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Home My WebLink AboutApplication and WC� _ i ' TOWN O�YARMOiTfH BOARD OF HEALTH � APPLICATTON FOR LICENSE/PERMIT-2017 ,: ` •Piease compiete form and attach all necessary documents by r 1¢,,211�. Failure to do so will result in the ret�m of your applicahon pac et. ESTABLISHMENT NAME: ' r. .% �/— I LOCATION ADDRESS: �/� /rJ9r�/ r.?�j" I,�r�y�e�y,q�2� TEL#• S"�3��?��f MAILING ADDRESS: 9/�i /)l�.�l S',j',�i�7'—��c�c�i�R.°i E-MAIL ADDRESS: R,�' T UrZtS�1f � ��A�'.9�•GGN� OWNER NAME: �tA�l'� � n�� CORPORATION NAME(IF APPLICABLE): �l.y"��,�'Q��,J'��f�!J�;�� NIANAGER'S NAME: � ' � TEL.#:f .- O— 6� MAILING ADD RESS: ��t C POOL CERTT FICATIONS: T6e pooi supervisor must be certified as a Poot Opemtor,aa r�uired by State law. Please list the designated Poot O�rator(s}and attach a copy of the certification to this form. l. f1/�� 2. /l/�/� b ... !��'i Pool aperators must list a minimum of two employees currendy certified in standard First Aid and Community = �Y � Cardiopulmonary Resascitation(CPR),having one ccrtified employee on premises at ali times. Please list the r� employees betow and attach copies of their certifications to this form.The Health Department wiU not use�ast � ,� yesrs'records. You mnst provide new capies and maiataia a fik at your pince of business. m �-�` 1. ./l/� 2. /r/� � �'' �-7 3. 4. � FOOD PROTECTION MANAGERS-CERTIFICATiONS: Ail 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 Fflod Service Establishments, 105 CMR 590.Q00. Please attach copies of certi fication to this application. The Health Departmrnt will not use past years'necortls. �' You must provide new copi�and maintain a file at yonr establis6ment. � l. �7.Z7/1 �. �/I'!�� ,��"T7'd�� xTi�%��..� �. �:x, PERSON IN CHARGE: �""� � Each food estabtishment must have at least one Person In Charge{PIC)on site during hours of operation. �-`" ..� 1. c:l�FY r�,�'�►l�'N�"',O 2. h3i�J �T.�/l/��,�r�� ,N , � ��.�, ALLERGEN CERTIFICATIONS: Ail food service establishments are required to have at least one fult-time employee who has Allergen certification, as defined in the State Sanitary Code for Food Service Establishments,105 CMR 590.U09(Gx3xa). Please attach �' copies of certification to this application. The Heaith Department wiil not use past years'records. Yon must � � provide new copies and maintein a file at your est�WishmenG � 11 .�> . 1. �_C�� .r/9Z�l7� 2. _ U�iG /�`.,.7iP C. P � HElML1CH CERTIFICATIONS: � � Ail food service establishments with 25 seats or more must have at least one emptoya trained in the Heimlich w W Maneuver on the premises at all times. Please tist your employees irained in anti-chokirtg procedures below and � attach copies of employee certifications to this form. The Health Department will not use past years'reeords. W �' You must prnvide new copiea aad mAintain a�fle at your place of basiaess. ►. �/� 2, �� 3. 4. ItESTAURANT SEATING: TOTAL#� �nc�Nc: OFFICE USE ONLY LtCENSE REQ�IRED FEE PERMIT k LtCENSE REQUIRED FEE PERMIT p I.ICENSE REQUIRED FEG PERMtT p B�B S53 CA8i13 S53 =LaDUE �5 CAMP SSS __�__ �SWIMMING POOL SI t0ea ____ _TRNL£R PARI: $105 _ _WHIRI.POOL il IOea. FOOD SERV ICE- LICENSE REQ UIRED FEE PERMIT N UCENSE RE UtRED FIiE PIiRMIT A� LICENSE REQUIRED fEG PERMIT# a100 SEATS S20(! COMMON�VI�C.L $60 _____ WIIOL.CSAI.E T80 RETAIL S£RVlCE: � ' —�SID.KITCHEN S8o ""` LICENSE 1tFQUtRGD FEE PERMIT#t LICEA[SE REQUIR�D FEE PF,RMITlt L►CENSE RkQU[RED FEE PGRMtT# =`�S°�0�•�- s�� O7 �I=ROZ N�ESSERTs�dO "- 11'UBRC n�F� EI 10 � NAMECHANCE: SIS AMOUNTDUE _ ` � "+**PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FOR1N""r• � � ADMINISTRATION ' Under Chapter 152,Section 25C,Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFtDAV[T MUST BE COMPLETED AND SICNED,OR CERT.OF INSURANCE A'ITACHED OR WORK�R'S COMP.AFFIDAVIT SIGNED AND AT7'ACH$D Town of Yarmouth taxes and liens mast be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROFRtATELY tF PAID: YES ✓j NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPAIYCY: For purposes of the IimitaGons ofMotcl orHotel use,Transient occupancy shall be limited to the temgorary and short term occupancy,ordinariiy 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 