HomeMy WebLinkAboutApplication and WC � TOWN OF YARMOUTH BOARD OF HEALTH =-,-`���.�_
d� APPLICATION FOR LICENSE/PERMIT-2017
*Please complete form and attach all necessary documents by De mber 16 2016.
Failure to do so will result in the return of your application pac et.
ESTABLISHMENT NAME: - �
LOCATION ADDRESS: 10 O S. v�3 TEL.#: ZS� O�'oL I`I�
' MAILING ADDRESS: O .1'-
E-MAILADDRESS: YVICbIRiav�.SL��}C,(12ari.r���i-
OWNER NAME: —�CS 1�aa- ,n:Se 1M c�
CORPORATION NAME(IF PLICABLE):
MANAGER'S NAME: i 2 TEL.#: .5' - = IcfO
MAILING ADDRESS:
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 forrn.
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Pool operators must list a minimum of two employees currendy certified in standazd First Aid and Communi = c-;; �
Cardiopulmonary Resuscitation(CPR),having one certified employee on premises at all times. Please list th -�
employees below and attach copies of their certifications to this form.The Health Department will not use pas m �,.z .�;
years'records. You must provide new copies and maintain a file at your place of business. � -v'' �
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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 Health Department will not use past years'records.
You must provide new copies and maintain a file at your establishment. � �_
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PERSON IN CHARGE: � � :;;j
Each foo�l establishment must have at least one Person In Charge(PIC)on site during hours of operation. ,� _
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ALLERGEN CERTIFICATIONS:
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Ail 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 Faod Service Bstablishments,105 CMR 590.009(G)(3)(a). Please attach
, copies of certification to this application. T6e Health Department will not use past years'records. You must
provide new copies and maintain a 61e at your establishment. ,
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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. T6e Health Department wiii not use past years'records.
You must provide new copies and maintain a file at your place of business.
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3. 4.
RESTAURANT SEATING: TOTAL#
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERM[T#
BBcB S55 CABIN $55 MOTEL 5110
INT1 $55 —CAMP $55 —SWIMMING POOL S110ea.
=LODGE S55 =TRAILERPARK S105 �WHIRLPOOL S110ea.
FOOD SERVICE:
LICENSE RE UIRED FEE P RMIT# L[CENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_�0-100 SEA�S a125 -�_�l� CONTINENTAI. E35 NON-PROFIT $30
,>100 SEATS $200 ��OMMON VIC. " �60 �� =WHOLESALE SSO
RETAIL SERVICE:
� —RESID.KITCHEN S80
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_<SOsq ft. $50 >25,000 R. $285 VENDING-FOOD S25
_<25,OOOsq.ft. SI50 =FROZEN�ESSERT S40 �QZ —'I'OBACCO $I10
NAMECHANGE: $IS AMOUNTDUE _ $ ��• �
****•PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM••**•
�o�F�S-a q z�{—o�..
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ADMINISTRATION
Under Chapter 152,Section 25C,Subsection 6,the Town of Yarmouth is now required to hold issuarice 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 COMPENSATTON INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR
CERT.OF INSURANCE ATTACHED�/
OR
WORKER'S COMP.AFFIDAVIT SIGNED AND ATTACHED
Town of Yannouth taxes and liens must be paid prior renewal or issuance of your petmits. 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 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.Traasient acctspancy shall ge�erally refer to continuous occupancy of not more than thirty(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 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 schedute 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
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:
Atl food service establishments must be inspected by the Health Department prior to opening. Please contact the
Health Department to schedule the inspec6on 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
obtained at the Health Department,or from the Town's website at www.varmouth.ma.us under Health Departrnent,
Downloadable Forms.
FROZEN DESSERTS:
Frozen desserts must be tested by a State certiiied lab priorto opening and monthly thereafter,with sample cesults
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 CAF�S:
Outside cafes(i.e.,outdoor seating with waitedwaitress 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.
;
� 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. �
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' ALL RENOVATIONS TO ANY FOOD BSTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW ;
� EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR I
TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. '
DATE: L C) 2 ( SIGNATURE:
PRINT NAME&TITLE: C,._� �� S "�� 1 !
Rev.l0/l2/16
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,
� Thc Co��rmoRwealth of Massarcl�useus
Departn�tnt oflndrastriolAccideRts
O,,�ice of I�tvtstig�o�s
� I E'oagress S�ree�Suite IOrl
Br�stor,MA 0211�F2017.
www�nassg�►v/dia
Workers' Compensation Iasucance Affidavir Genernl Businesses
Anal�ant Iaformation Please Priat Legi6►I�v
Business/Organization Nanne: m c_���_�('��n�S
Adaress: �d 61�v���. S�i� l �I� � �.��-I-�QVI I(�- ��3 5 �
City/State/Zip: Phone#: S�g '�3 O -�I�l�
Are y an employerT Cbeck the appropriate boz: Bnsisess TYPe(�9���)�
ri
1. I am a employer with employces(full and! 5. ❑Retail
or part time}.* 6. ❑ RestaurantlBar/Eating Establishu►ent
2.❑ I atn a sole pr�prie�tor or partnership and have no 7. ❑ Office and/or Sales(incl.reat estate,aub�,e�c.)
employees worldng for me in any capacity.
