HomeMy WebLinkAboutApplication and WC I s I
� �...--+�+..- .
� ` � ' ���a���:��
� ' � � �� TOWN OF YARMOUTH BOARD OF HEALTH
� APPLICATION FOR LICENSE/P�RNiI - 017. NQ� 2 � �o�s
O..o• �� .� c :..��� � .
* Please complete form and attach all necessary�doc ` sb� ber 016.
,
Failure to do so will result in the return��f yo application p ��'T
ESTABLISHMENT NAME: - 1 / �. TAX ID: C? -
� LOCATION ADDRESS: �. pu`� TEL.#: �$-Z��- p
; MAILING ADDRESS: �N
E-MAIL ADDRESS: ���l nz��,���i � �����-r'
OWNER NAME: ��fZ �v. .r KG
CORPORATION NAME (IF APPLICABLE): j . ,� K :s � t�va r2S, /�lL,
MANAGER'S NAME:��,q,�(+� }�� �(G S i Z� 1�l �b 1�'3�' � TEL.#: �"p�-17 5--
� MAILING ADDRESS:�/ 1�1'1�,n �S�-Gcl,��►�Mr���i-1-��
i
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated
Pool Operator(s) and attach a eopy of the certification to this form.
� ---- --- --
� - _ - _ �- - _
--�.
Pool operators must list a minimum of two e ploy s urrently certified in standard First Aid and Community
; Cardiopulmonary Resuscitation (CPR), having one ertified 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.
;
� 1• 2.
3. 4.
FOOD PROTECTION MANAGERS - CERTIFICATIONS:
; All food service estabiishments are required to have at least one iuil-iime empioyee who is certifiea as a Faod
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.
I 1• 2.
i
'�' PERSON IN CHARGE: �
' Each food establishment must have at leas one erson In Charge (PIC) on site during hours of operation.
1. 2.
_ _ _ - _ _ -- - _ __ _
__ _ __
i
ALLERGEN CERTIFICATIONS:
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 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.
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 procedures 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.
l. 2
3. 4
RESTAURANT SEATING: TOTAL#
- OFFICE IJS� ONLY
u �;;— - —
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
B&B CABIN $55 MOTEL $ll0
$55
I� $55 C�MP SWIMMING POOL$I l0ea.
_LODGE $55 _TRAILER PARK $$05 _WHIRLPOOL $110ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_�1 O�SEA SS $200 —CONTINENTAL $35 _NON-PROFIT $30
_COMMON VIC. $60 WHOLESALE $80
RETAIL SERVICE: —RESID.KITCHEN $80
LICENSE REQUIRED FEE PERMIT LICENSE RE(�UIRED FEE P IT LICENSE REQUIRED FEE PERMIT# f
�<50 sq ft. $50 ,�_�l�e >25,000 sq.�,. $285 VENDING-FOOD $25
_<25,OOOsq.ft. $150 _FROZENDESSERT $40 �TOBACCO $I10 ��
NAME CHANGE: $ts AMOUNT DUE _ $ I�O.OO �
;
i
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** �
got�F t4-�32�-p3 I
bo�TP�-t-�E-as��-o� �
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 �
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR
�
CERT. OF INSURANCE ATTACHED
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
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: Far 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 j
elsewhere.Transient occupancy shall generally refer to continuous occupancy of not more than thirty(30)days,and j
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.
E
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 f
inspected and opened.
POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard 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 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
obt�ined at the Health Department,or from the Town's website at www.varmouth.ma.us under Health Department,
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 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.
OUTSIDE CAFES:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health.
OUTDOOR COOKING: �
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 RETURN
THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 16, 2016.
'I 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 'i
I TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ;
DATE: 1 ' SIGNATURE:
PRINT NAME &TITLE: �R.i�1�r� /u �. "�1 t�G.� ���51 G�E,c7T :
Rev. 10/12/16 �
�
� � � The Commonwealth ofMassachusetts
Department of Industrial Accidents
Office of Investigations
' ' I Congress Street, Suite 100
Boston, MA 021I4-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legiblv
Business/Organization Name:_ ��r�-� f �1� v�� /,1��/,
Address: .���,'I r'I ,�i.
