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Home My WebLink AboutApplication and WC � TOR'N OF YARMOUTH BOARD OF KEALTH � , APPLICATION FOR LICENSE/PERMIT-2017 *Pl�ase complete form and attach all necessary documems by fle neber 16 2016. ''��`� Failure to do so will result in the return of your applicahon pac cet. - � ESTABLIS��vvIEENf NAME: 1 C G�� LOCATTON ADDRESS: 5�3 Ro vTC 2 g,�-rA'�'mOu� /N�} TEL#• ti0$��/-'�$�� "` MAILING ADDRESS: — 5 C - � �' — �'^ E-MAII,ADDRESS•�»�g i e'x ✓h o�2' Lvo(s�.e Sa-mca��- cAm � . OWNER NAME: s►( ��it7VAt�T Oh32� �,>z CORPORATION NAME(IF APPLICABLE): �►'u4 �flya}T►R r M A�� MANAGER'SNAME: '�t=n�n1(S P.R?' ( TEL.#• �O`$^�?I'''�$� � V"� MAILING ADDRESS: —S Ai'�f C'' AG ��D� — �' ; POOL CER'TIFICATIONS: The pool supervisor must be certified as a Pool Operatar,as required by State law. Please list the designated Pool Qperator(s)and attach a eopy of the certification ta ttris form. _ � t. D�'�✓n�/S Pfi-T�L 2. P�YuSH PA�� m Pool operators must list a minimum of two employees currently certified in standard First Aid and Community "'� —' � Cardiopulmonary Resuscitation(CPR),having one certified employee on premises at all Umes. Please list the = � m employees below and attach copies of their cemfications to this form.The Healt6 Department will not nse past � rv C years'rernrds. You mnst prnvide new copia and maintain a file at your place of business. � � IT1 i. 2�ivn��S �A�'�L- 2._ �r�rKl3/3C•,� PF�-�c L �' "' o' 3. 4. 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 Heatth Department will not use past years'r�ords. You must provide new copies and maintain a file at your establishment. 1. 2. PERSON IN CHARGE: Each food estabIishment must have at least one Person Tn Charge(PIC)on site during hovrs of operation. 1. 2. AT.i.FRGEN CER'TIFICATIONS: 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 Estabiishments,105 CMR 590.009{Gx3xa}. Please attach copies of certification to this application. The Heslth Department wili not use past years'records. You must provide new copies and maintain a Sle at yonr establishment L 2. HEIlvILICH CERTIFICATIONS: Ali food service establishments with 25 seats or more must have at least one empIoyee trained in the Heimlich Maneuver on the premises at all times. Piease list your emploqees trained in ami-choking procedures below and attach copies of employee certifications to this form. TLe Health Department will not use past years'records. Yoa must provide new copies and maintain a file at yonr place of busutess. 1. 2. 3. 4, RESTAURANT SEATING: TOTAL# LoncING: OFFICE USE ONLY LICENSE REQIJIgfiD FEE PERMIT# LICENiSE REQUIRED FEE PERMTT# LICENSE REQUIRED FEE PFRMIT#O S �B S55 CABIN S55 � MOTEL 5110 # �a�►v sss c.v� sss �swin�nacrooLs�io�.�g aoq _LODGE S55 TRAILERPARK 5105 �WHIRLPOOL SIIOea�� FOOD SERVICE: LICENSEREQ�U'SII2ED FEE PERMIT# LICENSE REQUIRED FEE P RMIT# LTCENSE REQUIRED FEE PERMIT# a00SEATS 5200 �COMMONNTACI. S�35o �� —WHOLESALE S80 RETAII,SERVICE: —RESID.KITCHEN S80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _SSOsq R S50 >25 OW ft S285 VENDING-FOOD S25 <LS,OOOsq.R SI50 =FRbZEN�ESSERT S40 =TOBACCO SI10 NAME CHANGE: S15 AMODNT DUE _ $ �I S•� a�:*tpJ�EASE TURN OVER AND COMPLETE OTHER S�E OF FORM***'+ r ADMIrTISTRATION 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 WORI�R'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR CERT.OF INSURA.NCE ATTACHED OR � / WORKER'S COMP.AFFIDAVTI'SIGNED AND ATTACHED V Town of Yazmouth ta�ces 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�cupancy,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 shali generally refer to continuous occupancy of not more than thiriy(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 subjec;t to the collection of R�m 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 wiuch have been closed for the season must be inspected by the Health Department pnor to opening. Contact the Health Department to schedale tLe 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 mvst be tested for pseudomonas,total coliform and standar�plate count , by a State certified lab,and submitt�to the Health Department three(3)days prior to opening,and quarterly . thereafter. . POOL CLU5ING: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 opemng. