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HomeMy WebLinkAboutApplication and WC1 � . . � ► TOWN OF YARMOUTH BOARD OF HEALTH ���'����� � � APPLICATION FOR LICENSE/P � �- 0 7 ', �E� �� 201s o.A� r? , * Please complete form and attach all necess � s� er 16 2016. Fai lure to do so wi l l resu lt in t he return o�your ap p�icahon pa ket.HEALTH DEPT. ESTABLISHMENT NAME: �C� �`"� � LI:�v�: TAX TD: � `� �2 a � F�1 '1 LOCATION ADDRESS: 1 0 � � Z~t'{. 2�' s' y A2r�a,��-i TEL.#: Sn� 3 h� ln b�� MAILING ADDRESS: E-MAIL ADDRESS: (J�p�,G S ;�,�ra,f5 ( .� Co�rv�c�,S�-. -,�¢- OWNER NAME: � 05� {-t o (L �S CORPORATION NAME (IF APPLICABLE): $r�.R-o�1 ( C.. MANAGER'S NAME: �OS�� 1�? c R S TEL.#: '�3� 18'�' � � b MAILING ADDRESS:_ 1 b i^^���v ST � 3 0\ �Lti vina �=�1 Nv�,� 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. 1. 2. 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 file at your place of business. 1. 2. 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 IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 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 file at your establishment. l. 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 USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $110 I� $55 CAMP $55 SWIMMING POOL$110ea. _LODGE $55 _TRAILER PARK $105 _WHIRLPOOL $1 l0ea. 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: ' �LI ENSE REQUIRED FEE P RMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# � <50 sq ft. $50 ��"� >25,000 sq ft. $285 VENDING-FOOD $25 _<25,000 sq.ft. $150 _FROZEN DESSERT $40 �TOBACCO $110 ��� ; NAME CHANGE: $ts AMOUNT DUE _ $ ( �O �" � I **x**PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** f i �0�-F—t�-63�3-03 Bo�-TP—I,�f-65z6 —�3 w 7 ' 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 t�es 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 �I 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 thirly(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 i Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient. � i POOLS � i 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. FOOD SERVICE SEASONAL FOOD SERVICE OPENING: 4 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. j 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.�armouth.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: � 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. 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 REQUIRE A SITE PLAN. DATE:��I�2��1 b SIGNATURE: PRINT NAME & TITLE: ���(`-'1 (��p�I� �- �I�N tb�- Rev. 10/12/16 r ` ' � The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ` I Congress Street, Suite 100 � Boston,MA 02114-20I7 ' p www.mass.gov/dia i Workers' Compensation Insurance Affidavit: General Businesses i Applicant Informatioa Please Print Legiblv � Business/Organization Name: S � � t\I 1 a� C, l��pc� �A-(�� L j T � S Lf e.���(C.S ; Address: ��`�( �,� Z� � y ��C`(�\1�l 1�1'1�- 0 2l�lo �'{' � City/State/Zip: Phone #: Sa� ��� � � �� + Are you an employer? Check the appropriate box: Business Type(required): j 1:(�] I am a employer with �� employees(full and/ 5. �] Retail ? or art-time .* ; P ) 6. ❑ RestaurantlBar/Eating Establishment � 2.❑ I am a sole proprietor or partnership and have no �, � Office and/or Sales(incl. real estate, auto, etc.) employees working for me in any capacity. i [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. **If the corporate o�cers have exempted themselves,but the corporation has other employees,a workers'com ensa6on olic is re uired and such an P P Y 9 or anization should check box g #1. I am an employer that is providing workers�compensation insurance for my employees. Below is the policy information. Insurance Company Name: �(h R TZek��1 Y1"1�e r t,1n�v��S 1�'C. f o.�,o ���,,, . Insurer'sAddress: `�o ��X gS�122Z - �Z22 �f��v.�-/'GQ �'V��4 a2t8'� City/State/Zip: Policy#or Self-ins. Lic. # �� � �� I�1,2 �0� �1 �o Expiration Date: Attach a copy of the workers' compensation policy declaration page(showing the policy number and ezpiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine 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 pains and penalties of perjury that the information provided above is true and correct. Si�nature• �.-- Date �'Z-���-��� Phone#: ��� 3� �S (�Co g� 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 Cierk 4. Licensing Board 5. Selectmen's Office � 6. Other ' Contact PersoB• Phone#• + � i www.mass.gov/dia � i . �� NOTICE NC�TICE au To M w To a EMPLOYEES q��� EMPLOYEES ,o� syp � The Conlm.onvv�alth �f Massachusetts DEFARTMENT OF INDUSTRIAL ACCIDENTS 1 Congress Street, Suite 100, Boston, Massachusetts 02114-2017 617-?27-4900 - http://www.state.ma.us/dia As required by Massachusetts General Law, Chapter 152, Sections 21,�2&30,this will give you notice that I(we)have provided for pa�yment to our injured employees under the above-mentioned chapter by insuring with: MA Retail Merchants WC Graup Inc. . NAME OF INSURANCE COMPANY PO Box 859222-9222 Braintree, MA 02185 ADDRESS OF INSURANCE COMPANY -014001022000116 1/O1/2016 - 1/Ol/2017 POLICY NUMBER EFFECTIVE DATES Association Benefits Insurance 299 Ballardvale St, Suite 1 Wilmington,MA:41887 NAME OF INSURANCE AGENT ADDRESS � PHONE# Daggett's Liquors 1071 Route 28 South Yarmouth, lVlA 02664 EMPLOYER ADDRESS � EMPLOYER'S VVORKERS' COMPENSATION OFFICER(IF AN� DATE MEDICAL TREATMENT The above named insurer is required in cases of persanal 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 Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the sex- vices provided by the treating physician will be paid by the insurer,if the treatment is necessary and reasonably connected to the work related injury. In cases requiring hospital attention,employees are hereby notified that the insurer has arranged for such attention at the NAME OF HOSPITAL � ADDRESS TO BE PQSTED BY EMPLOYER _ .._ =_�_ .