HomeMy WebLinkAboutApplication and WC,
� r 'TOWN fDF YARMOVTI�I BtDARE2 f2F�iEALTH
APPLICATION FQR LICENSE/PERMIT-Z017 :�v�.
•Please complete form and ati�ch all ne�essary documents byp�c__e_m�ber�Ib,�20I6.
Failure w do so will result in the retum of your applicat�on p�r
ESTABLISHMENT NAME: -�.
T,OCATION ADDRESS: � TEL.#: o �ji'
MAILING ADDRESS: a 6` C
E-MAII.ADDRESS: c: •C u
OWNER NAME•
CORPORATION N (IF ICABLE): G � �
Iv1ANAGER'S NAME: L' 'I�c TEL.#:
MAILING ADDRESS:
POOL CERTIFICATIONS:
T5e pool sapervisor must be certifled as a Pool Operator,as required by State law. Please Iist the designated
Pool Opt�s�aWr(s)and attach a copy af the certaficarion to this form.
1, 2.
Pool operators must list a minimum of two employees curnntly certified in standard First Aid and Community a
C�tdioputm�nary Resuscitation(C�'R),having onc certified cm.ployee or.grcm�scs at alt timcs. Pless.,;ist thc =� o a F `�
employees below and attach copies of their certificarions to this form.TLe Health Department will not use past '`� m �`
years'records. You musi provide new copies and mafntain a file at your piace uf bnainess. � � �,'; ;
3• ....�_4. , � r ,�
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FOt�v PRt7TEC 1 ION h�1ANAGERS-CEIt"IgICATIONS:
All food service estabiishments are required to have at least one full-time employee who is certified as a Food
Prutectior.Mansger,as defined in the State Sanitary Code for Fooci Service Establish.anenis, lU5 CMR 590.440.
Please attach copies of certification to this application. T6e Health Department wiU not use pasE years'records.
You mast provide new copies aad maintain a fite at your estx66sLmes� � .+�
.�'`:::�:.?t�t;.:��
1. 2. k ;�
PERSON IN CHARGE:
Each food estahlishment must have at least one Pets�n tn t'hei'�e{PIC}on sibe during hours of operatian. .
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1. 2. :,;,'�
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ALLERGEN CERTIFICATIONS:
Atl food service establishments are:equired to have at!east one fult-time emglc�,�ee who has Allergen certification, ���
as de$ned in the State Sanitary Code for Food Service Establishments,105 CMR 590.009(G)(3}(a). Please attach �`w
copies of certification to this application. The Heslth Department will not use past yes�rs'recorde. You mnst
provide new copies and mAfntaln a file st your establishment.
1. 2.
�IEIMLICH CEItTIFICATIONS:
All food service establishrnents with 25 seats or more must have at least one employee trained in the Heimlich
Maneuver on the premises at a!1 times. Please list your emmployees tisined in anti-choking procedures below and
attach cupies af e��playee certificatia�ta t�iis furm. T6e He�ith I3epart�eng will nui use pasF year�'r�ords.
Yoa must provide new copies and maintaln a flle at yonr place of business.
t. z.
3. 4.
RESTAURANT SEATTNG: TOTAL#
OFFICE USE ONLY
LODGING:
LICENSE REQU!!t£D FEE PERMIT q LICENSE REQUIRED EEF. PERMIT# UCENSE REQUIRED FEE PERMtT#
B&B $53 CABIN SSS MOTEI. SI10
�NN SSS CAMP SSS =SWIMMING POOL Si t0ea.
�Y.OD(3E E53 �fRAILERPARK SIQS ____WHIRLPOOL SllOea
FOOD SERVICE:
LICENSE REQU[RED FEE RMIT LICENSE REQUIRED FEE PERMI'f tl LtCENSE REQUlRED FEE PERMIT il
�0-100 SEAT'S 5125 ���' CONTINENTAL $35 NON-PROFIT S3Q
�>I00 S�ATS S2W �COMMON V[C. S60 �Q7`� —WHOLESALE S80
—RESIA.KITCHEN S80
RETATL SERVICE:
L1�ENSE REQUIP.ED �CG PERMIT# LICENSE REQUIREU FF.E ?ERMIT k L[CENSE REQUIRED FEE PERMIT#
<SOsq R. SSQ . >25 000sq iL 5285 VENDING-FOOD S25
=<25,OOOsq.ft. $iS0 �RaZENDESSERT S40 ^TOBACCO SUO
NAMECHANGE: SIS AMOiJNTDUE = SJ$�. i(,3(]
•*•••PLEASE TURN UVER AND COMPGETE OTHER SIDE OF FORM•�+*• f .