�
City/State/Zip: .\ � D�b�3 Phone#: �� -Z�15- ��j (�
Are ou an employer? Check the appropriate box: Busin ss Type(required):
1 1.� I am a employer with_��employees (full and/ 5. �,Retail
or part-time).* 6. ❑ RestaurantBar/Eating Establishment
_ �n T --- .- . .i�. �rTi17a'T; .0 nt3-- _ -- - -- -- -
7. �—Office and/or Sales(incl. real estate, auto, etc.)
I employees working for me in any capacity.
1 [No workers' comp. insurance required] 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.❑ Health Care
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.
j **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an
I organization should check box#L
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information.
Insurance Company Name.���Q 1�� 1�1�tt ��� �G��'c�iQ Vl� ��.� i��;t
Insurer's Address:�,� , �j�ju; � rJ q o'�pZ�— 9�o� a
City/State/Zip:�(:�1�l�/'P.p �'�,Y4- C'joZ i�'S '
Policy#or Self-ins:Lic. # ����fj l <��� � Expiration Date: !�I IE71 I� �
Attach a copy of the workers' compensation policy declaration page(showing the policy number and eapiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
finc tnj to$Y,56@.00 an;'or�rr�=y-ear'�n�rertt,-a.s vGei��civit p�ait�in t1�e-form-o�a-!s"�'`3s'O�n�a fine
of up to $250.00 a day against the violator. Be advised that a copy of this sta.tement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify, der the pains and p es ofperjury that the information provided above is true and correct.
Si ature: � Date: '
Phone#: FJC�S � �`�[� �"o�(� ;
_ �
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5.Selectmen's Office
6. Other
Contact Person• Phone#•
www.mass.gov/dia
--"""�'� i.UKEL-1 C�P!D:t�A�
.�►�,�zQ►° CERTI�ICATE C)F LIAl3lL�`�'1(' 11'rISU " NC� �1r�n�s'
TNiS CERTIF'!CA'P� IS ISSUE�AS A MATTER t}F WFOt2M�iTiON�NL,Y ANd CONF�RS NO RICiHTS UPQN TFiE CERT(FICA'TH HQI.DER.TNIS
CSR7IFICATE DOES NOT AFF[ftiWATiVEIY flR NEGATIVELY ,43fAEND, EXi'END t3R AL7ER THH GQYERAGE AFFQRDED BY T'F!� POUGIES
B�LQW. TfiiB CER71�iCATE OF fNBURANCE OOES MOT Ct)NSTITUI'� A CbN'fRAC7 8�T1M1t�EN 7HE ISSUINGt iNSURER(S), ALJ7Hf3Rt2�C1
REP32ESENTA3"IVE OR PftODUCER.ANO 7HE CERTIFICA7E NCILDER.
EMPORTAPiT: if the certiflcate holdet is an AD€}ITIONAi. INSUREp,the poticy(fes}must be endorsed. if 6UBRQGATION ES WAIVED,subject to
Ehe terms end eonditions a€the poticy,certain polic�es may requtre an endarsement A statement ars thls cer#iflcate does noi confe�rights to H�e
certificate halder in lieu of such endorsemen s.
PROEK7CER j
W�d.�.Bort�ek It�aurance Agency
311 Piymouth Stxeet uc
Haiifax,lUtA 02338 i
Scatt C Casagrande
INSU 8 APFORDfNSi CGVEftAG� NAIC N
�Nsu�a:Safe insurance 39454
i►�surtea �,UKES UQUQR3,INC.,ETAE, u+su�s:i�as itali Mutuat
24 5pringer Lane �5���;Massachuse#ts Retai!Merchanfs
WestYarmauth,MA0�673
��asu�o:
�sua3�e:
; INSURER F:
CQV�RAGES CERTIF{Ck't'E NUM��R: REVISEON Nt1�H�R: �
TH1S 1S TO CERTIFY TliAT THE POIipES OF IW3URANCE US7ED BELOW tiAVE B�EN tSSU�Cf TQ TFIE INSURED NAMED A80YE FqR THE PQLtCY PERIOD
INDtCATEO. NOTWITHS7ANDING ANY REQUER�M�NT, TERM Oft CONDITION OF ANY CQtJTRACT OR OTHER DOGtIMENT 1MTH RESPEGT Tp V1�{ICH THIS
CERTIFiCAT�MAY BE ISSUED QR MAY PERTAIN,THE lNSUR1INCE AFF4ROE0 SY 7HE POCtCIES OESCRIBEQ HEREiN tS SUB,fEC7 70 A!L THE T�RMS,
F.XCLUSiONS AND C�NQtTfONS OF SUCH POttGIES.LIMITS SHOWN MAY tiAVE$EEN R£DUCEQ BY PAtO CLAiMS.
