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HomeMy WebLinkAboutApplication and WC ._, � TOWN OF YARMOUTH BOARD OF HEALTH � �-�� �`�'`'� � � � APPLICATION FOR LICEf�T � ;: _,, �� � uAN 0 9��Q14 � �'" * Please complete form and attach a11 necessary dc��n�ts by� ec Failure to do so will result in the return of your applicat . � ESTABLISHMENT NAME: G� • I', LOCATIONADDRESS: �'�f' �!Z TEL.#: �''����t'� MAILING ADDRESS: i���'''Z ��'�l'f��„� i E-MAIL ADDRESS: � ' OWNER NAME: � CORPORATION NAME (IF AP] ICABLE): I MANAGER'S NAME: U TEL.#: d�'Q� - i MAILING ADDRESS: � 1 ; I POOL CERTIFICATIONS: � The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool ; Operator(s}anc�at#a+c�r a copy of the cer�ification�o this form. - 1. 2. I , Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and j 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. ' i L 2. � 3. 4. i ; t � FOOD PROTECTION MANAGERS - CERTIFICATIONS: i All food service establishments are required to have at least one full-time employee who is certified as a Food Protection k Manager, as defined in the Sta.te 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 IN CHARGE: Each food establishment must have at least one Person In Charge (PIC)on site during hours of operation. _ 1. 2. _ -? ALLERGEN CERTIFICATIONS: i 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. ; � HEIMLICH CERTIFICATIONS: f All food service establishments with 25 seats or more must have at least one em�loyee trained in the Heimlich Maneuver on the premises at a11 times. Please list your employees trained in anti-cholcing 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# � - - � OFFICE USE ONLY ' LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PE IT# , B&B $55 CABIN $55 �MOTEL $55 ��i -o�k�1 j INN $55 CAMP $55 SWIMMING POOL $80ea. i LODGE $55 TRAILERPARK $105 WHIRLPOOL $80ea. , FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FFE PE�I .# LICENSE REQUIRED FEE PERMIT# ', 0-100 SEATS $85 �CONTINENTAL $35 �t�`�5 NON-PROFIT $30 ; >100 SEATS $160 COMMON VIC. $60 WHOLESALE- $80 I — — —RESID.KITCHEN $80 i RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# ? <50 sq.ft. $50 >25,000 sq.ft. $225 VENDING-FOOD $25 =<25,000 sq.ft. $80 —FROZEN DESSERT $40 _TOBACCO $95 NAME CHANGE: $is AMOUNT DUE _ $ �(t7,Op � *****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 nof 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 OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES� NO I � MOTELS AND OTHER LODGING_ESTABLIS�MENT�_ _ ___—._ _ - i - - _. _ ------------__ _ _ 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 tliiriy(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 sha11 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 srt 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�round swimming pool must_be drained or c4v��i within s�ven (7�_slay� of---- � ---------_____ --- - . _ - - c�osing. ---- -- ----- ._-- __ --_ __ F(�(�IS S���ICrE . _ _ _ _ _ ---- _ _ 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 RETURN THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 13, 2013. 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 COMMENCEM NT. RENOVATIONS MAY REQUIR�A SIT PLA . DATE: l � � SIGNATURE: � � �� PRINT NAME&TITLE: ��/�/Z� Q�-� ld ��"�'r - l>l�✓'*� Rev.10/08/13 ; � � The Commonwealth of Massachusetts Department of Industrial Accidents r Office of Investigataons � 1 Congress Street, Suite 100 Boston,MA 02114-2417 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses A licant Information Please Print Le 'bl Business/Organization Name: �G ����`�`�! Address: � �- �cdL� City/State/Zip: �d� C51.