HomeMy WebLinkAboutApplication and WC .� �����` �o U$�Y'
� TOWN UF YARMOUTH BOARD OF HEAL'�,�� � �
,,, � � APPLICATION FOR LICENSEl�E�yIl'�'Y 241 �'� �� p� 20i 1 a
...e �� Y,
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* Please complete form and attach all necess docu�e -' '�cem er 1 S 0 _.
Failure to do so will result in the retur�i�your application pac �- � L" ` '�.=�_
ESTABLISHMENT NAME: � ��t S'S�.-��i��t �.���,.L TAX ID:
LOCATION ADDRESS: ��5.� _ —��� TEL.#: �' -3�'Gl--C�� �
MAILING ADDRESS: �� �� . S�f �,� ��-� /�!�- G f�G t�
OWNER NAME: ���L� �,�r.��'�---
CORPORATION NAME (ff APPLICABLE):
MANAGER'S NAME: s ^o-� TEL.#: �'i ? c - �-�
MAILING ADDRESS:
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 tliis foi7n.
1. 2.
Pool operators must list a minimum of two employees cun ently certified in basic water safety,staiidard First Aid and
Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies ofemployee
certifications to this forni. The Health Department will not use past �-ears' 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 establislunents are requued to have at least one fiill-time employee who is certified as a Food
Protection Manager, as defined 'ui the State Saiutary Code for Food Seivice Establishments, 105 CMR 590.000. '
Please attach copies of cei-tification to this applicatioii. The Iiealth Department will not use past,years' records.
You must provide new copies and maintain a file at your establishment.
l. 2.
PERSON IN CHARGE:
Each food establisTunenf must have at Ieast one I�eisou In C11ar�e (PIC) on site duri�i�llours of operation. �
1. 2.
HEIMLICH CERTIFICATIONS: � "
All food service establishments with 25 seats or more must have at least one employee trained in the Hennlich
Maneuver on the premises at all times. Please list your employees trauied in anti-chokuig procedures below and
attach copies of employee certifications to this foiYn. The Health Department�vill 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 #
OFFICE USE ONLY
LODGI\G:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PER�4IT� LICENSE REQUIItED FEE PERiVIIT#
_B&B S55 CABIN S55 I 1�OTEL S55 � �'O �
_INN S55 CAlbIP S5�– __z�___- --- _...S�V�.yI:vIINCrPnC�L_.S.Bp�a__.-- –
_LODGE S�5 �TRAII.ERPARK S10� ��,'HIRLPOOL S3Qea.
FOOD SERVICE:
LICENSE REQL�IRED FEE PERNIIT# LICENSE REQL�IRED FEE PER�2IT� LICENSE REQUIRED FEE PERIVIIT�
_0-100 SEATS S85 �CONTINENTAL S35 �I � _NON-PROFIT S30
_>100 SEATS S160 _COMMON VIC. S60 �'�'HOLESALE S80
RETAII.SER�ICE: —RESID.KITCHEN S80 '
LICENSE REQUIRED FEE PER'�IIT?� LICENSE REQUIRED FEE PER�IIT,� LICENSE REQUIRED FEE PER144IT#
_<50 sq.ft. S50 _>25,000 sq.ft. S225 VENDING-FOOD S35
_Q5,000 sq.ft. S80 _FROZEN DESSERT S40 TOBACCO S�5
�a�-zE cx.�`cE: sis AMOUNT DUE _ � ��.UO �
*****PLEASE TtiR\OVER A\D CO�IPLEI'E OTHER SIDE OF FORJ'I*****
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ADMINISTRATION �
X I
Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal j
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 AND ATTACHEI�
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"i�(�T�L��iN�"3 ty'�'�iE�Lt�1U��I'�T��:S`I'Ar3L�SHMEN`'r�:
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 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 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, 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 De�artment 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.
PC1UL CLO�IN(T: �very out6ioor in ground swirnming puol rr�ust be drained or covered within seven(7) days of
closing.
FOOD SERVICE
SEASONAL FOOD SERYICE OPENING:
All food service establishments must be ins�ected by the Health Department prior to opening. Please contact the
Health Department ta 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 obtamed atthe
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 i
Dessert Permit until the above terms have been met. �
�
OUTSIDE CAFES: i
Outside cafes(i.e.,outdoor seating with waiter/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 prohibited. ;
�
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NOTIC�:Permits run annually from January 1 toDecember 31. IT IS YOUR RESPONSIBILITY TO RETiJRN
THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 15, 2010.
ALL RENOVATIONS TO ANY FOOD ESTABLIS�IlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQLTIl'MENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ;
DATE: SIGNATURE:
-- �
PRINT NAME&TITLE:
io-o� ,n �
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• � �\ The Comnionwealth o M
f assachusetts
Department of Industrial Accidents '
NAfea Nirw�sd��tMrs
600 Washington Street, 7`"'Floor
Boston,Mas� 0211I
Workers'Compensalloa Insarxnee Afiidavft:Bailding/PFambiag/Ekctrical Contractors .
