OH, WA, W7C AND STATES DESIGl�ATSD IN �
ITII�i 3A OF THE INFORMATION PAGE. �
3D. TfIIS POLICY INCLIIDBS THESE IIdDORSB'dSENTS AND SCH�UI+ES: SEB ATTP,CHED SCIiEDULES j
--------------------------------------------------------------------------------- �
� 4. THE PREMIiTM FOR THI5 PQLICY WZLL BE DETERMINTSD BY OIIR MANIIAI+ OF RIILES, I
CLASSIFICATIONS, RAT�S, AND RATING PLANS. ALL INFORMATION RBQUIRED BELQW IS ,
StTBJECT 7'O VERIFICATION ANI) CHAN(38 BY AODIT. i
ADJUSTMSNT OF PRF.NIItilrt SHALL 88 MADE: AT POLICY B%PIRATION �
CLASSIFICATIEXd OF OPBRATION3 EST ANNNAL ;
PRF.NII[JM �
SEE AZTACIiED $1,424 ;
� PRE�IIUPI DISCOONT 0
,� E%PENSE CONSTANT 338
TBRRORISM PR�tItTM 32
� MINII+I�JM PRffi+tIIIM $277 TOTAL ESTII�IATED ANNIIAL FRENfIDM $1,794
� TOTAL STAT$ TAXES/ASSES�'I�OTS/SURCHARGES $g�
= TbTAL ESTIMATED COST $1,888
DI3POSIT PRF•MIUM $1,794
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� Rogers&Gray tnsurance hg��cy,�:�:.
�1t ACCOIINT NO1rIIBffit: 3009309429 �
� Di,ATE OF ISSIIE: 0?/16/10 . `
� POLICY ISSIIING OFFICE: NLInI ENGLAND � $Y. �`
� COIINTERSIGNED $Y � -- '
�e DATE AUTHdRIZED ENT ;
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� WC000001 P-33398-E (ED. 6/87)
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