HomeMy WebLinkAboutApplication and WC �
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- �� � TOWN OF YARMOUTH BOARD.,�F��AY.�TH � ' Q �`��
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= APPLICATION FOR LICENSE/P����.�0 ��,�� � �
e � ` �YV"'
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* Please complete form and attach all necessary d�cuments by Decemb IS�2010. ''" �r
Failure to do so will result in the return of your application pac t. HEALTH ���:
ESTABLISHMENT NAME: �a�- � TAX ID: - � �
LOCATION ADDRESS: p ��r EL.#: 3�8"- �'`'J
MAILING ADDRESS: `� - ",
OWNER NAME: � , ,
CORPORATION NAME (IF APPLICABLE): ���--
MANAGER'S NAME: �o/%���-- �oX TEL.#:��17D-�/37
MAILING ADDRESS: ���.� '
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated
Poal Oper�itor(s) aud att�ch a copy of the �e�-tification to this form. _ __, �
l. � 2. �
Pool operators must list a minimum of two employees cun ently certified ui basic water safety,standard Fu st Aid aud
Community Cardiopulmonary Resuscitation(CPR). Please list these employees belo�v and attach copies of employee
certifications to this foi�rn. 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 aze 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 Seivice 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 iood esta�ilislunent must liave af Ieast one Person In Cl�ai�e (PI�j on site cturuig houis of operation. �
L 2
HEIMLICH CERTIFICATIONS:
All food seivice establishments with 25 seats or more must have at least one employee trained in the Heimlich i
Maneuver on the premises at all times. Please list your employees trauied 'ui anti-choking procedures below and '
attach co�ies of employee certifications to this foi�n. The Health Department will not use past years' records.
You must provide new copies and maintain a �le at y our place of business.
1. 2.
3. q.
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RESTAURANT SEATING: TOTAL # �
OFFICE USE ONLY '
LODGI\G:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERivIIT# LICENSE REQUIRED FEE PERMII'� '
_B&B S�5 _CABIN S�5 MOrEL S55
_INN S55 _CAMP S5� S��'LVI.�III�1G POOL S80ea.
_LODGE S55 `TRAII.ERPARK 5105 _��'HIRI,pOOL S80ea.
FOOD SERVICE: !
LICENSE REQUIRED FEE PERI�IIT# LICENSE REQUIRED FEE PERi�1IT� LICENSE REQUIRED FEE PERMIT� '
_0-100 SEATS S8� _CONTINENI'AL S35 NON-PROFIT S30
_>100 SEATS S160 _COMMON VIC. S60 `�'HOLESALE S80 '
RETt1IL SERVICE: —RESID.KITCHEN S80 f
LICENSE REQUIRED FEE PER�IIT# LICENSE REQUIRED FEE PER�'�IIT� LICENSE REQL?IRED FEE PER�III'?? j
_<50 sq.8. S50 >25,000 sq.ft. S225 _VENDING-FOOD S25 i
�<Z5,000 sq.ft. S30 (� O rFROZEN DESSERT S40 �TOBACCO S» �(��ZD `
���zE c��cE: sts . _. AMOUNT DUE _ $ l 3S.00
***�*PLEASE TL�R\OVER A\D COVTPLETE OTHER SIDE OF FOR�I*****
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ADIVIINISTRATION
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 AND SIGNED, OR
CERT. OF INSURANCE ATTACHED
OR
WORKER'S COMI'. AFFIDAVIT SIGNED AND ATTACHED �
Town of Yarmouth t�es and liens must be paid prio to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES NO �
f
itiI(�'l�'�LS AND (�TtIER i.dl�'�a���i'v'Z� E�TARLISHM�NTS
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 sha11 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 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
pnor to opening.PLEASE NOTE:People are NOT allowed to sit 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 i
by a State certified lab, and submitted to the Health Department three (3) days prior to opening, and quarterly i
thereafter.
�'GUI.CIi.O�yNG: �very 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 ins�ected by the Health Department prior to opening. Please contact the
Health Department to schedule the inspection three(3) days prior to opemng.
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 obta.ined at the
Health Department,or from the Town's website at www.yarmouth.ma.us under Health Department,Downloadable
I 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
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 ofHealth.
_ _ _ _ _._ —
� OUTDOOR COOHING:
Outdoor cooking,preparation,or display of any food product by a retail or food service establishtnent is prohibited.
;
� NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILTTY TO RETLJRN
+ 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
; EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TI-�BOARD OF HEALTH PRIOR
TO COMMEN EMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
� DATE: /� U /� SIGNATURE: �
3
PRINT NAME&TITLE: Rich rd ourrner
ax ager
10"06'10
�
� The Comnionwealth o '
f Mrissachusetts
Departme�et of Industria!Accidents
�aar�
600 Washington Street, 7`"'Floor
Boston,Mas� 02111
Workers'Compensatioa Insarance Aflidavit: gaiidiag/Ptambin�/Electrical Coatractors
name: i.�.✓V� L!' l CL✓1 � Gt.d"V1�1� yi G
addrtss: _� Q_S S i Y1�_
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ic�t {�C.�Y1'l i d1A l�l 1 Wl state l' Y 1 zan ���,�i honc#������ ����
work site locahon(full addressp
Lj I am a homeowner perfornung all work myself. Pro�ect Type: �New Constnrction�]Remodel
❑ I am a sole proprietor and have no one working in any capaci st cti
h'• ❑Buiiding Addition
('�I am an employer providing workers'cornpensation for my empioyees wodcing on t6is job.
