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HomeMy WebLinkAboutApplication and WC � � F...��.�.� � I -_ �� i �' � � • TOWN OF YARMOUTH BOARD OF HEALTH � �.�Ti�Jao�j i � � APPLICATION FOR LICE . EI�'�T,�,r20�2, MAY 0; Zi�iZ , �..� �- -:>� �� * Please complete form and attach all ne r "' ,� ts��� ce beir! - �=:��, Failure to do so will result in the p on p . ! 4 I ESTABLISHMENT NAME:���•cJ��v��i� ,Gt�;�•r' i Ntt/ T��ID• LOCATION ADDRESS: 9ln/ MA�'�v <'T �'� .�Yr TEL.#:r�SD�,) 3��r~ fs"�1 Z-- , MAILING ADDI2ESS: �i�'- � i OWNER NAME: i CORPORATION NAME(IF APPLICABLE): ,n/ -t ,t/ ,�2�-�L:�!%�tl� r ' MANAGER'S NAME: ,Gt�. TEL.#: Ci'0� )�� ��C"/2_ i MAII.ING ADDRESS: M�� TU�/ �Z h C����••J� Y ��r r��'7� 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. �l�r-�.r,�3.. t,�if�.C/'�-� 2. , Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of employee certifications to this fortn. The Health Department will not use past years' records. You must provide new copies and maintain a�le at your place of business. � � 1. jLlGr�F /� r�/�Y�h� 2.�'S T�f�_� Ki ;�/ � 3. Mi�t./,r.� lCir;�� 4. � 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 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��st ye�s'reea�€��. ' You must provide new copies and maintain a�le at your establishment. � , L 2. i � ___�'ERS9N�T_CHARGE: � —_ _ ___ -- - —_ _ Each food establishment must have at least one Person In Cliarge(PIC� on site riuring hours of operatiou. ; � l. 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# I � OFFICE USE ONLY ' LODGING: i LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&B $SS _CABIN $55 1,MOTEL $55 �2'��9 _INN $55 _CATviP $55 � ��V;��fiLIL'dv r�O�L $SGEa. �Z Z _LODGE $55 _TRAII.ER PARK $105 �WHIRLPOOL $80ea �Z�3Z FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _0-100 SEATS $85 �CONTINENTAL $35 �2��� _NON-PROFIT $30 , _>100 SEATS $160 _COMMON VIC. $60 _WHOLESALE $80 ' RETAIL SERVICE: —RESID.KITCHEN $80 ', LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# li _<50 sq.ft. $50 _>25,000 sq.ft. $225 _VENDWG-FOOD $25 I _Q5,000 sq.ft. $80 _,FROZEN DESSERT $40 _TOBACCO $95 NAME CHANGE: $is AMOUNT DUE _ � a S�• OC� i *�***PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM**�** ' i i ADNIINISTRATION , 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 COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED ANll SIGNED, OR � t CERT. OF INSURANCE 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 ��O�EY.S �P� Q��T��LQrT�GIi�T�ES'�'�iBI.I��I[1VIENTS � 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 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, shall generally be considered Transient. POOLS � POOL OPE1vING: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 ; - prio:�o�e�i�.PLEASE NQTE:People are NOT allowed to sit 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 ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE SEASONAL FOOD S�RVICE 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 Yarmauth Ynust 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: i Frozen desserts must be tested by a State certified lab prior to opening and monthly thereafter,with sample results i 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. i OUTSIDE CAFES: Outside cafes[i.e.,outdnar s�ating�vitl�wa�te�lu�aitx�s�seruir.�),�usr_ha�}�r�r��pr�u�frem�t��-�c��d�€��it�:--- OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prolubited. ; � i NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN � I THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 15, 2011. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQU�'MENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIR�A SITE�N.�� � DATE:� / �- SIGNATURE:_ _`,�j 1%' �'� '~-- PRINT NAME&TITLE: °� �'�1�-�-1%�� f-�v}�,v�-,l ; � Rev.]0/25/I 1 l i _ � r R i � . '�`"� The Commonwearlth of Massachusetts . Department of Industrial Accidents > < �N�tMrs : . 