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Home My WebLink AboutApplication and WC TOWN OF YARMOUTH BOARD OF HEALTH APPLICATTON FOR LICENSE/PERMIT-2017 �,� "`Please complete form and attach ail necessary documents by Decernber 16.2016. �` Fai1w+E to do so will result in the return of your applicahon pac et. ESTABLISHMENT NAME: c �. fi � LOCATION ADDRES5: TEL.#: �� - b�-� 0�� MAII.ING ADDRESS: E-MAILADDRESS: Mr,..ho '�c�. G��nnCo��, �-r ^y-<nB OWNER NAME: � r��► C012PORATION NAME APPLICABLE : '�,n ��1 l.,uC� �r MANAGER'S NAME: � � � T'EL. : — _ �Ic �- -�'"' MAII,ING ADDRESS: 3 V o p �...� * �.�: POOL CERTIF'ICATIONS: 4 � The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated �,dr�� Pool Operator(s)and attach a eopy of the certification to this form. 1. 2. Pool operators must list a minimum of two empioyees currently certified in standard First Aid and Community Cardiopulmonary Resuscitation(CPR),having one ccrtified employee onpre mises at a11 times. Please list the employees below and attach copies of their certifications to this forrn.The Health Department will not use past = � � years'records. You must provide new copies and maintain a file at your plr�ee of buaine�s. � �i � �. 2. _ � rn 3. 4. m ,v C � � m FOOD PROTECTION MANAGERS-CERTIFICATIONS: � 0 All food service establishments are required to have at least one full-time employee who is certified as a Food Prot�tion 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 Healt6 Department will not uae 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. ALLERGEN CERTIFICATIONS: AU food service establishments are required to have at least one full-time employee who has Ailergen 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 paat years'records. You must provide new copies and maintain a file at your establishment. l. 2, HEIMLICH CERTIFICATIONS: All food service es�tablishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at ail times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this fom►. T6e Health Department will not uee past years'recorda. You mast pmvid�new copies and mainfain a Sle at yoar place of bnsiness. - -- 1. 2. 3. 4, RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: L3CENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �B SSS CABIN $SS MOTEL S110 �,OUGE ss$ ��' SSS _SWIMMING POOL Sl l0ea. S55 �TRAILERPARK S10S _WHIRLPOOL S110ea FOOD SERVICE: L[CENSE�Q UIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REp UtRED FEE PERMIT# 0-100 SEA7'S 5125 _CONTINEN7'AL. $35 NON-PROPIT S30 >100 SEATS 5200 COMMON VIC. S60 WHOLESALE S80 ItETAQ,SERVICE: —1�SID'KITCHEN S80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMTT# LICENSE REQUIRED FEE PERM[T# <50sq ft. $50 >25,000sq ft. 5285 VENDING-FOOD S2S �<25,000 sq.ft. $l50 � _FROZEN DESSERT S40 =1'OBACCO $I 10 � NAME CHANGE: S(S AMOUNT DUE _ $ 2(�Q,Qp **•"*PLEASE TURN OVER AND COMFLETE OTHER SYDE OF FORM*+��* � The Commonwealth ofMassackusetts DepartmeRt c►flndWstrial Accidents Of,fce of Investigations 1 Congress Stree�Srtite 100 Bostan,MA 02114-2U1� www mass gov/dia Workers' Compensation Insurance A�davit: General Businesses Analicant Information * Ple�se Print Le�ibiv Business/Organization Name: �GL_�'M 8 f,t,}� ��1`�1 E'_ � S`�c�� ,`�ST�„�C. , Address: �"`�y � �`�'D�,� �d'f1 �V � c��s��z�p:�o , `�c�,c rn 6�.�� (� �'bon# �o�s � 7�-a oo� Are n an employer?Check the appropriate boz: Basiness Type(reqnired): 1.�I arn a employer with�employees(full and/ 5. �Retail or part-time).* 6. ❑ RestaurantrBar/Eating Establishment 2.❑ I am a sole pmprietor or partnership and have no �, � Office andlor Sales{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,§2(4),and we have �0.Q Manufacturing no employees.[No workers'comp.insurance required]" 11.[]Hea1th Care 4.❑ We are a non-profit organi�ation,sta#�'ed by volunteers, with no employees. [No workers'comp.insurance req.] 12.[�Chher sAny epplicffit that ched�s box#I mtut atso fill out the section below showing their waaimss'oompensafion poticy informati�. s sIf the cwrporate officeis have exempted themselves,but the corporation has other employees,a workeis'compensation policy is required ffid s�h an organization should chedc box#1. I am an employer that is prnviding workers'compensation�itsarirance for my employee� Below is tlie policy�inforniation. Insurance Company Name: �� 2t-v.,1�, ��C G�C1G�lZ�C S �1.1 C �s.6�u-� �.�� Insurer's Adc�ress: � � `JO�G � 5�aa�.` Q�a� City/State/Zip: ��.1'f�� o� `�� Policy#ar Self-ins.Lic.