else�vhere.Transient occupancy shal]generally refer to cantinuot�s occupancy of noi more thaz�thiriy(30)days,and an a�,*rcgate of not more than ninety(90)days within any six(6)month period. Use of a guest unit as a residence or dwelling unit shail not be considered transient. Oc;cupancy that is subject to the collection of Room Occupancy Excise,as defiaed in M.G.L.c.64G or 830 CMR 64G,as amended,shall generally be considered Transient !'QOLS POOL OPENING:AIl swimming,wading and whirlpools wh,ich have been ciosed for the season must be inspected by the Heatth Department prior to opening. Contact the Health Dep ent to scheduk t6e iespectwn three(3) days prior to opening.PLEASE NOTE:People are NOT allowe�t�o sit in thc pool area until the pool has been inspected and opened. POOL WATER TESTING: The water must be tested for pseudom�nas,total coliform and standard plate count by a State certified tab,and submitted to the Health I)epartment ihree(3)days prior to opening,and qaarterly thereafter. POOL CLOSINC:Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE SEASONAL FQOD SERVICE OPENING: A(l food service establishments must be inspected by the Health Department priar to opening. Please contact the Health Department to schedule the inspecGon three(3)davs prior to opening. CATERING POLICY: Anyone who caters within the Totm of Yarmouth must notify the Yarmouth Health Department by filing the requ�red Temporary Food Service Appticatioa fortn 72 houts prior to the catered event. These forms can be obtamed at the Health Department,or from the Town's website at www.varmouth.ma.us under Health Deparqnent, Downloadable Forms. FR02EN DESSERTS: Frozen des�ris must be tested by a State certified 1ab prior to openin�and monthiy there�after,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 temu have been met. OUTSIDE CAF�S: Outside cafes(i.e.,outdoor seating with waiter/w�aitress ser�,iice),must have prior approvai from the Board of Health. OIJTDOOR COOKINC: Outdoorcookin�,preparation,or dispiay ofany food product by a retail or food ssrvice establishment is prohibited. NOTTCE:Permits run annuaily from January i to December 31. IT IS YOUR RESPONSIBILITY TU RETURN THE COMPLETED RENEWAL APPLICA'CION(S)AND REQUIR�D FEE(S)BY DECEMBER 16,2016. ALL RENOVATIONS TO ANY POOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND A ROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY RE A SI E PLAN. - DATE:_��`/��Ci`6 SIGNATURE: PRINT NAME&TITLE: �,��%/ � �� R�v.Io/12/16 �" The Commonweahh of Massackitsetls Department of I�cd�striat Accidents . O�ce of Investigations ' 1 Congress Stree�Suite 100 Boston,MA 02114-2017 www mas�gov/dia Workers' Compensation Insnrance Affidavit: General Businesses A�alicant Information Please Print Legibly Business/Orgaruzation Name: /��f'�t�''/�,��,?�j Address: g/,�fj /I�,�¢¢Tj� �'�'" City/State/Zip: �/U � � G�6� Phone #: �U� �3�-o�� Are yo b employer?Check t6e appropr�ate boz: Bnsin ype(reqnired): a 1. I,am a employer with��employees(full and/ 5. etail ar part-time)* 6. ❑ Restaurant/Bar/Eating Establishmern 2.❑ I am a sole proprietor or partnership and have no �, (�Office and/or Sa3es(incl.reaI estate,suto,etc.) emplayees working for me in any capacity. [No workers' comp.insurance required] S• ❑Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. l 52,§1(4�and we have �p,[� Manufacturing no employe�.[No workers'comp.insurance required)* �� Health Care 4.❑ We are a non-profit otganization,staffed by volunteers, wiih no employees. [No workers' comp.insurance req.] 12.(�4ther "AnY apPGc�nt thffi d�lcs box#i must a}so fiU out the section below showing their workers'compensation policy informati�. 'sIf the carporate oflicers have exempted themselves,but the caaporad�has otheremplaye.cs,a workers'oompensation policy is requirod and such an organi7atian should check box#1. I am an employer that is providing workers'compensation insurance jor my emplayee� Below ls the pot�iy lnfornuttion. Inseuance Campany Name: �/� ,��;Y��7` /�77�'G�/irr�/j� Gf/G ��.PDt�� Inswer's Address: l�G� �Ui�`��d�� City/State/Zip: �}�14-�/�✓� I�/f Qo�/Q/.� Policy#orSelf-ins.Lic.