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Home My WebLink AboutApplication and WC __!__.,.. ,....,��.. . ., � ^� . TOWN OF YARMOUTH BOARD OF HEALTH � _ � " � APPLICATION FOR LICENS�� 2' 1,�4 �' F�� .� �� V '" * Please complete form and attach all necess�ry �c e` ` � I mber 13 2013. Failure to do so will result in the return o your application acl ��• F�TART T�HMENT NAME•��.1�' -S�a� w �� TAX ID' LOCATION ADDRESS: `7 �3 K�� .�' S �A�'�"��'t TEL.#: (�C'L�g � ��,_9 7�3`� MAILING ADDRESS: �'c� ��i 1�1 `�°��v�M �/� -_t�� (�,� E-MAIL ADDRESS: ��.s��v a�v r•.�- C�� -a r-.;L4�„�<s�"�� • c� _ � OWNER NAME: s� t--�'�'Y (�!�'�-�� CORPORATION NAME (IF APPLICABLE): ��.G� �-�� t-t?y MANAGER'S NAME: � � L.-� b� K�h�`�'� �-l`�'`-�1 TEL.#: c� �i ) MAILING ADDRESS: POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool I Operator(s) and attach a copy of the certification to this form. � J 1. � ( �- f � �-1A^hl S�� 2. I Pool o erators must list a minimum of two employees currently certified in basic water safety, standard First Aid u �`� P 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. � � �---� � �..�� 1"��A�.,� 2. � 1 � A �,'.�`.U'A C,��A I 3. ' � 4. � � FOOD PROTECTION MANAGERS - CERTIFICATIONS: i 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. -� - — �t PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. f � I l. 2. ! i ALLERGEN CERTIFICATTONS: � 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 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. 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 all times. Please list your employees trained in anti-chokmg 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 business. i L 2. i 3. 4' RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICMNOS�RLEQUIRED $5 B PE�R�MIT� �- B&B $55 CABIN $55 �SWIMMING POOL $80ea.��1 —� $55 =�ILERPA1tK $105 WHIRLPOOL $80ea. LODGE $55 FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE P�I�1� LI NON-P O�FiT�D $30 PE�IT# 0-100 SEATS $85 .�CONTINENTAL $35 �F —�OLESALE $g� >100 SEATS $160 _COMivION VIC. $60 =g�SID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICE�NNEll�QUFOOD $25 PE�IT# <50 sq.ft. $50 >25,000 sq.ft. $225 — —TOBACCO $95 —<25,000 sq.ft. $80 —FROZEN DESSERT $40 — — AMOUNT DUE _ $ I�0 ,0 d NAME CHANGE: $15 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** ,,.:�— � � � _._ _ � t��.=� � I �.,_ `.,-rp�+` ` .. -�s, � -1. , �: � s' ADMINISTRATION � �_ -... � ; Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of iany 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 i COMPLETED AND SIGNED, OR i CERT. OF INSURANCE ATTACHED ; OR � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED j � 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 � ?imited 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. I __ POOL WATER TESTING. The water must be tested for pseudomonas,total coliform and standard plate count by a i State cer�ifr�d lab, and submitted to the Health Department three(3)days prior to opening, and quarterly thereafter. ' POOL C�OSING: 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 � Form�._ ; r � 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. QUTSIDE CAFES: Outside cafes(i.e., outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. � OUTDOOR COOKING: ' Oatdoor 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 APPR�VED'BY THE BOARD OF HEALTH PRIOR TO � COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE:_ � i 2�� __�j SIGNATUR.E: �.c�.. `�_.. PR1NT NAME&TITLE: � 1�. � ! �' �1�--) S6l�� /a�1 �i C� i Rev. 10/08/13 " ! f I -_ � ._ _ _ ' --".,-..::�� _�__ � -_ . ,:-� I - - 1 a ' � � The Commonwealth of Massachusetts Department of Industrial Accidents - Office of Investigations ' 1 Congress Street, Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Anulicant Information Please Print Legiblv Business/Organization Name: �S"� fz-��'� �-E�S� ( �T1��--�`�'`/ i Address: �� t t��t b't-t --� ; 4�!