HomeMy WebLinkAboutApplication and WC .� � �..�m� i
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�* TOWN OF YARMOUT BOARD OF HEAL � '
. ��'`�� ,•`X` �I
� APPLICATION FOR LI EN���P{��1�-2 1�� �`"� i� �r��_�
* Please complete form and attach al ne ��6�i��ents y=December 13.2013.
Failure to do so will result in cation p' ac�cet.
ESTABLISHMENT NAME: (/l � TAX I • �
LOCATION ADDRESS: M� S J2?�. 2 TEL.#: SC�'' �- p/
MAILING ADDRESS: �o� RR J ff .Q �6� :
E-MAIL ADDRESS: C!�/(a � �� . '
OWNERNAME: C��SZ(,)Ol�� L�IN�/�� ` '
CORPORATION NAME (IF APPLICABLE): ,�'l.qCL��✓, LLG
MANAGER'S NAME: ��d�A.�' f1?C' ;Cl1?rG�� TEL.#:
MAILING ADDRESS: C�4<►'�� �9S .�,8�xJC�) '
�(POOL CERTIFICATIONS: ;
/ The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool j
Operator(s) and attach a copy of the certification to tlus form.
l.�t��i S'?���/Sp�v 2. ��d119�.5 �c�j�l�� �
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Pool operators must list a minimum of two employees currently certified in basic water safety, 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. i
1. E/Yl! �(��YI �l� 2. �1 C,L/l� ..�L�L�-L 1�.��
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>C 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 atta.ch
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. G�2�S'7o,��C� Ly� 2. D�A/�EL P�R�o'zT�4
�
� PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. �
1. �ie cS7D�crl�i2 C,ynJC�{ 2.
�( ALLERGEN CERTIFICATIONS: f
/ 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 i
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. �i��.S700�C� j—yNCC( 2.
� HEIMLICH CERTIFICATIONS:
All food service establishments with 25 seats or more must have at least one em�loyee trained in the Heimlich
Maneuver on the premises at a11 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. ;
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RESTAURANT SEATING: TOTAL# �
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OFFICE USE ONLY !
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PE IT# �
B&B $55 CABIN $55 ✓MOTEL $55 —0 ;
INN $55 CAMP $55 �SWIMMING POOL $80ea. O�j J
_LODGE $55 TRAILER PARK $105 �WHIRLPOOL $80ea. _ �f
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FOOD SERVICE: f
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# !
�-100 SEATS $85 I -l � ONTINENTAL $35 NON-PROFIT $30
>100 SEATS $160 �OMMON VIC. $60 �— 0 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. $225 VENDING-FOOD $25
�'<25,000 sq.ft. $80 _FROZEN DESSERT $40 —TOBACCO $95
NAME Ct�ANGE: $15 AMOUNT DUE _ $ /T U. Q�
***'*PLEA3E TURN OVER AND COMPLETE OTHER SIDE OF FORM*****
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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 have a Certificate of Worker's Compensation i
Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE �
COMPLETED AND SIGNED, OR "
�
CERT. OF 1NSURANCE ATTACHED v
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
MOTELS AND OTHER LODGING ESTABLISHMENTS ;
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 thirry(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 i
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 Departrnent prior to opening. Contact the Health Department to schedule the inspection three (3) days
prior to opening.PLEASE NOTE:People are NOT allowed to srt 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 by a
State certified lab, and submitted to the Health Department three (3) days prior to opening, and quarterly thereafter. I�
i
i
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 Deparhnent 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.varmouth.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
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 of Health.
OUTDOOR COOHING:
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 13, 2013.
ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT,ETC.),MUST BE REPORTED TO AND A ROV D BY THE BOARD OF HEALTH PRIOR TO
COMMENCEM NT. NOVATIONS MAY REQ S PLAN.
��;
DATE: � � � I� SIGNATURE: - i
PRINT NAME&TITLE: �i�t S7 �� atlG� � 1U i
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,
Rev.]0/08/13
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The Commonwealth ofMassachusetts
Department of Industrial Accidents
Office of Investigations
' 1 Cortgress Street, Suite I00
Boston,MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Le�iblv
Business/Organization Name: ��'Q�L-y�i L—L-G
I Address: g 22 M�c tJ S7. !2 �� z$�
City/State/Zip: �0• �1�1�0�Z�f �'!� �P�fione#� �0 8 7 �1 — O/ DO
Are y an employer? Check the appropriate boz: Business Type(required):
1. I am a employer with�employees(full and/ 5. ❑ Retail
or part-time).* 6. �Restaurant/Bar/Eating Esta.blishment
2.❑ I am a sole proprietor or partnership 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 exemption per c. 152, §1(4),and we have 10.0 Manufacturing
no employees. [No workers' comp. insurance required]* 11.� Health Care
4.❑ We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp. insurance req.] 12.❑ Other
*Any applicant that checks box#1 must also fill out the secrion below showing their workers'compensation policy information.