#_ D/�/Od S"�,3��if�G Expiration Date:__ l /�- 0�0� Attach a copy of t6e workers'compensation policy declaretion page(showing the policy number aad ezpirstion date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penaides of a fine up to$1,500.04 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 advis�that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I alo kereby certify,u er the pains and penalties of perjary tkat the in,formation provided abave is true and corret7. . � � //- `� 2�/6 Ph �: o -3 �-a/% Offiela/use only. Do not wr#e iir tlris area,to be completed by city or town offieiaL City or Town• PermiULicense# Issaing Anthority(circle one): I.Board of Health 2.Buildtng Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office 6.Other Contact Person• Phone#- www.mass.gov/dia INFORI�ATION PAGE R�SGTAL AGRSENt�iT Insurer. PRODUCER: Agent# 932 MA Retail Merchants WC Group Iac. Dawling & 0'Neil Insurance Agency PO Box 859222-9222 pp g�� 19gp Braintree, MA 02185 Hyannis, MA 02601 (Carrier Cade: 34355) Carrier Policy �: 014005030948116 � Carrier Prior PoYicy �: 014d4503Q998115 1. The Insured: Smithfieid Market of Yarmouthport, LLC Peterson's Market Mailing Address: c/o Barnstable Market 3220 Main St., PO Bax 323 Barnstable, MA 42630 Fein: 205023Q32 Other workplaces not shown above: Tqpe of Business: Limited Liability Co SEE SQ�DULE OE OPERATIONS Risk ID: 2. The galicy geriod is from 12:01 a.m. on __ 1 41 20�6 to 12:01 a.m. on � O1 L2017_ at the iasured`s mailing addres�. 3. A. Workers Compensation Insurance: Part One of tbe policy applies to the Workers Compensatian Law of the states listed here: MA B. �nployers Liability Insurence: Part Two of the policp applies to work in each state listed in Item 3.A. The limits of our liability uader Part Two are: Bodilp Injurp by Accident $_____,._ 500,000 _ eacb accident Bodily Injury bp Disease $ SOU.QOU _�.___ policy limit Bodily Injury by Disease $______ 500.,OOQ each employee C. Otber States Insurance: D. This policy includes these endorsements and schedules: WC004004C(O1/15) WC000308 WC�0040b(08/84) WC040414(07/90) WC0004225(01/15) WC2Q03Q1(04/84) WC200302(�5/86) WC200303B(07/99) WC200306B(�6/13) WC200403{06101) WC280bQ1A(t17/U8) 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verificatian and change by audit. Classifications Code Prem3um Bas3s Rate Per Estimated No. Total Estimated $100 of Annual Annual Remuneration Remune=ation Premium SEE SCHBDtII.B OF OPERATIONS Total Sstimated a�nnual Premiunn $ 14,193.40 Minimum Premium $ 536.00 �pense Constant .00 Deposit Premium . � 'i ; �� _ 1VOTICE �voTlc� ; TO Tp EMFLOYEES EMPLUYEES The �o�rlmanwealth of Massachusetts DEPART'MENT OF �TDUSTRIAL ACCIDENTS 1 Congress Sireet, Suite 100, Boston, Massachusetts 02�14-2017 617-727-4900 - http:/Iwww.state.ma.usldia As required by Massachusetts General Law,Chapter 152,S�6ons 21,22 8c 30,this will give you notice that I(we)have provided for payment to our injurcd employees under the abo�re-mentioned chapt�r by insuring with: MA Retail Merchants WC Group Inc. NAME OF INSURANCE COMPANY PO Box 859222-9222 Braintree,MA 02185 - � ADDRESS OF INSURANCE COMPANY 014005030998116 1/Ol/2016 - 1/01/2017 POLICY NUMBER EFFECTNE DATES Dowling&O'Neil Insurance Age FO Box 1990 Hyannis,MA 02601 508-775-16� NAME OF INSUREINCE AGENT ADDRESS � PHONE# Peterso.n's Mazket clo Barnstable Market Banastable,MA 02630 EMPLOYER ADDRESS EivlPLOYER'S WORIZERS' COMPENSATION OFFICER(IF AN� DATE MEDICAL fiREATMENT The above n�me.d insurer is required in cases of personal injuries arising out of and'm the course of employment to furnish ad�and reasona.ble hospital and medical services in accordance with the provisions of the Workers' Comp�n�sation Act A copy of the First Report of Injmy must be given to the injured employee. The employee may sele.ct his or her own physician. The reasonable cost of the ser- vices provided by the treaiin�physician will be paid by the insurer,if the treatment is necessary and reasonably connectsd to the work related injury. In cases requiring hospi#al attention,enxployees are hereby not�ified that t�insiu�er has anauged for s�h attention at the ��' C�� h�S`��-� �7��5%�� /��_�i�U��o/ NAME OF HOSPITAL ADDRE55 TO BE POSTED BY EMPLOYER