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Home My WebLink AboutApplication and WC � .� � �* TOWN OF YARMOUTH BOARD OF HEALTH � � � APPLICATION FOR LICEN�T ; , T'<� 0�`�, ` _:;, � , * Please complete form and attach all necr s, t`cem�erg13��013. Failure to do so will result in the r�tu�rn � applica on�H DEPT. ESTABLISHMENT NAME:�t Cv� �'►.;S L. i'/r�� TAX ID: LOCATION ADDRESS: $a� /�lu�n S� tZ� .�� S�. �.,�au,�. K�6a66�fI'EL.#: �6�' 3�1�/-q3�0 MAILING ADDRESS: Sur•z E-MAIL ADDRESS: i r�s�.v: llr�e � can,�.s-F. h e -f- OWNER NAME: CORPORATION NAME (IF APPLICABLE): � ' MANAGER'SNAME: �Tok� 1��K�S TEL.#: MAILING ADDRESS: 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. r0l•- Cc �i S 2. Pool operators must list a minimum of two employees cuxrently 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 �le at your place of business. 1. �2'�''�✓ �d��h�0✓� 2. F/rr C�� C �r�PG��I 3. 4. i 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�le at your establishment. 1. � w,,� �a 1;ci Gt,�� 2. --.��4 � PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. '��t��.5 1'j � L.��,w�,�� 2. � Q�Y�-�(�c �-(a(�G� ___-___ 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. �;��S�P(�,�'� ��,� 2. I � � HEIMLICH CERTIFICATIONS: j 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-cholcing procedures below and attach ; copies of employee certifications to this form. The Health Department will not use past years' records. You must i provide new copies and maintain a file at your place of business. ' 1 '`J`r�� e�iU' 2 �''Za-�.u.e.x, t��. ; 3. F1��,�.��'y✓ �C� �zfi 4. S�t ��-� u7� � � � � RESTAURANT SEATING: TOTAL#_�T'J �_ _ ; — —._.e.. OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# ' B&B $55 CABIN $55 �MOTEL $55 #��—t?z-3 ' INN $55 CAMP $55 Z SWIMMING POOL $80ea�i�2. Cy3 _LODGE $55 _TRAILER PARK $105 �WHIRLPOOL $80ea. —� ! , FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# i � 0-100 SEATS $85 #/�f—O�� CONTINENTAL $35 NON-PROFIT $30 I >100 SEATS $160 1 COMMON VIC. $60 / —G7 —WHOLESALE $80 RETAIL SERVICE: —RESID.KITCHEN $80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $50 >25,000 sy.ft. $225 VENDING-FOOD $25 � <25,000 sq.ft. $80 =FROZEN DESSERT $40 =TOBACCO $95 NAME CHANGE: �is AMOUNT DUE _ $ �+��,p(� i *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** � i --a - , ; � _ _ , �.....M ' �� ADMINISTRATION � � s Under Chapter 152, Section 25C, Subsection 6,the Town of Yaxmouth is now required to hold issuance or renewal of any licerise or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORK�R'S COMPENSATION INSURANCE AFFIDAVIT MUST BE i COMPLETED AND SIGNED, OR ', CERT. OF 1NSURANCE 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 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 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 prior to opening.PLEASE NOTE:People are NOT allowed to srt 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. ' i � POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven (7) days of closing. _ _ _ �__ .. _ _ ----�-`_--- -- -- --- - -- --- -_ lH'��------- 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 obtained at the j Health Department, or from the Town's website at www.varmouth.ma.us under Health Department, Downloadable � Forms. f � 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 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 I EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUT A SITE PLAN. DATE: �`L��'V�1`� STGNATUR.�: PiZINT NAME&TITLE: , �1 __ Rev. 10/08/13 � � � �- � r c i% � The Commonwealth of Massachusetts Department oflndustrialAccidents - Office of Investigations ' 1 Congress Street,Suite 100 ' --- Boston,MA 02114-2017 www.mass.gov/dia ; Workers' Compensation Insurance Affidavit: General Businesses ( Applicant Information Please Print Legiblv ' Business/Organization Name: � � Co � �,-s L, (/i�(a P � � i Address: �a � �(a�� -� /L f��' sv. �o� i City/State/Zip: ,So�,.(ti. ��,.w�� 1 q 15,t6G�f Phone#: �6� 3�1�- �3�o � Are you an employer? Check the appropriate bog: Business Type(required): 1.[� I am a employer with employees(full and/ 5. ❑ Retail or part-time).* 6. ❑ RestaurantBar,Bating Es��ablisluneni 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.❑ Manufacturing no employees. [No workers' comp. insurance required]* 11.❑ Health Care 4.❑ We are a non-profit organization,staffed by volunteers, j with no employees. [No workers' comp. insurance req.] 12.❑ Other i *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy informadon. � **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 I am an employer that is providing workers'com ensation insurance for my employees Below is the policy information. � Insurance Company Name: �✓ F��!rn ��?'� T�'0� �.S , CU . Insurer's Address: ��Q 6 �re'L��'t C.0�Oy��-, ,Or. City/State/Zip: �u r'nC y /�'f/� d o��6 CJ Policy#or Self-ins.Lic. # ROR`l 5�0 � t3 Expiration Date: � I3 / Attach a copy of the workers' compensation policy declaration page(showing the policy number and gpiration date). Failure to secure coverage as required mder Section��of MGL c. 152�an��a tne impos�csn of�ritrii�:a1 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 certify,under the pains and penalties of perjury that the informataon provided above is true and correct. Si ature: Date: �� 3 Phone#: b � �� Official use only. Do not write in thds area,to be completed by city or town offaciaL City or Town: �A-Q�o� Permit/License# Is (circle one): ard of,IIg 2. Building Department 3. City/Town Clerk 4.Licensing Board 5. Selectmen's Office 6.Other Contact Person: Phone#:__.�rQ-32�--a-a31 X�2-`�� www.mass.gov/dia NOTICE . �� NOTICE TO TO �MPLOYEES � � ' EMPLOYEES Th e Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street,Bo,ston,Massachusetts 02111 � 617-727-4900-http://www.mass.gov/dia As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30,this will give you notice that I (we) have�rovided for payment to our injured employees under the above mentioned chapter by insuring with: Arbella Protection Insurance Company NAME OF INSURANCE COMPANY 1100 Crown Colony Drive,Quincy,MA 02169 — ADDRESS OF INSURANCE COMPANY #9099540613 6/13/13—6/13/14 EFFECTIVE DATES • P�LICY NUMBER Hart Insurance Agency Inc 243 Main Street Buzzards Bay,MA 02532 NAME OF INSURANCE AGENT ADDRESS ' 822 Realty Trust dba Gull Win Suites LL� 822 Route 28 S.Yarmouth,MA 02664 EMPLOYER ADDRESS EMPLOYER'S WORKERS COMPENSATION OFFICER(IF ANY) DATE MEDICAL TREATMENT `'The above named insurer is required in cases of personal injuries�rising out of and in the course of �mployment to furnish adequate and reasonable hospital and medical services in accordance with the �rovisions of the Worker's Compensation Act A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician.The reasonable cost of the ser- vices provided by the treating physician will be paid by the insurer,if the treatment is necessary and 're�sonably connected to the work related injury.In cases requiring hospital attention,employees are �hereby noti�ed that the insurer has arranged for such attention at the �Iame of Hospital Address T(l RF. P(ICTF,I� RV F.MPT�nYER