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Home My WebLink AboutApplication and WC ., - �....�..�...... � �a' TOWN OF YARMOUTH BOARD OF HEALTH ��-��`��1-°% � � � APPLICATION FOR LICENSE/PE 1 �?: �, � ��EC � 2 ��i�1 , * Please complete form and attach all necessary doc �AM nts y� ecemb �5 2011. " Failure to do so will result in the return of yo �pplication pac c t. ' �H b��'�• ESTABLISHMENT NAME: � U� ID' LOCATION ADDRESS: TEL.#: C� - �� ' MAILING ADDRES OWNER NAME: y CORPORATION NAME( APPL • � ' MANAGER'S NAME: �(.. TEL.#: MAII.ING ADDRESS: POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operatar(s) and attach a copy of the certification to this form. 1. 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 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. ' 3. 4. ' FOOD PROTECTION MANAGERS - CERTIFICATIONS: ' All food service establishments are required to have at least one full-time employee who is certif'ied 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. 1. 2. , PERSON IN CHARGE: ' Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. 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. 1. 2. ' 3. 4. : I RESTAURANT SEATING: TOTAL# ' OFFICE USE ONLY LODGING: LICENSE REQUII2ED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# ; _B&B $55 _CABIN $55 _MOTEL $55 ' _INN $55 _CAMP $55 _SWIMMING POOL $SOea. _LODGE $55 _TRAILER PARK $105 _WHIRLPOOL $80ea. FOOD SERVICE: " LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _0-100 SEATS $85 _CONTINENTAL $35 _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# _<50 sy.ft. $50 _>25,000 sq.ft. $225 VENDING-FOOD $25 ', i _,�t3,u00 sq.ft. $80 l � � _FROZEN DESSERT $40 7TOBACCO '�CL3� � NAME CHANGE: $15 AMOUNT DUE _ $ �� ' *****PLEASE TURN OVER AND COMPLETE OTI�ER SIDE OF FORM***** ' ; I ` ,_ - ' �, 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 Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MIJST BE COMPLETED AND SIGNED,OR 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. PI.EASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LODGING ESTABLIS�IlVIENTS 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 De�artment 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 obtained at the Health Department,or from the Town's website at www.yarmouth.ma.us under Health Department, Downloadable 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 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( REQUIRED FEE(S) BY DECEMBER 15, 2011. Ai.i" RENOVATIONS TO ANY FOOD ES ABLIS NT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTE TO AND PROVED BY THE BOARD OF HEALTH PRIOR TO CO NCE NT. RENOVATIONS Y REQ A SITE PLAN. DATI�7• � � , � SIGN�T PRINT NAME& U�� Rev.10/25/11 . # � • /7\ � �"� The Commonwealth of Massachusetts _ Departinent of Industrial AcciJents �N�M� 600 Washington Street, f�'Floor Boston,Mas� 02111 Worlcers'Compensalloa lasanete AfRdav�t: name: � � � �� a s• -.�- �� --- i stat • zj ��v� � � � work site location ffull addressl: ❑ I am a homeowner performing all work myself. ❑ I am a sole proprietor and have no on working in any capacity. ��an e�np er providing work mpensati fa m plqyees�qrlcing on Wis job. com �ame �'�1/� address: ` "'� V� - . �: �"d �q - �' �. �a � �/�'o�.ro 3�� l � : _ _ ;::.. : . ❑ I am a sole proprietor,ge■eral co.trxtor,or 6omeowaer(cirde oRe)and have hi�d the contractas listed below who have the following workers'compensation polices: wmwov�ame: addreas: citv oYaae�• ies�raxe eo. �o1i M co�mtv�e• ad�inss- ' chv- oro�e M: I im ao. * ', A1111ri �'i0rl�f ' FaYve r �re as reqaired��dv Se�tle�2SA�[MGL 132 cn Ind b fYe�dai�ial pe�allin�f a�e�p b i1,3N�N aid/�r o�e ye� imp a�wd as cM pe�altles i�t6e t�r�o[a STOt WORK ORDER a�d�O�e d 516�.N a day atalmt me. !oadas�d tiu a capy �ta�eveat y be firwardcd 1s the Omee�[1m�Wd ot t6e DIA far c�rerase verlAaMw !Jo b by cerBjy er NYe pel�s aw�P��*�fP�3+�1'NY�t NYe iaforn�r�don previ�el eboae ir a�e m�d �v+�ct Si �� / � j� ,/ v► � Phom# �v 6 (��l7 / V��( , ef8cfal ax osly da aet wrife�t6b area ts 6e co�Pieted 6Y ekY or 1�wa s�l city or tewn: permiMiceose N �Depar�eat ❑edeek ittm�edia�e re�psme b re9� �SeleetAee �ce � , cA�act persoo: pdNe#; a��t i ��a s�a mm► � W�RKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE CERTIFICATE INFORMATIQN PAGE Producer: Agent# 960 MA Retail Merchante WC Groug Inc. Association Benefits Ins Agcy Inc 10 British American Blvd. 210 Broadway. Unit 241 Latham. NY 12110 Lynnfield. MA 01940 (Carrier Code: 3435�) Cartificate �: 0140Q5032844111 Prior Certificate #: NEW 1. The Employer: Seascape Wine & Spirits Seascape Spirits. LLC Mailing Address: 4 Carlton Drive Norton. MA 02766 Fein: Other workplaces not shown above: Type of Business: Limited Liability Co SEE SCHEDULE OF OPERATIONS Risk ID: 2. The certificate period is from 12:01 a.m. on 7/O1/2011 to 12:01 a.m. on 1lO1/2012 at the insured's mailing address. 3. A. Workers Compensation Coverage: Part Qne of the certificate applies to the Workers Compensation Law of the states listed here: MA B. Employers Liability Coverage: Part �ro of the certificate applies to work in ea.ch state listed in Item 3.A. The li.mits of our liability under Part Two are: Bodily Injury by Accident $ 100.000 each accident Bodily Injury by Disease $ �00.000 ce�tificate limit Bodily Injury by Disea�e $ 100.00p each employee C. Other States Coverage: D. This certificate includes these endorsements and schedules; WCOOOOOOA(04/92) WC000308(04/84) WC000414(07/90) WC000422A(09/08) WC200301(04/84) WC200302(0�/86) WG200303B(07/99) WC200405(06/O1) WC200601(06/92) 4. The contribution for this certificate 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. �lassifications Code Contribution Basis Rate Per Estimated No. Total Estimated $100 of Annual Annual Remuneration Remuneration Contribution SEE SG�DULE OF OPERATIONS Total Estimated Annual Contribution 1.361.00 Prorated Contribution 686.00 Minimum Contribution $ 219.00 Expense Constant $ .00 WC 00 00 O1 A Issue Date: 6/22/2011 Countersigned by ,