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Home My WebLink AboutApplication and WC� CGC�L�MGD � � TOWN OF YARMOUTH BOARD OF HE�,L,TH= � �£�E w . � � APPLICATION FOR LICENSE/P�I'T�201 � � i�� MAY �. y [Ulb � �'" * Please complete form an d attac h a l l necessary�docu�ai�� e��er S 2 �TH D�PT. Failure to do so will result in the return ofyour application packet. � ESTABLISHMENT NAME: TAX ID: � ; LOCATION ADDRESS: 9� G�.G 7 3 TEL.#: �- --oZa � MAILING ADDRESS: ' e, ma B � �. � E-MAIL ADDRESS: _� �a�. _ -�� r7 �� Ce,,t�, � OWNER NAME: � CORPORATION NAME (IF PPLICABLE): Sr�,,oL&t.,rJk.,�,,�- S�-c.� � MANAGER'S NAME: _L-.�,,dL, V1�.air•- � TEL.#: 9Z��3?,S—SS�-z-= MAILING ADDRESS: i�v Ba C��t lv� �rttrf�� 1/h� vu?3 � 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 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. 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. ' 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: 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: 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 file at your place of business. l. 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# L CENSE REQUIRED FEE PE IT B&B $55 CABIN $55 � MOTEL $110 _� INN $55 CAMP $55 SWIMMING POOL$1 l0ea. _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: $is AMOUNT DUE _ $ !!O. 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Workers' Compensation Insurance Affidavit: General Businesses � 3 Aunlicant Tnformation Please Print Le�iblv Business/Organization Name: �c% �h �l�ai�.��, I�'J r�,y�,L��-n s ��t-- .� �6 � Address: `l ,�. �''i�� ac,, �� City/State/Zip: �J�� v �� , �� d�E� �..3 Phone#, y ?�' '3 �'`�"Yv z-- Are you an employer? Check the appropriate bog: � Business Type(required): l.[� I am a employer with �� employees(full and/ 5• ❑Retail or part-time).* 6. ❑ RestaurantlBar/Eating Establishment 2.❑ T am a sole proprietor or parcnership and have nn �, � p�'ice and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. g, �Non-profit jNo workers' comp. insurance required] 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]* 11.0 Health Care ' 4.❑ We are a non-profit organization, staffed by volunteers, i with no employees. [No workers' comp. insurance req.] 12.�Other %-r�-c�•f�-� � ' *Any applicant that checks box#1 must also fill out the section below showing thieir workers'compensation policy information. � ""If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required end such an organization should check box#1. I am an employer that is provtding workers'compensat�on�nsurance for my employees. Bedow is the policy information. Insurance Company Name: l � 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 egpiration date). � Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 a�id/or one-year imp;isonment,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 staternent may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certYfy, under the pains and enalties ofperjury thal the informatton provided above is true and correct. e: � D te: �!!�" /� ne#• ?��3 7S'�4� L . Official use only. Do not write in this area,to be completed by city or town offic�aL City or Town: PermitJLicense# 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#: www,mass.gov/dia � f i � ' BERKSHIRE HATHAWAY ��er's Com�n��n aad Emnlav r�� :��,i��„i ��; , { �UA�Q COMPANIES �°��D insurance Poli�Number�AWC61083n1 '' Renewal af SAWC592556 NCCI No. [258447. ' Paltcy Information Pege i � [1�Named Insured and Mailing Addt�ess /`gEncy � Sandbar Management Inc. CNOICE INSURANCE AGf(UCY PG Box 481 376 Summer Street West Yarmouth, MA 026�3 Fltchburg, MA 01420 � Agency Code: MACHOIIO Federal Empioyer's ID Insured is Corporation � Risk ID Number 825476 I � �' L.ocations on Poiicy (L3) 518 Rt 28, West Yarmou#h, MA 02673 ��tol/2U15- 1o/02/2016) [2� Policy Period From October 1, 2015 to October i, 2016, 12:01 AM,standard ttme at the Insured's mailing address. . [3] Covet�ge - . A. 1Norkers'Compensatton Insurance- P�rt One of thts polky applies to tfie Worke►^s'Compensatton Law of the foilowtng states: Massachusetts B• E,mployer's l[abliity Insurance - Part 7tivo of this pollcy applies to wo�ic fn each of the states listed 1n ttem [3]A. The Hmlts of our Itabiilty under part Two are: � Bodily Ir�jury by Accident-each accident $1,�00,000 ! Bodliy Injury by Olsease-each employee � Bodity injury by Disease- policy limit $1,000,000 { $i3OQQ,000 C. Other States insurance- Part Three of this policy appties to all states,except any state listed In ftem [3]A. and the states of Pforth Dakota,Ohlv, Washington, and Wyomtng. D. This policy Inciudes these endorsements and schedules: See Extenslan of InFormatlon Page�Schedule of Forms •' [41 Premium 'f'he Premtum Basts and, therefore,the premium witf be determined by our Manuai of Rules, Classificattons, Rates,and Rating Plans...AlI r�qutred informatlon is sub�ect to verfflcation and change by audit. (Continued on anotl�er page) - - - Total Estiet�ated Policy Premium # _ Tota1 Surcharges/p�e�� $ Tota! Estimated Cost $ � 3�BNA1.Us� xx _ � :5AWC610831 ��-1' Infprmation Page �� :o9/li/201S WC OOQOQIA MANQTE Zs�ing Offfce:P.O.Box A=H, 16 S.River St�t,Wilkes-Barre,PA 18703-OQ20.veywwguard.com