[No workers' comp.insurance required] 8. ❑Non-pzofit
3.❑ We aze a corporation and iLr of�"icers have exercised 9. ❑Ent�tainment
their right of exemption per c. 152,§1(4�and we have 10.�Manufacturing
no employees.[No worke,zs'comp.insurance required�*
4.❑ We aze a non-profit organization,staffed by volunteers, 11.[]Healtt►Care
with no employces. [No workers'comp.insurance req.] 12.[� (}ther
'Any�plicant that checics box�kl must also fill o�rt�e saxioo below showiug then�vrorka�s'000u�msation Po]i�Y m�cmation-
:sif the carpo�ate offiocis have exempted thtmselves,but the�o�poratian has other employoes,a vw�rs'oo�o�Policy is requinod and such an
ot�anizatian should checdc box#1.
I am an enrployer that is providing workers'c»n�per�swtlon 3nsurance for my employee� B�low is the policy iafon»a�ou.
Insurance Connpany Name: �.S�t �� �C��1�'��/��
Insw�er's Aaaress: ,3v I� �C�,f�2�h u��� S�t 7og
City/State/Zip: �
Policy#or Se1f-ins.Lic.# ''I�1� � 1 � Expiration Date: �,�a�17
Attach a oopy of the workers'compensation po�y d�aelaration p�ge(showing the policy nnmber and ezpiratioa date�
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of eriminat penalties of a
fine up to$1,500.00 and/or one-year im�isonment,as well as civil penalties in ffie form of a STOP WORK ORDER and a fine
of up to 5250.W a day against the violator. Be advised that a copy of this statennent may be forwarded to tl�Office of
Investigations of the DIA for insurance coverage verification.
I do Ikereby cerkfy,uad�r the pains and perralti�s ofperjury tkat the�ieformat�on prov�ded above is brce and correc�
i �0 I�( (
�o�#: so 'a3o- ac�a
Of,�fcial r�e only. Do�rot write�u tlkis ar�to Ix cohy�ldad�y city ur toKm o,,�iciaL
City or Towa: Permifll�oe.ase#
�ssaing Ant�ority(cirele oae):
1.Boa�rd of Hea[th Z.�ildi�g Departmest 3.City/Towd CI� 4.Ia�x�g Biard 5.Select��'s Offioe
b.Other
Coatact Peraon• Phone#:
www.mass.�ov/dia
Massachusetts
McDonald's Operators' Workers' Compensation Group, InG.
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WORKERS' COMPENSATION AND
EMPLOYER'S LIABILITY
CERTIFICATE DECLARATIONS
ITEM 1.
Name and Address of Member: Certificate Number:MAWC-17973(16)
McBee Enterprises, LLC Type� Corporation
McDonald's Restaurants '
50 Oli�er Street, Suite W-16 FEI#: 043544475
North Easton, MA 02356 .
Locations:All usual workplaces of the member at or from which operations covered bythis fund are conducted and
located at the abo�address unless otherwise stated herein.
ITEM 2. Contract Period: From 01/01/2016 to 01/01/2017 12:01/�M Standard Time at address of inember stated herein.
ITEM 3a. Co�erage Aofthis certificate applies to the workers'compensation law and anyoccupational disease law of Massacuse
ITEM 3b. Employ�rs Liabiliiylnsurance: PartTwo ofthe policyapplies to work in each state listed in item 3. The limits of
liability under Part Two are:
BodilylnjuryByAccident 500,OOOEachAccident
BodilylnjuryByDisease 350,000 Each Employee
Bodily Injury By Disease 500,000 Policy Lim it
ITEM 3c. OtherStates Insurance: PartThree ofthe policyApplies to the State,ifany,listed here: Massachusetts
ITEM 3d. See Endorsements: End No.1,End No;I(2/82),End No.R(12�J3),End.No.G(4/84)
CLASSIF CATION OF CODE CONTRIBUTION p R$00 CONTRIBUTION
OPERATIONS BASIS REMUNERATION
SUPERVISORS 8742 $226,524� 0.16 $362
CLERICAL 8810 $221,247 0.08 $177
RESTAURANT 9079 $5,579,684 1.15 $64,166
S UBTOTAL: $64,705
Experience Modification 1.04 $2,588 $67,293
DIA A�essment Factor $1,396 $68,689
Net Contribution with DIA Assess�nent $68,689
DEPOSIT CONIRIBUTION........................................................................See Enclosed Payment Schedule
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For fnqu►nes Concemn►g�rour "" Atlmn�strator ponna Zarb � 'Z�.
t Workers'Compen'sahon"f:overage4=: �rtFier J Gallager l�sk Nlar]agement Services inc� By� �`��f '
please dia1�727-796-6210 �`3015Q Telegraph Road Ste 408� �`� Fund AdminiStl'ator
"'" �Bingham Farrrs,IW'48025 