**If the corporate officers have exempted themselves,but the corpora6on has other employees,a workers'compensation policy is requ'ued and such an
organization should check box#1. j
I am an employer that is providing workers'compensation insurance for my employees Below is the policy information. I
Insurance Company Name: l'Y� Q�cC,L�Q (�,S. G!�-
Insurer's Address: v�t3 �/4� S7, �
City/State/Zip: �1�ZZ1Q•�V S D'� !�Q ��� j �i i
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Policy#or Self-ins.Lic. # Expiration Date:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and ezpiration date). r
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 statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby un the pains and penalties of perjury that the information provided above is true and correct.
Si atur : Date: � �� l �
Phone#: SU�J �2� - a10D
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):
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
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' c�d CERTIf ICATE OF L1ABILITY INSURANCE °"o�rz"no�4"'
IS CERTIFlCATE 18 ISSUED AS A MA?TER OF INFORMATION ONLY ANO CONFERS NO RIGHTS UPON THE CERTIFiCATE Hp4DER THIS
CERTIFlCA'IE DOES NOT AFFIRMATIVELY OR NE6ATIYELY AN�ND, EXTEND OR ALTER 1'HE COYERACiE AFFORDED BY THE POLICIES
BELONI. TFqS CERTIFlCATE OF INSURANCE DOES I�T COM8TiTUTE A CpNTRpCT BE7VYEEN THE ISSUING It�URER(8), AUTMORIZED
REPRESENTATiVE OR PRODUCER,AND THE CER7fFiCATE HOLDER.
UNPORTANT: If the cerdRcata Aoid�r k an ADOfIIONAI IN8URED.tha poNcy(ies)mtut be erMwsod. If SUBROGATION IS WANED,subJect ta
tAa Eerms and condidoia o#the Pak7l.cerbM PoNcks may ro�ire�endorsament A sa6amerrt on this certiflca6a do��confx ri�Ms to tlw
cortificate holder&�liwi aF s�h s.
� HART INSURANCE AGENCY,INC. �°����
243 MAIN STREET � . 508-T59-7326 X207 � .508-759-7388
PO BOX 700 '�- . Imurphy�hsttlnsuranceagenCy.wtn
BUZZARDS SAY.MA 025320700 a�c ��oaomo cav�rnce rwc r
�R�: ARBELLA PROTECTION INS GO 41360
n+su� Madyn LLC&Irish V'�Iqige Restau►ant&Resprt LLC
822 Rt 28 �sv�n s:
South Yartnouth.MA Q2664 �R c:
NSUI�R D:
�E�
M�RRo-
COVERAGES CERTIFiCATE NUMBER: REVIEION NUMBER:
THIS IS TO CERTIFY THAT THE P06iCIES OF INSURANCE U&TEQ BELOIN HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. N071MTHSTANOING RNY REQUIREMENT,THRM OR COI�ITION OF MIY CONTRACT OR OTHER DOCIlMENT VNTH RESPECT TO WHICH THIS
CERTIFIG4TE MAY BE ISSUED QR INpY PERTAIN,THE INSUR/WCE AFFORDED BY THE POLJCIES DESCRIBED HERqN IS SUBJECT TO ALL THE TERMS.
EXCLUSIONS AND COND1T10NS OF SUCH POLIGES.Lpu11TS SFIOWN MAY W4VE BEEN REDUGED BY PAIO CLA�1S.
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RTIFICATE HOLDER CANCELLATlON
Town af Yarmouth
1146 AAain StrBCt SHOULD ANY�THE ABOVE OE8CR�ED POlIC�B�CANCELLEO�FORE
South Yamwuth�Ma.02664 TNE ExP�AT10N OA7E THEREOF. NOTIGE NI�I BE DELNERED IN i
ACCORDANCE W17Fi THE POLICY PROYISIONB. :
. - � M�D RE�SENTATNE':��`� � ;"��`!�-.
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O 1988-2010 ACORD CORPORATION. AN NgMs ressned.
CORD 2B(2010/a5I The ACORD name arM logo are rogisbersd marks of ACORD .
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