� hone #: �"�¢r "��� Are you an employer? Check the appropriate boz: Business Type(required): l.❑ i am a e�nployer�vith employees(ful��d! 5. ❑ Retail _ __ or part-time).* 6. ❑ Resta.urantBar/Eating Esta.blishment � 2.❑ I am a sole proprietor or partnership and have no �, ❑ Office and/or Sales(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 organization,staffed by volunteers, �G�� with no employees. [No workers' comp. insurance req.] 12.[�Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. **If the corporate officers ha�e 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 providin rkers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: ���� rG1�C �=�Cd � !�G c��.f Insurer's Address: � � X L 1^o City/State/Zip: � d � > r � � i Policy#or Self-ins.Lic.# �? ��� � �� ��'� ��� Expiration Date: 7 � ! .. Attach a copy of the workers' compensation policy declaration�page{s3�owing the poZicy nuffiber and eggirati�n date). , Failure to secure coverage as required under Section 25A of NIGL c. 152 can Iead to ihe imposition of criminal penalties of a ; fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine 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. � I do hereby certify under the pains nd enalties ofperjury that the information provided bove is true and correct. ,L � Si ature: Date: � � �T ! � ; � Phone#• ������'�'�� i � Official use only. Do not write in this area,to be completed by city or town officiaL City or Town• �ArIZMl�t7'i'M Permit/License# � ircle one): I 1.Board of Health .Building Department 3. City/Town Clerk 4.Licensing Board 5. Selectmen's Office 6.Ot er � �� Contact Person: Phone#: �B-v?QB-��I X lZtf'l ' www.mass.gov/dia � TRAVELERS� . -� �. � � - . Wt�tKERS COMPENSATION -'- ; . . � � ANa . � � EIIAPLOYEHS LIABlL17Y PQLlCY` � . � � 7YPE AR INFORINATION PAGE WC 00 00 01 { Aj � PO11CY NUi1�BER: (6HUB-5B48924-7-f 3) . � REPEWAL OF (6lQJB-5648924-7-12) . - � IN3tJRER: � �avF��Rs in�Nvi�nr c�a�w oF ar�RicA . 1. . . . NCCI CO COQE: 1343s � INSURE[�: . " PRODUCER: Bass R=vER aEca�arroN iNc eENsav �ou� � oowNs inis � 73 SOU7H SI�E DRI VE . � P 0 BOX 1 S8 BASS RI Yf R MA 02664 - . HARMII CH.P6RT N!A 02646 . j' I�ured Mt A (�2PORATI�1 � � . / Other w�k piaoee and Identlfica�lon�numbers are�own In the schedule(sj attached. . 2. Ttla�1diCy p6tbd ie fr�m 47-13-!3 t�D 07-13-14 12:Oi AM.ffi tl�IneUr�ed'S m8ling addree8. . � 3. A. VI�RKERS CO�APENSATlON fNSURANCE: Put.One d the�IcY aPpites to the 4Vorkers Cornpenaedlon l.aw d tl�e s�e(s)I�d Fisr� . .- MA . . . � . � , . �- .� - . . '� B. �MPLOYEHS LUIBIL.ITY INSURANCE: Part Twa d ttre pollcy appiies to arork In each gtate ltsted ln - � i�em 3.A. The E1mRs of our Ilabuky under Part 7wo ar+� � � Bodly l�ury by Aoclderi� S 500000 Each Acdder�t � ��Y�M�I►bY�Iseea� S. �500000 Pd�y Limlt - � Sodly Injuty by Dl�eese: S � 500000 Each Employe� � C. 07HER 8TATES INSURANGE Part Three of the Pdlc�l aPP�lee to the statee� �any.ll�ed here: -� COVERAGE It�PtACED 8Y EI�DORSE[�IENT U1C 2p p3 p6p .� . , . � . .. - . , : . , , : � • � . �'� D. Thls�IICy h�dudes theee et�or�ements snd scFted�ee: : . �. �,; a� SEE �ISTING OF EI�2SE�ENTS - EXIENSION OF INFO PAG'E a� - . - , ..�, 4. The pr�eminm for this pall�y vWll 6e debermirasd by our Man�ls of R�es, � � Plans. All requlred(nbrmption(s�bJect to verMlcatbn an�chenge by audit�o be made AI�IUA�Y�� . •� ' . � . . . ou►�oF�uE: o�-os-�� wc sT assic�: ru� � QF'�lCE: dZtAPDO IMUS /►Ff 16i PRODtJCE� �NSOW YOI�IG & DOMMS INS 261�A1 - ooanst � � � .