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Home My WebLink AboutApplication and WC Florio, Mary Alice From: Florio, Mary Alice Sent: Friday, November 18, 2016 4:10 PM To: 'permits@globalp.com' Subject: FW: 2017 Licensing -Alltown Yarmouth, 511 Station Avenue, South Yarmouth Attachments: MA State Workers Compensation Insurance Affidavit Form - General.pdf Thank you for submitting the 2017 application for your establishment's licenses issued through the Yarmouth Health Department. However, prior to issuing the license to you, we are required under Massachusetts State Law, Chapter 152,Section 25C, Subsection 6, to have you submit a completed State Worker's Compensation Insurance Affidavit form, or to have you submit a Certificate of Insurance from your insurance agency indicating that your State Worker's Compensation is in effect. Please complete the attached affidavit form and return it to our office, or have your insurance agency send us a 1 certificate of insurance showing Worker's Compensation coverage. As soon as our office receives the required information regarding your worker's compensation coverage, we will be able to process the license. If you have any questions on the above, please feel free to contact the Health Department at (508)398-2231, ext. 1241. Thank you for your anticipated cooperation. MaryAlice Florio, Principal Office Asst: Yarmouth Health Department 1146 Route 28 South Yarmouth, MA 02664 508-398-2231,ext. 1241 1 lN��r`��n� � ��uCDD TOWN OF YARMOUTH BOARD OF HEALTH �� APPLICATION FOR LICENSE/PERMIT-2017 ��T c' S1016 *Please complete form and attach all necessary documents by De ember 16 201 . Failure to do so will result in the return of your applicat�on pac et. Hrv�^,�_,,,j,� ��P �r. ESTABLISHMENT NAME: ` - : LOCATION ADDRESS: (I TEL.#: MAILING ADDRESS: E-MAIL ADDRES :PQ o .� OWNER NAME: � �,_� CORPORATION NAME(IF APPLICABLE): �OI�C..' � ` Yl� `►' - � MANAGER'S NAME. ' TEL. . MAILING ADDRESS: � � POOL CERTIFICATIONS: � ''� The poot 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. C�J�:, 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 times. Please list the employees below and attach copies of their certifications to this form.The Healt6 Department will aot use past years'records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. FOOD PROTECTTON MANAGERS-CERTIFICATIONS: All food service establishments aze 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 certificarion to this application. The Health Department will not use past years'records. You must provide new copies and maintain a�le at your establishment. 1. 'f�G�`�`"►'I�Q.S�-I�l WI.Ca� 2.��i�/�� D(7 PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. 1. rU�f-�Iti-kJ�ClL.�'1 UU�`� 2��(.l (.r��R,I�c� ALLERGEN CERTIFICATIONS: All food service establishments aze required to have at least one full-time empioyee 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 maiutain a file at your establishm 1. `�� I.�V v�.� 2. G� 'O 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 procedwes 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. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT N LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FE6 PERMIT# B&B $55 CABIN $55 MOTEL $110 IND1 S55 CAMP $55 SWIMMING POOL$1 IOea. LODGE S55 TRAILER PARK $105 �WHIRLPOOL 5110¢a. FOOD SERVICE: LICENSE REQUIRED FEE RMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �>100 EA SS $200 �� COMMONrV C $60 WHOLESAI.E $80 — '— —RESID.KITCHEN S80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUTRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT l� <50 sq.ft. S50 >25,000sq ft. 5285 VENDING-FOOD S25 =<25,000 sq.ft. S150 �(o _FROZEN AESSERT S40 �TOBACCO SI 10 �O�O NAME CHANGE: S15 AMOUNT DUE _ � 3�:�•UCl "*"**PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***"* � 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 COMPENSA'I'ION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR ' CERT.OF INSURANCE ATTACHED OR WORKER'S COMP.AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth 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 OCCUPANCI': For purposes of the limitadons 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)clays,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) ciays prior to opening.PLEASE NOTE:People aze 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 piate 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: Ail 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 Hea1th Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Heatth 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 therea8er,with sample results submitted to the Health Departrnent. Failure to do so will result m the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAF�S: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. i OUTDOOR COOHING: �, 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 RETtJRN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 16,2016. � ' 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 REQUIRE A SITE PLAN. DATE: I�I.�� p SIGNATURE• � �- PRINT NAME&TITLE: Cs�✓�(� �� Rev.10/l2/I6 ��,t,(M(i�� , �� , ..