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Depatttnent by filing the requu�ed Tempo Food Service Apptication form 72 hours prior to the catered event. These fornLs can be obtained at the H�th Department,or from the Town's website at www.yarmouth.ma.us.under Health Department, Downloadable Forms. FROZEN DESSERTS: Frozen desserts must be test�by a State certified lab prior to opening and monthly thereafter,with sample results submitted to the Health Depart�nent. Failure to do so will result in the suspension or revocarion of your Frozen Dessert Permit until the above terms have been met. OLTTSIDE CAP'�S: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. j OUTDOOR COOKING: i Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. i � NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN ; TI�COMPLETED RENEWAL APPLICATION(S)AND REQLTIKED FEE(S)BY DECEMBER 16,2016. � � � ALL RENOVATTONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW � i EQUTPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR I TO COM11� CEMENT. RENOVATIONS MAY REQUIRE A S AN. ` DATE: �(� ZD�� SIGNATURE: Pxnv�'NaME��rrrt,E: En�N VAN T pA l�(- O�ZTi�� te�.taivi6 ; i � The Commonwealth of Massachusetts Deparb��ent of Indr�sd�ial Accidents O,,�ce of Investigatiwns ' 1 Congress Stree�Suite 100 Boston,MA 021I4-20I7. www mas�gov/dia Workers' Compensation Insurance Ai�davit: General Businesses Analicant Information Please Print Le�iblv BusinesslOrganization Name: M��i� /k D ('OR /�o D(s1 C AddY'05S: �r�� f��C Z� y (��gT ��I'�'fQ(J�i"i City/State/Zip: u9• r7p 1� 1Y�}- p � Phone#: h�"�"�`"� `� �"g�� Are yon an employer9 Check the appropriate bog: Bnsiness Type(r�nired): 1.� I am a employer with � employees(full and/ 5. ❑Retail or part-time).* 6. ❑ RestaurantrBarr/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no �, �Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any ca.pacity. [No workers'comp.inswance r�uired] 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]* 4.❑ We are a non-profit organization,staffed by volunteers, 11.Q Health Care with na emrloyees. [No workers' ��r.�5�,�re�.� 12.�Other 1��L /�J�C L 'Any applicant that chedcs box#1 must also fill out fihe sectia�n below showing theu workets'oompensation policy information. s sff the corpoiate off czrs have exempted themselves,but the c�rporation has other employces,a work�ers'compensation palicy is required and such an organi�ti�should check box#1. I am an emptoyer that is providing workers'co�npensat�on 3nsurance for my emp[oyee� Below is the pol�iy i�eforniation. Insurance Company Name: �1��OLK -� D�DNRr�I N1 u�uA-L �I l�� r•J s uR A-��= ��P�y Insurer's Address: �2Z f�M C�3 S'j�d��T� �Ei�H Ai`E) .M A �202G City/State/zip: 'D C 0 H F}M i M�A o 20 2-6 Policy#or Self-ins.Lic.# �-t�L= f ri g�C70 A Expiration Date: _�1T?-Z f� I� Attach a copy of the workers'compensation policy dectaration page(showing the policy nnmber and ezpirstion date). 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 imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwazded to the Office of Investigations of the DIA for insurance coverage verification. I do henby certify,u the pains and penaltles ofperjury that the informotJon prov�ded above is true and correc� Si Date: �o /`�` 2�I� Phone#: �O$��"�"- � � �- • Offlcia!use oRly. Do not write in this area,to be co�npleted by c�ty or town official City or Town: Permit/License# Issaing Aathority(circle one): i.Board of Health 2.Building Department 3.City/Town Clerk 4.Licensing Board S.Selectmen's Office 6.Other Contact Person: Phone#: www.ma4s.gov/dia i -;: � N OTf CE . ; N OTI CE TO TO r EJ►ll PLOYF�S EM PLOYEES The Con�lmonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston, Massachusetts 02111 617-727-4900 - http://www.mass.gov/dia As required by Massachusetts General Law,Chapter 152,Sections 21,22 8c 30,this will give you notice that I(we)have provided for payment to our injured employees under the above-mentioned chapter by insuring with: NORFOLR & DEDHAM MUTUAL FIRE INSURANCE COI�ANY F INS CE COMP 222 AMES STREET DEDHAM MA 02026 ADD S INSURAN MPANY WL158500A 07 22 2016 LICY DA 215 MAIN STREET PO BOX 330 G.H. DIINN INSURANCE AGCY INC BII87,ARDS SAY MA 02532 F IN CE G ADDRESS PHONE# 573 ROUTE 28 MAA GAYATRI MARINER LLC WEST YARMOUTH MA 026T3 EMPLOYER ADDRESS 09/15/2016 EMPLOYER'S WORKERS'COMPENSATION OFFICER(IF AN� DATE M EDICAL TF�ATM ENT The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers'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 reasonably connected to the work reiated injury. In cases requiring hospital attention, employees are hereby norified that the insurer has arranged for such attention at the NAME OF HOSPTTAL ADDRESS TO BE POSTED BY EMPLOYER Form WC 88 20 01 C Printed in U.S.A. iNsuR�co�v