N R 7Y'PE OF�iBURANCH
PQUCY NUMBBR M N{ DtYYYY ��M�ffi
DENEitAI WiBIUTY EACN pCCURRENCE S 1,bOQ,4�
� A �C COM�tERCint t3ENERA�Llaellmr $MAtiQ'i5774 4S!'(313Q16 OS11312017 ��g T�E�� g � 300 QO
Cu►iMs.nnan� X�oocua e,�o�+ mw a*�+ s 14,
�Rsowu�s�v autusr s 1,QOO,tl
flENERAI AGGREC3A7E 5 2,00�,0
GEhCt AGGREC3A7E LIMITAPPLtES PER PRUaI,�TS-C4t�JOP Ati(3 S ZtdQ��Q
POtICY pg�` �� 5
� AU70MO611E tJAHfIITY L
ANV AUTp BQDIlY�IJURY(Per pMSort? ;
AAUTOS�E� AUTOS�� B�ILYINJURY(Pera�t} g .�..
� HON-CiWNE4 .....—'—'
I nIRED AUT48 p�ps � S
� S
}( uMa�.�a une X c�cuR eactt accurtac-�ce s 3,040,fl0
� q gxc�sssuae GtRIM$�tAAUE U{100t)18'ti D81131ZQ1B ObM3J2ti1� ar,c�tgC,ns� s 3,p00,0i}
I aea � RETENFION 'tQ�O s
WORKERS COMPENSATta1! WC STkTU- H�
i Aapg�saWt�s't�elu7v
C aNv�aoa����at��tt�xecuTtve Yr� 14D47Q898 01l0112�16 09109/38't7 £.t.�nCt+aCCioa� s 5�3D,�
OFFICERIMEMBEREXCLt�CJ? tv � N1A ACH
C (iArndatory in NH} L3CY R�NEYVAL Q1/4112417 01tQ4120f8 E.t.OISEA8E•EA EMPLOI" s SOO,tiO
�o�`sc��8�aanoHs�e� E.t.DISEASE-POLtCY LqullT s 600,00
B QU�R LlABtLiTY OQ56842Lt a5113120t6 051i3t20l7 PEl2 OCC 1,000,
t3{3REt3ATE 2,d130,4Q
a�sc�w�ro�oa a��e;�roasttoca�s�v�uct�s{aa.en ncor��+�,aaamo�.��,,.,x.awti�t��,�rmor��.ts roqw..ay
GOVERSD LOCAT�ON: 51I bSA2IJ S�RE�T, & ZO 3PR22�tGER LJ�tt�L, S4E3x' YAI2MOUx'Fi, b!A'
0�573
GE�2TtFlCATE HO�DER C�tNCELLA710N
SHOULD ANX OF THE ABOVE DESCE216E0 POUCIE3 BE CkWCELlEO BEFORE
TOWt�QF WEST YARM�JUTH 7HE �J(PtRRT10N DATE THEt2E0P, NQ'CI� WILL BE REI.IVE,RED !N
Acca�awce w��rt�PaucY PRav�s�aNs.
WES7 YARMO!lTH,NG4 02673
Ai1TNORIZ�p REPRL°SENTATEVE
Scvtt G Casagran���j�� ����,..
J
�'E9&8-2Q'f0 ACORD GORPORATION. Ati rights t�esetved.
ACDRD 25(2010t05} The ACORD narrse and logo are registered marks of AGflRD