# � �� 5 �� Expiration Date: ` �O l t a O 1� Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration dake). Failure to secure coverage as requir�i under Section 25A of MGL a 152 can lead to the imposition of eriminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties i.n the form of a STOP WORK ORDER anci 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 O�ice of Investigations of the DIA far insurance coverage verification. I do l�ereby�fjr,under ' s naltles of jury tkat tAie informatlore provided abave�s true and correc� �i¢naxure• � � ` Date• � �, �� \�0 � � Phone#: �� o'� �� " �� Official use only. Do not write in tliis area,to be con�pleted by c�ty or t�►wn ofJiciaL City or Town• Permit/License# Issuing Anthority(circle one): 1.Board of Hea1tL 2.Building Department 3.City/Town Cterk 4.Licensiag Board 5.Selectmen's Office 6.Other Contact Person• Phoae#• www.ma4s.gov/dia NOTICE _ 1�IOTI�E TO � tl TO EMPLC�YEES 4�� EMPLO�EES .e� 54� The �ommanwealth of Massachusetts DEPART'MENT OF Il�DUSTRIA�L A�CIDENTS 1 Congress Street2 Suite 100, Boston, Massachusetts 02114-2017 __ _ 617-727-4900 - http://,cvvwvv.state.ma.usldia As required by Massachusetts General Law,Chapter 152, Sections 21,22&30,this will give you notice that I{we)have provided for payment to aur injured employees under the abave-mentioned chapter by insuring with: MA.Retail Merchants WC Group Inc. NAME OF INSURANCE COMPANY PO Box 859222-9222 Braintree,MA 02185 ADDRESS OF INSURANCE COMPANY 01400050223b116 � � � iJ01/2016 - 1lOU2017 POLICY NUMBER EFFECTIVE DATES Association Benefits Insurance 299 Ballardvale St, Suite 1 Wilmin�on,MA 01887 NAME OF INSURANCE AGENT ADDRESS PHONE# Yarmouth Wine &Spirits LLC 484D Station Avenue South Yarmouth,MA 02664 EMPLOYER ADDRESS EMPLOYER'S WORKERS' COMPENSATION OFFICER{IF AN� DATE _ _ _------- ---- - -- _ . MEDICAL TREATMENT The above named insurer is required in cases of personai injuries arising out of and in the course of ernployment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers' Compensatian 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 wi11 be paud by the insurer,if the treatment is necessary and reasonably connected to the work related injury. In cases requiring hospital attention,employees are hereby notified that the insurer has arranged far such attention at the � Co c�, �lo S �-t� NAME F HOSPITAL ADDRESS TO BE POSTED BY �MPLaYER ADNIINIST'RATION Under Chapter 152,Section 25C,Subs�tion 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or pennit 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 COMPLETED AND SIGNED,OR CERT.OF INSURANCE ATTAC�� OR WORKER'S COMP.AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens musi be paid prior to renewal or issuance of your pernuts. PLEASE CHEGK APPROPRiATELY IF PA1D: YES� NO MOTELS AND OTHER LODGING ESTABLISIiMENTS 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(3�)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 sabject to the collection of Room Occupancy Excise,as defined in M.G.L.c.64G or 830 CMR 64G,as amended,sha(1 generally be considered Transient. POOLS POOL OPEIVING:All swimming,wading and whiripools which have been closed for the season must be inspected by the Health Department prior to opening, Contact the Health Deparkment to schedule the inspe�on three(3) days prior to opening.PLEASE NOTE:People are NOT allowed to sit in tt►e pool area until t1�e pool has been inspected and opened. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and siandard 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 5ERVICE OPENING: All food service establishments must be inspected by the Health Department prior to opening. PIease contact the Health Department to schedule the inspection three(3)days prior to opening. CATERING PULICY: Anyone who caters within the Tawn of Yarmouth must notify the Yarmouth Health DeparOment by filing the reqwred Tempo Food Service Appiication form 72 hours prior to the catered event. These forms can be obtau�ed at the H�th Department,or from the Town's website at www.varinouth.mai,�s under Health Depar�ient, 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 Healih Department. Failwre to do�will result im the suspension or revocation of your Frozen Dessert Pecmit untii the above tem�s have been met OUTSIDE CAF�S: Outside cafes(i,e.,outdaor seating with waiter/waitress service),rrtust have prior approval from the$oacd of Health OUTDOOR COOKING: Outdoor cooking,preparation,or dispiay of any food product by a retail or food service establishment is prohibited. NOTICE:Permits run annuaily from January 1 to Decemkser 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQUJRED FEE(S)BY DECEMBER 16,2016. ALL RENOVATIONS TD ANY FOOU ESTABLISHMENf, MOTEL OR POOL (i.e., PAIlV'I7NG, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TI-IE BOARD O HEALTH PRIOR TO COMMENCE NT. RENOVATIONS MA�tEQ��^�—''TF pi• D��: �a��ao�� c� �-c SIGNAT'URE: PRIIVT NAME&TlTLE: C�O�`�. �D�J(�� OI�.7�,�,1�� (YI(��f1��-°� Rev.10/IZ16