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Home My WebLink AboutApplication and WC ^' � TOWN OF YARMOUTH BOARD OF HEALTH �� APPLICATION FOR LICENSE/PERMIT-2017 `' *Please complete form and attach a11 necessary documents by December 16.2016. Failure to do so will result in the rehun of your application packet. ESTABLISHMENT NAME: �L i t��2 S � t�s�c6Zg /t4 iJ�'/L�dt'AX ID• a�/ 28�3.�� LOCATION ADDRESS: �>G o /Y�F�� , Y,q.2n ac,e� TEL.#: _.�2 666� MAILING ADDRESS: A►�� E-MAILADDRESS: �D2r�-toN� bt�[ �2< � �c.��`,q.s��,�g l OWNER NAME: 1 Ai QR�"lo CORPORATION NAME(IF APPLICABLE):_��►/�/L �/z�10�1 .J�`�. MANAGER'S NAME: LE ORJV►o�' TEL.#: G �' ,S6 y MAILING ADDRESS: y 9' l7#th EY�S i LN k 2Eu1 S iE �ZG I POOL CERTIFICATIONS: � n �r7 The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated '� ` '" Pool Operakar(s)and attach a copy of the certification to this form. � �v r�;�� . 1' 2. �r' �v ;,l :� i Pool operators must list a minimum of tiwo employees currentiy certified in standard First Aid and Community �� ' '; Cardiopulmonary Resuscitation(CPR),having one certified employee on premises at all rimes. Please list the ; � 1 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. �`- "'�"-v-' 1. 2, 3. 4. � a; ;.,;-;;. FOOD PROTECTION MANAGERS-CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food � ''� � t,� Protecrion Manager,as defined in the State Sanitary Gode for Food Service Establishments, 105 CMR 590.000. �� Please attach copies of certification to this application. The Health Department will not use pastyears'records. �, You must provide new copies and maintain a file at your establishment. � .,� K 1.�V�1 � v�� 2. �� lr'�i Z G C.esf L� �.�.,,�„4 � �,, ' PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. �. ��E D�wo�t! 2. ��t�zy ��tro�� ALLERGEN CERT'IFICATIONS: 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 590.909(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. _�� 0� 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 a11 times. Please list your employees trained in anri-choking procedures below and attach copies of employee certificarions 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. 1�'AT�'`/ �i cH�2�1 2. /�oEcc.a ,d�2lz Y 3. 5'Er�ro�Fc 2 Su D6L 4. �nl Fw, s RESTAURANT SEATING: TOTAL# � OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B�B $55 CABIN $55 MOTEL $]10 INN $55 —CAMP $55 —SWIMMINGPOOL$IlOea. _�.ODGE $55 _TRAILERPARK $105 _WFIIRLPOOL $110ea. FOOD SERV[CE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# 0-100 SEATS $125 _CONTINENTAL $35 NON-PROFIT $30 —>100 SEATS $200 �j�f��1 _COMMON VIC. $60 �(� =WHOLESALE $RO — .�• •�—� � r��r� _RESID.ffiTCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIIZED FEE PERMIT# <50 sq.ft. $50 >25,000 ft. $285 VENDING-FOOD $25 =<25,000 sq.ft. $150 =FROZEN�ESSERT $40 _TOBACCO $1/10� NAME CHANGE: $i 5 AMOLTNT DUE _ $_�QE7', � **'"*PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM**'T*"' go k�F-t�f-6 363-6'3 , 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 taaces and liens must be paid priar t 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,sha11 generally be considered Transient. POOLS POOL OPENING:All swimxning,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. FOOD SERViCE SEASONAL FOOD SERVICE OPENING: All food service establishments must be inspected by the Health Department prior to opening. Please contact the Health Depariment 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 Deparhnent by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health Deparhnent,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 CAF'�S: 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 dispiay 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 RESPONSIBILITI'TO RETCTRN 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 APPR BY T BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQ A SIT PL DATE: �Z�Z3'I6 SIGNATURE: PRINT NAME&TITLE: /'l, ��i� Q.�J OU1n1�✓Z Rev.10/12/16 , �� I�TC�TICE � l�T��'�CE � . . � 'T`O � a .�� 'I'� EI�JIPLOYEES A ��4 EMPL,�YEES , . , q S� The C�mmonwealth of Mass.ach�.s�etts DEPARTMENT OF INDUSTRIAL ACCII�ENTS � 1 Congress Street, Suite 10�, Boston, Massachusetts 02114-2017 617-727-4900 - h :/iwww.state.ma.us/dia � As required by Massachusetts General Law,Chapter 152, Sections 21,22&30,this will give you no�ice that I(we}ha.ve provided for payment to our injured employees urider the above-mentioned cl�apter by insixring with: MA Retail Merchants WC t�'rroup Inc. NAME OF INSURANCE COMPANY PO Box 859222-9222 Braintree,MA 02185 ADDRESS OF TNSUR.ANCE COMPANY 014000502163116 - 1/Ol/2Q16 - l/Ql/2017 _ POLICY NUMBER EFFECTIVE DATES' Rogers &Gray insura.�ce Agency 434 Route 134 South Dennis,MA 02660 NAME OF INSURANCE AGENT ADDRESS PHOi�TE# Oliver Ormon,In�. 6 Bray Farm Road Yarmouthport,MA 02675• -. EMPLOYER ADDRESS EMPLOYER'S WORKERS' COMPENSATION OFFICER(iF ANY) DATE � MED,ICAL TREATMENT � The above narned insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers' Compensation Aet. A copy of the First Report of Injury must be given to the injured empioyee.: The employee may select his or her own physician.. The.reasona.ble cost of the ser- _ vices provided by the treating physician wi11 be paid by the insurer,if the treatment is necessary and reasonably connscted.to the work related injury. In cases xequiring hospital attention,employees are hereby notified that the insurer has arranged for such attention at the C'�� nf� �� os P��L �l�;�-��1 S - NAME OF HOSPITAL ADDRESS TO BE P�STED BY EMPLaYER , INFORMATION PAGE RENEWAL AGREEMENT ; Insurer: PRODUCER: Agent# 542 � MA Retail Merchants WC Group Inc. Rogers & Gray Insurance Agency, In PO Box 859222-9222 434 Route 134 Braintree, MA 02185 South Dennis, MA 02660 (Carrier Code: 34355) Carrier Policy #: 014000502163116 Carrier Prior Policy #: 014000502163115 1. The Insured: Oliver Ormon, Inc. Mailing Address: 6 Bray Farm Road Yarmouthport, MA 02675 Fein: 042800368 Other workplaces not shown above: Type of Business: Corporation NO OTHER WORKPLACES FOR THIS POLICY Risk ID: 2. The policy period is from 12:01 a.m. on 1/O1/2016 to 12:01 a.m. on 1/O1/2017 at the insured's mailing address. 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA. B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident $ 500,000 each accident Bodily Injury by Disease $ 500,000 policy limit Bodily Injury by Disease $ 500,000 each employee C. Other States Insurance: • D. This policy includes these endorsements and schedules: WCOOOOOOC(O1/15) WC000310(04/84) WC000414(07/90) WC000422B(Ol/15) WC200301(04/84) WC200302 (05/86) WC200303B(07/99) WC200306B(06/13) WC200405(06/01) WC200601A(07/08) 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 verification and change by audit. Classifications Code Premium Basis Rate Per Estimated No. Total Estimated $100 of Annual Annual Remuneration Remuneration Premium SEE SCHEDULE OF OPERATIONS Total Estimated Annual Premium $ 8,938.00 Minimum Premium $ 269.00 Expense Constant .00 Deposit Premium .00