� - City/State/Zip: �3 �5 �-�.-� N�� , Phone#: �Q `7 �� (� a � �� Are you 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 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] 8• ❑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]* 1 l.� 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 empioyees,a workers'compensation policy is required and such an _ _ organization should check box#L I am an employer that is providing workers'compen�tion insurance for my employees. Below is the poldcy information. Insurance Company Name: �-�� `��:-#7�-t /'rN� � fi-1 S c� tz-9��-► �� ,nP�)`y Insurer's Address: �2-Z- �� `S�� City/State/Zip: � �� 2�� Policy#or Self-ins.Lic. # 1� � � 2.�33 A Expiration Date: �' ( �� (� Attach a copy of the workers' compensation policy declaration page(showing the policy number and egpiration ate). 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 imprison.ment,as well as civil penalties in the form of a STOP WORK ORDER and a fine ' of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of , Investigations of the DIA for insurance coverage verification. ' I do hereby certify,under the pains and penalties of perjury that the information provided above is true and correct. ' � Si ature: � Date: �- � 1 Phone#: �� 7�1 � `� Official use only. Do not write in this area,to be completed by city or town officia� City or Town: Y�� Permit/License# '. Is ' cle one): ' Board of Health 2. ilding Department 3. City/Town Clerk 4.Licensing Board 5. Selectmen's Office 6. Ot er ' Contact Person: Phone#: �5b8�3q3-Z23i X lZ�� www.mass.gov/dia -.""_----� _ � � -� WORKERS COMPENSATION AND EMPLOYERS' LIABILTY ` ' INSURANCE POLICY----INFORMATION PAGE � INSURER: POLICY NO: WE1280333� NORFOLK & DEDHAM MUTUAL FIRE INSURANCT COMPANY RENEWAL 222 ANlFS STREET ' �EDHAM, MA 02026 NCCI Company No: 21059 ; Account No: FEIN: ITEM 1. NAMED INSURED AND MAILING ADDRESS: AGENT NAME AND ADDRESS: ' SARKAR HOSPTTALITY LLC DBA RED MZLL MOTEL BNYNT4N INSURANCE AGENCY, 793 MAIN' STREET RT 2$ • 72 RIVER PARK STRgBT YARMOUTH MA 02664 NEEDHAM, MA 02494 AGENT NO.: 20272001 LEGAL ENTITY: LIMITED LIABILITY C4MPANY (LLC) OTHER WORKPLACES N�T SHOWN ABOVE: (See Workers Compensation Classification Schedule) ' ITEM 2. POLICY PERIOD: From: 0 5/15/2 013 To: 0 5/15/2 Q 14 Effective 12:01 A.M. Standard Time at the Insured's mailing address. ITEM 3. COVERAGE: A. Workers Compensation,Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers' Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits of liability under Part Two are: Bodily Injury by Accident: $ 10 0, 0 0 0 each accident Bodily Injury by Disease: $ 5 0 0, 0 0 0 policy limit Bodily Injury by Disease: $ Z 0 0,0 0 4 each emptoyee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: SEE ENDORSEMBNT WC 2Q 43 06 A D. This Policy includes these Endorsements and Schedules: See Schedule of Forms and Endorsements. ITEM 4. PREMIUM: The premium for this Policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required on the Workers Compensation Classification Schedule is subject to verification and change by audit. Total Estimated Minimum Premium: $ �3�, Annual Premium: $ 2 57 Audit Period: ANN(7AL Additional/Return Premium: Comments : Issued At: Date: p 4/0 5/2 0 Z3 Countersigned by V1IC 00�0 01 A Copyright 1987 National Counci!on Compensation Insurance i - - �__ :