`.-.., � The Cammonweatth nf Massachusedts y Department oflndr�strtal Accfder�ts O�ce o1'7r�vestigatlans . � 1 Con�ress Street,Suite X DD Boston,�IA 021Y4-20I7. ; www.mass gov/dla ' Workers' Corapensation Lisuranc�A,ffidavit: General Bnsinesses ' ApplxC�lA��R�OP1aA8.�A0ri P se Print Le�fblv Businass/flrganzza�ivn Name: ,� °� � �Q�`�vu�-1�.., �ddress• � City/State/�ip: Y �1 (�hone#: �� ^�``� Are you an employer?Check tl�e apprnpriate box: Bnsiness Type(required): 1.[� 1 am a�nployer wlth emplvyees(futl and/ S• ❑Retail or part-time),* 6. ❑RestaurantlBarBating�stablishment 2.[� I acn a solc proprietor or partnership and have no 7, �Office and/ar 5alos(incl.reel estate,aato,etc.) emplayees working far me in a�ny capaoity. (Na workars'comp,insurance re�uired] $• �Non-prafit 3,D Wo are a corpora�ion and Its aff'icara have exereised 9. ❑Entertainment their ri�t of e.�amAtion per c. 152,§l(4),snd we have �p,�]Manufacturing no employees,[ATo wor[zers'cornp,insurance requ�red�� 11.(�Heslt�s Care 4.❑ We ar�a nan-profit organizatton,xtafFed by volunteecs„ � with no emptoyees.[I+10 workers'eomp.insuranas r+eq,] 12.�Other RAnp epplicant tlaat cheal�bax#1 must also fill out the sectian betow stuowing thau workers'coroponsaNcm poliey infmmation. �'If the oorporata affioers h�ve exempted themsalvcs,but ihe co:porstion has other employees,a warkers'compensadon poJloy is reqnircd end such an oap�anization shovld che�c bmc#F. �` I am an ernployer ih at 1s prav irig workers'onmper�sartlon tn�uranae for ray�rnpfoyees. .�3eYo�v�s th�poltcy informartto�r. Insurancs Company Name: i � I s('� �E�t�F P Insurar's Address� !�� 1,.�� i �� _,� _ , . City/State/Zipc fJ�4^��,�,W �� Q . Policy#� r SsJf-ins.Lia#�,�� t"��""�'�.�'_��" �J�.�f5 �xpiratian DaGe:, ��,��"1 , c a copy of the wprkers•compen�ation policy dectaration page(showing the poliuey apmber and ezpfrat�ou date). Fai lure ta secure coverage as required under 3ect�on 2SA af MQL a l 52 can lead tn the impesitlon of crlmin�l penalties of a fine up ta$1,500.�7 and/or one-yesr imprisonmen�,es well as eivii penal�ies in the forcn of a STOP WORK�RDER and a fine of up to$ZSO.QO a day againsi tha violawr, Be advised that a copy of this statement may be forwarded tv the Qfl�ca of Investigations of the DIA for insuraaca coverage verif�cation. v, 2'do itereby ert�,ut�d r the pa�rrs anr!p�nal�tes a,fp�rJury ihat dhe�tnforntatlon provided above is lrue and correct. Ph�n��"l�S�,' ��"�� , pflfcial use only. Do riot write in tl:t�atea,to be cofnpletert by clty or tnwn of',f�ctrt� � City or Town: PermitlLicense# � Isauing Aathori�Ey(oircic one): • 1,Board of Yiealth 2.l3uildiq�D�partment 3.City/�'own Clerk 4.I,iceusing Baard 5.8electmen's Offfce ' 6.Other . Con#aet k'erson: phaIle#; � www.mass.gw/die � WORICERS COMP�NSATION ANQ EMPlO1fER5 LfA81LITlf tNSURANCE POLICY Liberty Mutual. IMFO}ZMATION F�AGE 775Be►keley8treet Bas►on,MA91118 Issued by liberty insurance Corporetlon (a s#ock company) 2981�4 Polfcy Number WA7-89D-460066-016 Issufng Office Lewlston,ME Renewal Of WA7�83D-4600fifi-015 Issue Date 1d/1812018 ACcount Nurnber 9-46d086 5ub Account 0000 t. fnsured and MailEng Address F�iN 74-3140887 G[obal Partners,l.P NJ TIN 1419242�2D00 800 South 5treet,Sulte 60D pQ B�g�� Risk 1D 911385333 WAL7HAM MA o2R153 Status Limlted Partnersttip Other workplaces not shown abave:Sea Item 4.Premium-�xtension pf Inforrr�ation Fage 2. Po�icy F'eriod:The poiicy perind Is from 90/01/2018 to 1U/p1/20�7 12:01 A.M. ate�ndatd tlms at the �naured's rnail}ng address. 3. Cn�erage A. Worfcers Camp�nsati� Insurence:Part One of the palicy appltes ta the Worksrs Compensslion Law of the statas Ilsted here: C�'FL GA IN IA ME MD N1A MT NH NJ NY NC OR PA RI TX VT VA B. Emplaysr& Liabilliy Ensurance:Rari 7wa af the policy appEles tn work In 6ad��tate ilsted In item 3.A. The limits of n�x flability under Part Two are: Bodify in�ury byAccldent�$ 1,0OO,OQO each accidenk eodf�y InJury by Disease $ 1,OOO,DOfl policy limit �odEly En]ury by bisease $ 1,0OO,OQd eaCh employee C. Odier States Irtsurar�e:Part Three of the poficy appUes to the statea,if�ny,I�ted here: AIt States except those tisted In Item 3.A and the St�tas oC ND dH iNA WY D. This policy inciudes thesa endorsements and schedutes; See Item 3.Coverage D-Extension nf lnformation Fage 4. Premium: The premfum#ar this palfcy wllE be detsrmined by our Manusis nf Rules,Classiflcations,Ratea and Rating Plans. All information requi�d betaw is subJsct to veriflcatton and change by aad{t. Classlflcations Code Rremfum Basis Total fiake per$900 Estimated AnnuaE IVum er Estimated Anwa!Remunewatlan of Remunetation Premlurrt Ses Extens(on of Informatlon Page Minlmum Premium Totai Estimated Annual Fremfum � Premium wili be bEllea Hnnual Dsposit Premfum $ � Oeposft Tax/Sur�chargelAssessmen# $ � Producer 00�2 000489 Countersigned by Autharized Rep. (FL) L�CKTQN COMPAWIES LLC(OALLAS SERI�S) 210U ROSS AV�57E 'l400 DALLA9 TX 752U'f 67U8 Rroducer MAST�RS 6828 lrving,T7t WC 00 p0 07 A �1957 NaHonal Councll on Comp�sation Insurahce,Inc. WC 00 OD fl1 8 (CA) Ed.O7/0i/2411 Aff Rig[�ls R�served P�e 1 of 1 ;