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Home My WebLink AboutApplication and WC� Br2�N�-�oo� j � , 1 � °� y� TOWN OF YARMOUTH BOARD OF HEALTH ��c�J�'��U APPLICATION FOR LICENSE/PERM 17 i { : �"°� * Please complete form and attach all necess ' � , ;� ' i� r 1��6 �l�i.� ��016 Failure to do so will result in the retur�� yo ��l�C t ti i��e t. HEALTH DE� ESTABLISHMENT NAME: � d� � TAX ID: S/ ; LOCATION ADDRESS: _G/(p/ �T �2� , S�► OZlo(o`-� TEL.#: �b� 3�1�- �'i� '' MAILING ADDRESS:_____ S'/,� ! ' E-MAIL ADDRESS: j ' OWNER NAME: fV-+- M ,�.�Lr�/ �lLIiST . � CORPORATION NAME (IF APPLICABLE): � MANAGER'S NAME: ,�/',l'�-�r� �t15/N�-� TEL.#:�� GJ�-4"f�I 2— MAILING ADDRESS: „Q �1�L��`aN �h Q��v�y it�lt�- �r 7 / 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 copy of the certification to this form. . ��_- � ,---_--- ��l4---� _ ` t " , ; �_� _ - --- — - - - � A -----?- -_ r - — _., . � _-- 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 Health Department will not use past years' records. You must provide new copies and maintain a fle at your place of business. ; � / 1. � 2.�v��C --Ch/�r�/��ll" l`�%�� 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. 1. 2. PERSON 1N CHARGE: i Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. I 1. 2. 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 �le 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# _____ r nnrrNr.• OFFICE USE ONLY -- - — _ _— - - ----- LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PE IT# B&B $55 CABIN $55 �MOTEL $110 -�� INN $55 CAMP $55 SWIMMING POOL$I l0ea. _LODGE $55 _TRAILER PARK $105 �WHIRLPOOL $110ea.�,�� FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 _CONTINENTAL $35 NON-PROFIT $30 >100 SEATS $200 _COMMON VIC. $60 WHOLESALE $80 —RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 =<25,OOOsq.ft. $150 _FROZENDESSERT $40 _TOBACCO $110 NAME CHANGE: $ts AMOUNT DUE _ $_�,30• OO *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** 3��t�-ly-byo�-o3 G�So�sp-ly-o�(o5-03 Cw�P�6oktSP i4-U��b-03 � � 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 ar 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: 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.Transient occupancy shall generally 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 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 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. .. ___ __ -- . FOOU�EIZVI�E , , ,,.__ 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 Depa.rtment 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 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 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 RETURN � 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 REQUT A SITE P AN.� DATE:�(J —2 S= ��i SIGNATU : "� -'� PR1NT NAME & TITLE: �(ll ,r �Jc r � Rev. 10/12/16 I � • ` � The Commonwealth of Massachusetts ; Department of Industrial Accidents Office of Investigations ` ' 1 Congress Street, Suite 100 Boston, MA 02114-20I7 ' www.mass.gov/dia ; � Workers' Compensation Insurance Affidavit: General Businesses ! Applicant Information Please Print Le�iblv ; Business/Organization Name: ��,�v�� it�lOTO,Q �,4V� I Address: ��/ �� 2� City/State/Zip: ' v� T Phone #: ,�0� .��12 Are you an employer?Check the appropriate box: Business Type(required): ' 1.❑ I am a employer with employees(full and/ 5. ❑ Retail { ; or part-time).* 6. ❑ Restaurant�Bar/Eating Establishment ; . . —. _-- _ -- -- i . ' ' ` ` ` ' 7,�Office and/or Sales(incl. real estate, auto, etc.) � employees working for me m any capacity. [No workers' comp. insurance required] 8• ❑ Non-profit �' 3.❑ We are a corporation and its officers have exercised 9. ❑ Enterta.inment ; their right of exemption per a 152, §1(4), and we have 10.❑ Manufacturing � no employees. [No workers' comp. insurance requiredJ* 11.❑ Health Care � 4.❑ We are a non-profit organization, staffed by volunteers, 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. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an 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: f/�¢ l�tl C.� � �r,C Qh�i^r_ h t�i u/cz.0 _S � Insurer s Address: City/State/Zip: Policy#or Self-ins. Lic. # /'Q 2 G�/C �� Expiration Date: g'�>G� — I' 7 Attach a copy of the workers' compensation policy declaration page(showing the policy number and egpiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a __�Il�e u�t� e� 53 nn nn a„�i�,.r n„A_y��mr risor�i�?e?��,�s u��a�6�v-1��3€l�alf�€S:�t�€fnr�}n£��'�9g�?A-�-r`o��-ar:�a�:e- of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify,under the ains and penalties of perjury that the information provided above is true and correct. Si ature: Date: !�— S �'1' Phone#: S?�f( �C'�'- �'�� Official use only. Do not write in this area,to be completed by city or town officia[ 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 , �: Worker's Compensation and Emnlover's Liabilitv Polic - �/ AmGUARD Insurance Company -A Stock Co. , �V1 Berkshire Hathaway Policy Number R2WC763822 '�`` G UARD Compan es Renewal of R2WC642549 , NCCI No. [21873], Policy Information Page (AR) [1]Named Insured and Mailing Address Agency Brentwood Motor Inn Inc DOWLING &O'NEIL INSURANCE AGENCY 961 Route 28 973 Iyannough Road S Yarmouth, MA 02664 P.O, Box 1990 Hyannis, MA 02601 Agency Code: MADOWLIO Federal Employer's ID 65-1192191 Insured is Corporation Risk ID Number 72144 �2� Policy Period From August 16, 2016 to August 16, 2017, 12:01 AM, standard time at the insured's mailing address. [3] Coverage A. Workers' Compensation Insurance - Part One of this policy applies to the Workers' Compensation Law of the following states: Massachusetts B. Employer's Liability Insurance - Part Two of this policy applies to work in each of the states listed in item [3]A. The limits of our liability under Part Two are: 500,000 Bodily Injury by Accident- each accident �500,000 Bodily Injury by Disease - each employee �500,000 Bodily Injury by Disease - policy limit � �, Refer to Residual Market Limited Other States Insurance Endorsement-WC2003066 D. This policy includes these endorsements and schedules: See Extension of Information Page - Schedule of Forms [4] Premium The Premium Basis and,therefore, the premium will be determined by our Manual of Rules, Classifications, Rates, and Rating Plans. All required information is subject to verification and change by ; aud�t. (Continued on anather page} �, i i , � ` Total Estimated Policy Premium $ 1,150 j !, Total Surcharges/Assessments $ 48.00 f Total Estimated Cost 1 198.00 � INTERNA�u5E xX Page - 1 - Information Page MGA : R2WC763822 WC OOOOOlA Date : 06/27/2016 i MANOTE [ Issuing Office: P.O. Box A-H, 16 S. River Street,Wilkes-Barre, PA 18703-0020 •www.9uard.com