(Ij 0 N F-I�-�O y 2--�� • "
_ __ _ �-
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� ADMINISTRATION
Under Chapter 152,Section 25C,Subsection 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 II�i1RA1�iCE ATTACHEO
d�t
WORKER'S COMP.AFFIDAV!`T 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 AIYD OTHER LODGING ESTABLISHMENTS
TR.ANSIENT 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 hotei use.
Transient occupants must have and be able to demonstrate that they maintain a principal place of residence
elsewhere.Transient occupancy shail generally refer to continuous occupancy af 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 subject to ttie collection of Room Occupancy
Excise,as defined in M.G.L.c.64G or 830 CMR 64G,ss t�tiended,sha31 generally be considered Transient.
POOLS
POOL OPENING: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 Department to achedule the Inap��on three(3)
days prior to opening.PLEASE NOTE:Peopie are NOT allowed to sit in the pool area until tlie pool has been
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�(3)days prior to opening,and quarterly
thereafter.
POOL CLOSING:Every outdoor in ground swimming poc�l m�be drained or covered within seven(7)days of
closing.
FOOD SERVICE
SEASONAL FOOD SERVICE OPENING:
All food service estabiishments 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 Yazmouth Health Department by filing the
reqwred Temporary Food Service Application form 72 hours prior to the catered event. These forms can be
obtatned at the Health Department,or from the Town's website at www.varmouth.ma.us under Health Department,
Downtoadable Forms.
FROZEN DESSERTS:
Frozen desserts must be tested by a State certified lab prior to opening and monthiy 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 tem►s 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.
OUTDOOR COUKING:
Outdoor cooking,preparation,or display of any food product by a retait or food service estabtishment is prohibited.
N01'ICE:Permits run annually from Januaty 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED RENEWAL APPLICA"i'ION(S)AND REQUIRED FEE(S)BY DECEMBER 16,2016.
ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NF.W
F,QUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PR10R
TO COMMENCEMENT. RENOVATIONS MAY REQ 1RE A SITE PL
DATE: I°L j IQ�`ZGI�v SIGNATU •
PRINT NAME&TITLE: �i� <(�
Rev.10/12/lb
• � The Co�onweolth ofMassach�rsetts
.
Departme�tt of Indr�ial Aecidents
0,f,�ice of IRvestigations
1 Cor�gress S�te;Saite 100
B�it,MA Q�II�2017
W�vti�+.�pr�g�vv/dia
Workers' Compen�ie�t�Af�'idavit: General Bnsinesses
Aaalicant Informatlou „�„s, Please Print Legiblv
� �
Business/Organization Name: i V_ �'.
Address: ��.� fiT i'-}�, �...� .
c���s��iz�,: oz���e#: �oS� 39� ly��
4---
Are you an employer?Cbeck e appropriate boz: Bnsiness Type(reqnired):
1.❑ I am a amployer with employees(full and/ 5. ❑ Retail
or gart-time).* 6. (�Restaarant7Bar/Eating Fstablishment
2.❑ I arn a;oc,f�rprnprietor or partnership and have no �, � pffce snd/or Sa1es{incl.real estate,auto,etc.)
employees working for me in any capacity.
[No workers' comp.insurance required} � g• ❑Nan-profit
3.❑ We are a corporation and its officers have exercised 9. ❑�tlfdtainment
their right of exemption per c. 152,§1(4),and we have 10.� Manufacturing
no employees. [No workers'comp.insurance required)* 1 l.� Health Care �
4.❑ We are a non-profit organization,staff'ed by volunteers,
with no employees. [No workers'comp.inswance req.] 12.�Other
'�Y aPPlicant that chedcs box#1 must aiso ff11 out the sxtion below showing their vvorkers'compensatioa policy infocmatia�.
"•tf the cotporate oflicers bave exempud�Ives,but the corporation has otMx an�loYees,a workers'compeosation poIicy is nequirai and such aa
orgaeiaation should check box#l.
I am an employer tkat is pmvlding worA�ers'compensardon lierl�,)Qir my employeeS Below Js the pollcy fnjorn�ation.
Insurance Company Name:
Insurer's Address: .��..�` ,� f���
City/StateJZip:
Folicy#or Self-ins.Li�.# Expiration Da*.,e.:
Attach a copy of the workers'compensation policy decfaration page(showing the policy number and ezpiration date).
