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HomeMy WebLinkAboutApplication and WC r .. ,; .l5�-• O c-E1��.1 C�,$ � � TOWN OF YARMOUTH BOARD OF HEALTH Gd����GM�D ' � � APPLICATION FOR LICENSE/PERMIT-2016 ' �'"' * Please complete form and attach all necessary documents by Decemb r IS���1�< <��� ; ' Failure to do so will result in the return of your application ck t. HEALTH DEPT. ' ESTABLISHMENT NAME: TAX ID: � I LOCATION ADDRESS: Y� �- TEL.#: MAILING ADDRESS: �OS E-MAIL ADDRESS: OWNER NAME: ' CORPORATION NAME (IF LICABLE): '! MANAGER'S NAME: Lt � 1 /9- TEL.#: 5 ; MAILING ADDRESS: �'1�- ' PdOL CERTIFICATIONS: ; The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated � Pdol Operator(s) and attach a copy of the certification to this form. ; _�_�� __ /� �Q 1.- 1"G�',��C — . �fr Ur/`I �__ 2.J��1 �[� Y1_f.7 t /1(J t�l^�� 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' ords. You must provide new copies and maintain a file at your place of business. i �� �� ���-� 0 r ��1� r�a�n� , ,�dv��- 'i 1. �T!� � "� 2. ;,� � 3. 4 G' ' 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. � Al�1. 2. c !" PERSON iN CHARGE: �Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. !' -- _1. __— ___ ---_ __ __ �_ 2 __ __._._______ _ . C A,LLERGEN 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. i RESTAURANT SEATING: TOTAL# : - --- _ --- nr,r.7r� - - 1 - LODGING: ' ! LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# ; B&B $55 CABIN $55 MOTEL $110 ' INN $55 CAMP $55 =SWIMMING POOL$i l0ea.��j �' _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 UIC. $60 WHOLESALE $80 — —RESID.KITCHEN $80 � RETAIL SERVICE: ' LICENSfi REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# i <50 sq.ft. $50 _>25 Q00 sq.ft. $285 VENDING-FOOD $25 i =<25,000 sq.ft. $150 —FROZEN DESSERT $40 TOBACCO $110 — ; NAMECHANGE: $is AMOUNTDUE _ $ //O .00 ' *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** L � 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 not havje a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORK�R'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR I CERT. OF iNSURANCE ATTACHED OR II � � WORKER S COMP. AFFIDAVIT SIGNED AND ATTACHED 'I Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: � YES� NO MOTELS AND OTHER LODGING ESTABLISHMENTS � � TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be i 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 thirly(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 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 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 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 obtamed at the Health Department,or from the Town's website at www.varmouth.ma.us under Health Department, Downloadable Forms. FROZEN DESSERTS: 1 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 i 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 15, 20�15. 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 COMMENCEMENT. RENOVATIONS M QUIRE A SITE PLAN. � DATE: ���"�f� SIGNATURE: PRINT NAME& TITLE: �`� �� Rev. 10/01115 � ������� � ; � � The Commonwealth ofMassachusetts Department of Industrial Accidents � " Office of Investigations ' ' 1 Congress Street, Suite I00 � Boston,MA 02114-2017 ' www.mass go�/dia � Workers' Compensation Insurance Affidavit: General Businesses ; A licant Information Please Print Le 'bl � Business/Organization Name: �a � � �� � ; Address: �p y City/State/Zip: �/'!/1d�1 hone#: Are y u an employer? Check the app priate boz: Business Type(required): 1.[q�I am a employer with�_employees(full and/ 5• ❑ Retail - �_.vr=a�t-=�'—"'e�* - ---- -- _ ___ __ _ 6. ❑ RestaurantlBar/Eating Establishment _ _ _ - -- - 2.❑ I am a sole proprietor or partnership and have no � - - 7. ❑ 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 exemption per c. 152, §1(4),and we have 10.0 Manufacturing no employees. [No workers' comp. insurance required]* 4.❑ We are a non-profit organization, sta.ffed by volunteers, 11.0 Health Care _ with no employees. [No workers' comp. insurance req.] 12•C�YOther �� C� �Uh i *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#L I am an employer that is providing workers'compensation insurance for my employees Below is the policy information. Insurance CompanyName:__ �r i/�j �C/�vf�-� �j�s Cn Insurer's Address: /�'� �� - i City/State/Zip: /f / �{/� ?j -- � g `7O� Policy#or Self-ins.Lic.#�/`T w �— �d --��� � 7� �l�Xpuation Date: Attach a copy of the workers compensation policy declaration page(showing the policy number and ezpiration 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 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 sta.tement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify,under the pains and pen 'es of perjury that the information provided above ts true and correct. Si atur . � � ,�� / Date: /�J Phone#: ��` lQ�—,� S� Official use only. Do not write in this area,to be completed by city or town official City or Town• Permit/License# ' Issuing Authority(circle one)c ' 1.Board of Health 2. Building Department 3.City/Town Clerk 4.Licensing Board 5. Selectmen's Office ; 6. Other i Contact Person: � Phone#: � www.mass.gov/dia � I � WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE A.I.M. Mutual Insurance Company 54 Third Avenue, Burlington, Massachusetts 01803-0970 (800)876-2765 NCCI NO 26158 POLICY NO. AWC-400_7008176_2016A --- -- --- -- - PRIOR NO. ,AWC-400-7008176_2015A ` ITEM _ _ 1. The Insured: Great Island Ocean Club Homeowners Association Inc DBA: Mailing address: P O Box 684 FEIN: **-`*• W Yarmouth, MA 02673 Legal Entity Type: Corporation Other workplaces not shown above: See Location 2. The policy period is from 05/25/2016 to 05/25/2017_ 12:01 a.m.standard time at the insured's mailing address. 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers'Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A. The limits of liability under Part Two are: Bodily Injury by Accident $ 100,000 each accident Bodily Injury by Disease $ 500,000 policy limit Bodily Injury by Disease $ 100,000 each employee C. Other States Insurance: Coverage Replaced by Endorsement WC 20 03 06 B D. This Poticy includes these Endorsements and Schedules: SEE SCHEDULE 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. _. __ __ Classifications — ! --- _ __ Premium Basis - Rates _----------, , _. _ _.____ ----- __--- ---; � Code Estimated Per$100 i � � No. Total Annual Estimated � Of Annual ( _—.._---—---- _. __._.. Remuneration Remuneration Premium _._.. ___. . i � INTRA 295860 � I I I NTER SEEI C�AS I I I S CODE SCHEDU�E i I ------..__. __..___ I � - --_ _l.__ ___ I _..__ ----�-- _._. _._ _.._---._ Minimum Premium $284 Total Estimated Annual Premium $614 ' � GOV GOV Deposit Premium $634 �STATE CLASS ' MA 9015 ; State Assessments/Surcharges $341.00 x 5.7500% $20 This policy,including all endorsements, is hereby countersigned by ��+"��"'�`"�`...�-�� 04/29/2016 __._ __ Authorized Signature Date Seroice Office: A N Nunes Agency Inc 54 Third Avenue P O Box 627 Burlington MA 01803 Bristol, RI 02809 WC 00 00 01 A(7-11} Includes copyrighted material of the National Council on CompensaHon Insurance, used with its permission.