I/ � /� � �
wm �ame: ��/✓l J � til't 5 � � 4,� '�
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et ��i-m e M: �
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❑ [am a sole proprietor,geaeral costractor,or 6omeo�vner(czrc%owe)and have hired the contractots listed below who 6ave '
the fo(lowing workecs'compensation polices:
oomn.nv aamr
addres�-
citv;
naoee!t
iaaaraoee ee. #
com��•
address:
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A11�d!tii��!iut�te� � i
Failvr 0�saare orwa�e as reydred�edv Seetfoa 23A�f MGL 152 eu Ind b He I
�P'��vi�Wl pmMin�t a�e�p b i1,3KM aad/�r
°k Y�n'�aprLoo��nt as weY as e1H pemltln h tAe fir�ata STOl WOR�C ORDBR asd a�e dSlA�.N a dap a�ai��e. !o�deisOiW tbat a
�ry�[tht��tahme�dy be f�rwarded�s tAe Oetce et Isve�Wd of t6e DIA far e�rerase veriAeatlN. �
/�o herrby certf,fy weder NYe pelw d nalh' of rJa tkot t iafonw�/on prov�ded above fs brre awd rrect �
Signature
Date �� �
Print name Riehard Fo er f
Phone#
ofBelai ux oNy d0 aM w�rke ia thh arra ta 6e mopleted by dly or bwio oBkiai . �
dty or tawn:
p�noiNkeme# Q�ll���a B�earrd�nt
Q eheck if imme�abe r+eepeme b reqaired
OSdeeheea's(lf8ee
rnntad penoo: phoee p� ����r���
t�e s�mm�
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, � The �'ommonweatth ofMassachusettr
Depm�ment of Indu.strial Ac�idents
Offace of InvestibQutions
600 Washington Stred .
Boston,MA 02I11
I . www mass gov/dia
' . Workers' Campeasation Insuraace A�davit: General Businesses '
Anpiican�Informa#ion Please Print Leaiblv
Busines5/Or� ni�ation Nam.e: C�ERLAND FARMS , INC.. ,
Address: 100 CROSSING BOULEVARD
City/State/Zip: FRAMINGHAM , MA 01702 Phon.e #: (508)270-1400
Are you an employer?Check the apprapriate boz: $nsiness Tppe(requiresi):
1.� I am�,employer with 6�09 2 e�mployees(fuIl and/ 5, �Resail
or part-time).* : ` ' b. ❑RestaurantBar/Eating Establishment '
2.� I am a sole proprietor or parinership and have no �, �Office and/or Sales(incL real es�te, auto,etc,)
employees worldng for me in any capacity. g Non- ofit
[No workers' comp.insisan.c�required] ❑ �
� 3.❑ We are a corporation and its officers have exeraised 9. ❑ Entert�ainment '
thefr right of exemption per c. I52, §1(4),and we have 10.�Manufact�mg
no employees. jNo worlcers' comp.insurauce required]* 11.Q Health Care
4.❑ We are a non-profit organiz�tion,s�taffed by vohmteers, .
with no employees.[No workers' comp.+7+�,+�*+ce req,] 12.❑ Other
'�Y aPPjicant that ch�hox#1 must slso fill out thc section belaw•showing their workers'campcnsati�policy informstioa,
**If the corporate o�ccs have exanpte�i themselves;but tUe corporation has ot}�er omp3oyxs,a workers'compeasation policy is required and such m
or�tanization should c3ieck box#1. • .
I am an e�nployer that is provid'ing workers'campe�rsation msurancP fo'r rny emplvyees, Beiow is ihe policy in,formafion.
Insurance CompanyName: ILLINOIS NATIONAL INSURANCE C�MPANY
Ins�er's Address: 50 KENNEDY PLAZA / lOth FLOOR
City/State/Zip: PROVIDENCE , RI 02403-2393 '
PoIicy#or Self-ins.Lic..# WCO20342628 Expaa.iionDate: 04/Ol/2011
Attac� a copy of the workers'compeusation policy deciarafion page(showing the policy nnmber and ezpiration date),
Faili�re to secure coverage as required tmder Section 25A oi 11�GL c. 152 c�aa lead to the�position of�riminal prnalries of a
fine up to$1,500.00 and/or one-year imprisonme�xt,as well,as eiv�penalties m ti�e form of a STOP WORK ORDER�d a fine
of up bo�250.00 a day�against the violator. Be advised tlsat a copy of this statemeirt may be foiwarded to the Office of
Investigations of the DIA for in�,.ra�e coverage verification.
I dn hereby certify,under the pains pen ' of that the irmformation provaded a.�nve ' irue and corred �
,.,. .
Si ature• Date:
Phone#: 508 270-1400 � �AGER ''
O,�}"icial use only. Do not write in this area,to be enmplereri'by ctfy'riri�eiim o,,�j``iciaL .
Ciiy or Towa: Permit/License#
�ssning Anthotity(circle one): �
1. Baard of Health 2.Building Department 3.Ciiy/Town Clerk 4.Licensing Board 5. Selectmen's Off ce �
6. Other i
Contact Persoa: Pbone#•
www.mess.gw/die