Failure ta secure coverage as required under Section 25A of MGL c. 152 can iead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonnnent,as well as civil penalties in the farm of a STOP WORK ORDER and a fine
af up to$250.00 a day against the violator. Be advised that a copy of this state�nent may be forwarded to the Office of
Investigations of the DIA far insurance caverage ve�ification.
I do kereby certify,under the� of perlr�ry that tlte i�tfotnration provlded abave ls true and corred
. t 2 C4 2a/�
Phone#:
Offtclal use only. Dv not write�n th�s area,to be can�pleted by city or town o,j�'ic�iiL
City or Town: Permit/License#
Issuing Anthority(circk one);
1.Baard of Health 2.Building I?�partment 3.City/d'a�vn Cterk 4.LicensocEg Board 5.Sel�en's Office
6.Other
Contact Person: Phone#:
www.ntass.gov/dia
qc�o��. 26. 20�6 �o. 38�MTIFICATE �F LIARILITY INSURANCE Nn� 655' 1a��2�8izo 6
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THIS CERTfFICATE 19 133UED AS A MATTHR OF INFORMATION ONLY AND CONF�RS NO RIGHT$ UPON THE CERT�FICqTE HOLDFR. THIS
CERTIFICATH DOES NOT AFFIqMA71VELY OR N�GA7IVELY AM�ND, EI(TEND OA ALTEH THE COvERAGE AFFpRDED 9Y THE POLICIE9
BELOW. 7HI3 CEHTIFICATF OF INSURAldCE DpE3 eOr CON9TITU7E A CONTRACT BE7wEEN THE iSBuING INSURER(S�, AurHORIZED
REPRESENTA7IVF Op PqODUCER, +4PfD TME CERTIFIGATE HOLDER.
IMPOqT1WTc 1��he cetiNlCate hold6r iy an ApDIT10NAL lN3URED,th0 policy(les) muaf be endor9ed. 11 3UBROOATION IS WAIVED,aub�ect to
the terms antl eondltlon9 0�tMe pellcy,cehaln poltriee may reqWre an endo�aemenf. A aleteme�[on thle cerlilicale doea not conler rlghta to the
cerin�ca�e hoitler in�leu or sucn endoroemenl(s).
'�oDWGER
MCSHEA INSURANCE AGENCY INC ""'"E
PNONE ,�, (508)420-9011
1550 Falmouth Rd Ste #2 A,4 ruo:(508)420-9010
Centerville, MA 02632 aooAess��ngure@mcehesinsurance.com
EF
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�SURED . . . . .. . . � R19UNlBIS) aFFodoN�IG COYEpape . .. .IM�Gr . . . �
Jez'k Cafe, TNC IN$URERA:Ngt10118,�, Gr�.q(�0 Mi1tU91 II18 Co,
Glen Roy Hurke ��,RER a:The Hartford Iaaurance Gompany
' 39 Joe LinColn Road iNsuqEac;
Weat Harwich, MA 02671 in�suAeR o:
iNSURBR E:
NJSURER F:
:OV�RAGES CERTIFICATE NUMBER: REVIS�ON ►VUMBER:
THIS I��'o CERTIFY THA7 THE POLICIES�F INSURANCE LISTED eELOW HAVE BEEN ISSU�D TO 7HE INSURED NAMED A80vE FOR THE POuCY PERIpp
IND�CATED. NOTWITHSTANDING ANY REQU�PEMENT,TERM OR CONDRIQN OF ANY CONTRACT OR OTH�R DOCUMEN'f WITN RESPECT TO 1NNICH THIS
CEHTIF�pTE NtAV eE fSSUED OR MqY PEFITAIN, THE INSURANCE pFFORDED eY THE PbuCIES DESCFIIeED HEREfN IS SUBJECT TO ALL THE TERMS,
i EXGlUS10NS AND CONDITIQNS 0�SUCN POLICf�S.IIMITS SMOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
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j tn Tl'PE OF WSUqANCE �gq POL�Y NUMBER F P
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:EfiTIFICqT� H�LDER CANCELLATION
Board o£ Health
1146 R011t6 ZE SHOULD ANV OF TH�ABOVE DESCRIBED POLICIES BE GANCELLED 6EFOFE
THE El(PIRATION DATE THFREOF, NOTI�E WILI BE DELIVEREO IN
South YarmoUth, DQA 02669 �CCORDANCE wirH 7HE POL�Cr PRov�SiONS,
. AUTHOAkED flEPRES6NTq71VE .
P`� Y�(C��-
�`d 1986-2009 ACORD CORPORATION. All rights reserv,�ci.
�CORL�25(2008/p9) The ACORD name and logo are�egistered mdrks or ACORd