600 Washington Street, 7`"'Floor . - __. , ' Boston,Mas� 0211�1 . . . ` _. . Worl�ers'Compeesatios t�uaraace AfRdav,it: _ .. � ,_. .•- . , ; . An�Ne�at i�firmatMa: Plea�e PR�1T le�ibN- : : . .. . _ • •. . . _ natne• address: cit� state• zio: phone# work site lceation(fiill addresslc ; ❑ I am a homeowner performing all work myself. ' ❑ I am a sole proprietor and have no one working in any capacity. i I � I am an einployer providing workers'compensadon for my employees working on this�ob. � _- , >.. _ ,__ L . ., _ �-- - - Y:���#�� - l_ � co �-�' ' '�-� /"U ��"/�`f�J ' ' _ __maav nme: Ltf7?9l�' O � � ' ". , . ` _ a�- �'(� � � T �� ' citv: �o �. �/N'�M c�ct 7'1'f oiwse N: St9� �G/� �S�S" j� �.�a.ee rn.�T'�.ne�ol c��.r rt,�r e:rx:-�r�f NS p�lkt# f ��o c� J � O�o�ti- C c� � .� /( ; _ ,... ,. i � I azn a sole proprietor,geoeral co�tractor,or Iwmeowser(cirde owe)and have hirad the contixtas listed below who have ; the following warkets'compensation polices: � �` � . ;. �. � ._ . ; CO'IUi�Y ri�ll: ._ ... . . , �. . . , . . . � � � � ..: . ,: : �. . - ;:,:�.... . ,, j fd�f: � CI�Y' Dt9N!N' .� j�30'f�Cl.'C0. � � . � � . . �(Ci� . � � : . .. . � . i � �O'ID1��vm!' � � �d1'H1: i .xi� cit,- olo�e�• , - — __-- ---_ _—_ __ _-- ____ ---- ____ �__ _�__-- — — — - j iAM�e1���iYiYi�rt�a�e�� ooliev f! ' � Fsil�re 1�seese or�era�e a reqdred�adv 3eetlN 2SA�[MGL 132 ea�Ind a tre��t�l�al pwNia�ta A'e�p b il.3N�N aadl�r f ooe qan'imptiw��t n wd as dv�pe�altla h the t�r�ot a 3TOt WORK ORDER ud��e ef t1M.N a day apiet se, i�mh�d t6at a � cepy o[thb�tate�e�t my 6e firwawlcd 1s Ne Omee a[loratlpWm o[1ie DIA hr e�reraae ve�lAeatlw. F /!o bertby cerBjy xwder�e poiwJ !pes� ojperjwry tl4�t tlYe lwfonwetlo�provlred aboae!s ea�e owd mrt ; Signahue -7 Date .�' �� � /`Z. � � Print name ��/`.�1�-� �CJ`�i�-�/t Phone# �S�_�a���f I �Z._. � —,. = ef�cial ux oaly� do net write li t6lt�arei to be ce�picted by eily or 1�we s�i , . ' s . cily or Eown: , permitltleeme# �Boidbqs pep�rbneut. ����� ❑eheek if immc�le reapeme is reqoirsd �Sekrtu�n's(M6te i �deallY De�arteest I cantact penea: pYae#; QOIbe (mricd Sryc ZAOr!) � �.. . _._ .. ..... . I VDA� . � � � ���R� WORKERS COMPENSATI�N AND I EMPLOYERS LlABI�.ITY POLICY TYPE AR INFORMATION PAGE WC 00 00 Of ( A) POLiCY NUMBER: (6560U6-0694C06-5-t 1 ) Ij RENEWAL OF (6S60UB-0694C06-5-10) � � INSIlRER: HARTFORD UI�ERWRiTERS INSURANCE COMPANY � � ; NCCI CO C�DE: 8041 1 ! �- � I INSURE�: PF�GIDUCER: � ; BRENTWOOD N�TOR It�i`INC DOWLIMG & ONEI� INS AGCY ' 961 ROUTE 28 973 I YANNOUC�i RO 5 YARMOUTH MA 02664 HYAI�VIS MA 026�1 InSured (s A CORPORATION ' i Other work ptaces and identfficatian numbers are shawn in the schedule(sJ attached. j 2. The policy period is from 08-16-11 to 0$-i�-12 12:01 A.M. at the I�sured's mailing address. � { 3. A. W�RKERS COMPENSATION INSURANCE: Part Qne af the pollcy appl?es ta the Workers � Compensation Law of the state(s) Iisted here: � •� � j ao� g, � EMPLOYERS LIABfLITY INSURANCE: Part Two of the policy applies to work in each state Eisted in ! '°'—"" item 3.A. Th�Ilmits of our liability under Part Two are: ( o� Bodily inJury by Accident: � 100000 Each Accident ; „�,_ 8odily In�ury by Dlsease; � s80Qoo PWlcy Limit I �"` Bodily In�ury by Oisease: � t o000o Each Em�oyee � a= � C. OTHER STATES INSUF�4NCE: Part Three of the policy appiies to the states, if any, listed here: i � COVERAGE REPLACED BY EI�ORSEMENT WC 20 03 06A 4 ��� �� � ��� �,—� ..�. Q— D. This policy inciudes these endorsements and schedules: .�.. o� SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE o` 4. The premtum for thfs policy wiil be determined by our Manuals of Rules, Ciassiffcations, Rates and Rating �,� F1ans. All required information is subject to verification and change by audit to t�e made At�A��v. � � ..__. QATE OF ISSUE: 07-28-11 WC ST ASSIGN: MA OFFICE; OR�ANDQ DA HTFD 05G �' PRGIDUCER: DOWL I NG & ONE I l I NS AGCY 76RPkJ ooaaee "