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_a_dd[ess: _yT`��-����--��. _ �4���G"'--- —
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ci T�J�✓�✓ j'G!/jh state: (��- zip: C� I��� LI ohone# � ` �����l0 1 Z �
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work site Iceation(full address):
❑ I am a homeowner perform�ng all work myself. Pro�ect Type: ❑New Constnxxion[]Remodel
❑ I am a sole proprietor and have no one working in any capa¢ity, �gui�ding pddition
[�I am an employer providing workers'compensadon for my employees woricing on this job.
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❑ I am a sole proprietor,geeeral cootrsctor,or homeowner(circ[e on�)and have hired the contractocs listed below who have
the folbwing workers'compensation polices: '
COI�WLY Olal!• .. . . .
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CILY' AI100!� �
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Failve 1r saare orense n reqdr+ed ieda Seetb�2SA�t MGL!32 eu kad b i�e��fQ1siW pnaltla�C a Ane np b f1,3KN aad/K
�3'd�'�mprieo'aeat a�we8 as dH peBaltla in t6e tor�et a 3TOT WORK ORDLA aed a ene d S1U0.0�a day s�inst me. 1 oeden�d that a
npy�[tib�ta�eme,t m�y 6e for+nrded ts tse dAlce�Idv�cstlgaWn of t�e DIA for avera=e veriAa�MN.
!do IFenby cerEffy wnder Nie palws awd e`lties olP�HWr3'tlttt NYe lajonuadto�provlded abo►�e Ls�r+re mrd rnn�ecx
Signature �
Date 1��� � �
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Print narne !'r=o(Z/J ll' Phone#J'�'" ���"' �/ �� �
of8cial ux onty do nM w�ife to thb arca to be mmpkKed by cNy or 6awa oHkial
eity or tawn•
���°"�� OBnidWa Depattment
❑eheck if i�eme�ah re�peme b reqaired ��'�°��� i
QSdectmes's flfBit i
mntad penoa: �Hakh Dq�arf�e�t I
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' WORKERS CON9PENSATlON ANC� EMPL�3YERS' LIABILTY I
INSURANCE POLICY •---lNFe)RMATIO��V P�GE I
fNSUR�R: �I�
POLfCY Pl�. WE083085A
N'ORFOLK & DEDFiAM MUTUAL FIRF INSURANCE COMPAIV"Y
222 AM�S STREET FNDORSBMEN"T EF'F 07jA2J2010 '
DEDHAM, MA 02026 ',
NCCI Company IVo; 21059
Account No:
FEIN:
4TEM 1. i��MED JNSURE[}A.ND MAfL€NG ADDRESS: AG�NT NAME f►ND ADDRESS: '
BA�S RZ'�''ER RECREA�]C�N It3C BENS4N, Y0�7NG & DOWNS ZNS
?3 SdUTH SHORE DRIVE AGCY i
Sc�UTH YARMUUTH MA 02564 565A RC?UTE 2� '
Important Po �ox �ss
PLEASE AFTACH TN(S �RW 2 CFi PO]2T, MA 0 2�4 6
ENDQRSE�VIE11tT AGENT NO.: 2�?413
TQ YOUR POLfCY
LEGAL ENTlTY: CO1tPORATIQN
!
OTF�ER WORKPLACES NOT SHOWN ABOVIE: (See Workers Compensation Classification SchEadul�) �
tTEN!�. POU�CY PERlC3D: From: 07/12/2010 To: A7/12/2Q11 �
Effective 12:01 A.M. Stan�ard Time at ths lnsurad's maiPing address. ;
lTEWt 3. COVERAGE:
A. Workers Compensation lnsurance: Part One of the palicy applies to the V'�orkers Comd�ensatic7n Law of the �
states 4'sst�d here: �
N!A
I
8. Employers' Liability Insurance� Psrt Two of the policy applies to work in each state iisied in item 3.A. ThE limits !
c�f liability und�r Part Two are: �
i
Bodily Injury by�ccident� $ 5 0 0, 0 Q 4 each acci�ent
Bodily lnjury by Disease: $ 500, D00 policy I;mat '
Bodily �n�ury by�Jisease: � �4 Q, p�p p each employee
r':__ , �r 5tates-lnsurance:-PariThree_of th�-poli�Y-�p�zl+��to.the statss_, if ar�y,fEsted her�,: �
J SEE ENDORSEMENT WC 20 03 06 A --- - ;
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D. This Policy i�cludes these Enaarsements and Schedules: �
�es Schedule of Forms and Endorsements.
i
iTErVI�4. PREMlUM: The premium for this Policy wiiP be determined by our Nlanuals of Rules, CE,�ss��ications, Rates an� ,
R�ting Plans. Alf �nformaiion required on the Woricers Compensation Classificatiorr &chedule i;�subject to
verification and chang� by aesdit. ,
Tatal Estimated
P,Ainimum Premium: $ 234 Annual Premium: $ l, t}30
Aud+t Penod: ANNTJAL Additional t Return Premium: $ ��g �1�ITIONAL
Comments; CHANG� PAYR4LI, PSR At7DZ�`
l�supd At: �
Date� 09/.02 j2010 Countersigned by � ,
WC{30�n 01 A Capyright 1987 Nationat Courtcil on Compen�atian Insurance
iNSUREU COPY