HomeMy WebLinkAboutApplication and WC t ° - ��
* �* � TOWN OF YARMOUTH BOARD O � + 5�����P i I�5 '
�� � �, ; !
� � APPLICATION FOR LICE '
� � G>>� � NOV 0 4 �013 '
� * Please complete form and attach a11 necess cember 13 2013. � '
Failure to do so will result in the re rn o your applicati n H DEPT.
ESTABLISHMENT NAME: �E��c�c:QG tu,�,E-����P..rfs TAX ID: �
LOCATION ADDRESS: '-{Sl S'f��nN ¢�J� S- �14rwbStr� Dwt�4 TEL.#: S'f�5^(o�1"i►-7�'�`r '
MAILING ADDRESS: '�t S1 STk t � .� '
E-MAIL ADDRESS: 'CLo,u k t��- w�u C'P��� � Ca+.�t cci S7 ,NE7 ,
OWNER NAME: e�v�t,v �N�, C,.,'�-� � !Mv r�ok��
CORPORATION NAME (IF APPLICABLE): S��i�P� � �e��S L{,. i�
MANAGER°S NAME: ��,� r k• TEL.#: y-7� �
MAILING ADDRESS: S l �t' o , .� rs� �
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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. 2.
..___. .... .. ... ... _..__ _. ___ �_._ __�_. _ __ ._ .__ ___ ____.__ ._ . - --------- -_ _._ _. _ ----- - _ _ __ ,
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.
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1. 2. '
3. 4. i
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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.
1. 2. �
PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
l. __ 2• '
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. 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-cholcing procedures below and atta.ch ;
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 busmess. ',
l, 2.
3. 4•
RESTAURANT SEATING: TOTAL#
QFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# .
B&B $55 CABIN $55 MOTEL $55
—INN $55 CAMP $55 SWIMMING POOL $80ea.
LODGE $55 TRAILERPARK $105 _WHIRLPOOL $80ea.T—
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
— , —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 �k'� -oC —FROZEN DESSERT $40 �TOBACCO $95 ��#f�F-C;G.`-
rraME c�KGE: $i s AMOUNT DUE _ $ 17� .r�t� ;
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*****
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i � r.�-:. ADMINISTRATION �'i
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Under Chapter 152, Sec�io�25C,��kise�ti,�,�,,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 AFFIDAVTI"�1VIUST 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. 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 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 Deparhnent 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 th�e required
Temporary Food Service Application form 72 hours prior to the catered event. These forms can be ob�ained 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. ;
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OUTSIDE CAFES: I
Outside cafes (i.e., outdoor seating with waiter/waitress service), must have prior approval from the Board of Health. '
OUTDOOR COOKING:
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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 APPROVED BY THE BOARD OF HEALTH PRIOR TO
COMMENCEMENT. RENOVATIONS MAY RE A SITE PLAN.
DATE: � 1 �L � 1�, SIGNATURE:
PRINT NAME&TITLE: �-k L� (yC�,0'�4,�w�,�o,,,���_
Rev. 10/08/13
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� � The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Irevestigations
� 1 Congress Street, Suite 100 j
Boston,MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Auplicant Information Please Print Legiblv
Business/Organization Name: �'E�SL�-P� �t N �E--�' � ('���-s
P
Address: `l S 1 ��1 olU �� i
y �
City/State/Zip: s , ya�uno�C�C w�- az��� Phone#: ,S'8� �6 4'�� 7i$ I
Are you an employer? Check the appropriate boz: Business Type(required): I
1.�I am a employer with � employees (full and1 5. [�]'Retail
or part-tirrre).* 6. ❑ RestauranfBar/Eating Establishment
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 R
their right of exemption per c. 152, §1(4),and we have 10.❑ Manufacturing
no employees. [No workers' comp. insurance required]* 11.0 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 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 Company Name: � � '[�G�4w� ���r��d'fG, C�.L° � �.' P
, _
° �4 �io� �"S`f' 2 �-Z � �'z�Z
Insurer s Address: . - _ - �..
City/State/Zip: � � /U���� �6�' � � 7s� ,
Policy#or Self-ins.Lic.# � r � O n j O� L$tl"'L l l � Expiration Date: ;
Attach a copy of the workers' compensation policy declaration page(showing the policy number and ezpiration date). '
Faiiure io se�'e coverage as required und�r Section 25A of iVIG�,c. 1�2 can tead to the impositiatrof criminal penalties of a
fine up to$1,500.00 andlor one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine ;
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of �
Investigations of the DIA for insurance coverage verification. �
I do hereby rt ,un the pains and penalties of perjury that the information provided above is true and correct. i
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Si ature: Date: l � `�
Phone#• �� �� � 7i`� -1 ?�
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Official use only. Do not write in this area,to be completed by city or town officiaL j
City or Town: �FFQIVtovTt# Permit/License# i
Iss ' circle one): '
.Board of He�t 2.Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office
Contact Person• Phone#: 5��—3g$—�r33� X/2-`�/ '
www.mass.gov/dia l
�"+t�►'�'���; N�T'I��
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���'�t��i!'���"� EMPI��i!���
Th� ���r�t��wea��th o� ��as�achuset��
D.�PART��EI�T C�F l��USTI�IAL ACCIDENTS
600 �ash�ngton Stree�, Bostan, Massachusetts 02111
61'1-727-49��0 - h�.p://vwvw.mass.gvvldia
As required by M�ssaclsusetts General Law, Chapter 152, Sectivas 21,22�3U,this will give you notice
�hat I(we}have provided for;payment tp our injured ernployees un.der the above-mentioned chapter by
insuring with:
MA R�tail Merchants WC Groub� Inc.
I'+tAME QF II�tSURAI*ICE CO1ViPANY
PO Bax 859222-9222 $raSntre4, MA 01285
ADDRES�4F INSURAAICE GOMPANY
Oi4005�32644113 ' 1f01l2013 - 1/O1/2Q14
POLICY NUI�iBER EFFECTI�E DATES
Assoaiat3on $�nefits Insu�a�c• 244 Ballardvale St, Suit• 1 Wilminptan, MA Q1887
tdAME OF INSURANCE At�ENT ADDRESS PHQNE##
5easeap• pline � Spirits 4 Carl#on Dr1ve Horton, MA 027G6
EMPLOYER ADDRESS
EMPLUYER'S WORI�ERS' COMPEN�ATT4N OFFiCER(IF A►1wIY) BATE
NIEDIC.f�L �'R�ATi��1VT
The abQ�e nsmed ins�u�er is required 'm case�of per�onel izijuries a.rising aut of and in the caur�e vf
emplayrne�t ta furnish adequa�e aud reasvnable hospital and medical services iu accordance with the
pmvisiflns of the Wozkers' Coimpensation Act. A eopy of#he First R�port of injury mus#be given to the
injured employ�e. Th�emplo�►ee may select his or her.flwn physician. The reasonable cost af the ser-
vices provided by the treating�hysici�a will be��id by the insuz�r,if the tre.atment is necessary and
reasonably connocted to the wt�rk related injury. in ca$es ret�uiring hosgital$ttention,emplayees are
hereby notified that the insur�hss anauged fc�r sueh attentian at tlie
N.AME C?F HC�SPITAL � ADDRESS
�r� B� Fos�r�D �� ��Lo��R