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Home My WebLink AboutApplication and WC� Gti3�C�C��MGD �* � TOWN OF YARMOUTH BOARD OF HEALTH � � APPLICATION FOR LICENSE/P�'3��T `,2 1� '� ', MAY 19 ZO�s ` , :,; ^_s�; , �"" * Please complete form and attach all necessaryx doc s� `. ? �� p 1 DEPT. Failure to do so will result in the return of your app ica ion pac ESTABLISHMENT NAME:�,�'Lswc-` (,yw��l TAX ID• LOCATION ADDRESS: ..5�� . �. {VYi� o"2d73 TEL.#: Sd�r-?7/ -o t vl MAILING ADDRESS: p 0 p,�-� �/ tu_ l.,,z,,,�,,,,��,�dZ,,G�► �z.��3 E-MAIL ADDRESS: �`o�, G„K�� ,�,,,�, OWNER NAME:_ I�a - � CORPORATION NAME (IF APPLICABLE): Sar-�-�... l�,u�,� T�,.,�.. ? MANAGER'S NAME: TEL.#: �'7� -37�-5�i � MAILING ADDRESS: o ld, _ 0" 73 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) and attach a copy of the certification to this form. � 1. 2. ' 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 1 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 �le at your place of business. i , � � l. 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. 1. 2. � PERSON IN CHARGE: � Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. � ' l. 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. � i 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 remises at all times. Please list our 1 p y emp oyees 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# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE P IT��$ _B&B $55 CABIN $55 �MOTEL $110 � INN $55 CAMP $55 SWIMMING POOL$110ea. _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 bESSERT $40 _TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE _ $ I� O,. 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Check the appropriate bos: � Business Type(required): 1.[� I am a employer with $�� employees(full and/ 5. ❑Retail or part-time).* 6. ❑RestaurantlBa�r/Eating Establishment 2.❑ T am a sole proprietor or parmership 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 exernption per c. 152, §1(4),and we have 10.� Mar�ufacturing � no ernployees. [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 ��s�•.f<'-/ � '"Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. ; "*If the corporate o�cers have exempted themselves,but the corporation has other ernployees,a workers'compensation policy is required end such an I organization should chock box#1. i i I am an employer that is providing workers'compehsation insurance for my employees Below is the policy informat�on. Insurance Company Name: i � Insurer's Address: i City/State/Zip: Policy#or Self-ins. Lic.# Expiration Date: Attach a copy of the workers' compensation policy declaration page(showing the policy number and espiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of cximinal penalties of a fine up to$1,500.00 a�id/or ane-year imp�.sonmcnt,as well as civil penalties in the form of a STOP WORK�RDER 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 certi,fy, under the pains and enalties of perjury that the information provffded above ds true and correct. i e• � Date� �/i f'l Ito ; � P e#• �7�— 37.S�—S'�fo2 � Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/I.icense# ' Issuing Authority(circle one): � i.Board of Health 2. Building Department 3. City/T�wn Clerk 4.Licensing Board 5.Selectmen's Office 6.Other Contact Person• Phone#• www.mass.gov/dia , � BERKSHIRE HATHAWqy • •- �u�R� o�p p�Es nor�UARD Insurance�m D�dV21�a ��s.. .�. .. PoilcyaNumber SqW 610832 Renewai of SqyVC5925S6 ; NCCI No. [258447. ' PoltcY=Morn�ation Page . [1]Named=nsure��nd Mailing Address Sandbar Management Inc. �Y Ayen ! PO Box 48I CHOICE INSURANCE AGENCY � West Yarmouth, Mq 02673� 376 Summer Street � . Fltdlburg, MA 01420 � Agency Code: MACHOIIO �dera�Entployer'a ID ' Risk=D Nun�ber In�u� �� Corporatlon 82547b Locations on Policy �� 5Z8 Rt 28, West Yarmouth, MA 02673 (1p/p1/2015- 10/O1/20I6) [2� Pollcy Period F+nm October 1, 2015 to October 1, 2Q16, 22;Ol,qpq,standard tlme at the tnsured's mailing address, , ��7 Coverage � . A. �o�e�'s'�ompe►'isation Insurance- P�rt One of thfs oH a Hes to the WoHcers'Com Law of the foqowing states; (yassachusetts p � pp s• Employer's LlabiHty Insura�ca .pur��of Lhis oli a Nes to woNc!n each of ��o� !r►Item [3]A. The iimJfis of our itabtilty under Part'fwo arep the states listed ! Bodfly injury,by Accldent-each accldent � Bodlly Injury by Dlsease-each employee $�,000,000 Bodily Injury by Disease-poiiry iimit $1,000,000 $1,000,000 � Other States Insurance-Rart Thrsee of this poltcy appN�s to ali states, except any state�I��d In ftem [3)A. and the states of North Dakota, Ohio, Washington, and Wyoming. �• This policy includes these endorsements and sct�eduies: See�nslon oP infnrmation pa e.; 9 Schedule of Forms .• [47 Pr+e.nnium The Premtum Basls and, ther+efore, the prernium wt(1 be determined by our Manua!of Rwies ClassificatJons,Rates,and Rating Pla�s. .AlI r.�qul� ��adon Is subject to verfflcaClon and audtt. (Continued on anotl�er page)' ' . . change by Total Estimaled Po11�y Premlurt� Total Surcharges�q�ants � . Totaal EetimAtad Cost $ - M�AL_U�XX $ :SAWC610831 page_ 1_ MAN07-E :09/li/20iS Infiprmatbn Page WC OOpp01A ' � I�tuinQ ORlce:P.O.Box p�H�18 S.Rivar Ste��,Wilkea.ga��PA 1 �7'�3-0020�vyy�yy.�Wtd.aon