HomeMy WebLinkAboutApplication and WC,
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a 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 return of your applicarion pac et.
ESTABLISHMENT NAME: � • � ` Z
LOCATION ADDRESS: , TEL.#: � rf'�
MAILING ADDRESS: •+
E-MAILADDRESS: � (��� � �Ltl�'�;Cn..nfA
O WNER NAME: ��-.�z �'_.,,.i C_h: r� �,�7�/ld���Xl'i�'
CORPORATION NAME(IF PPLICABLE):
MANAGER'S NAME: � a` TEL.#: — 1�[� ���
t�tt,nv�aDDttEss: � -� �1�,
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 a11 times. Please list the
employees below and attach copies of their certifications to this form.The Health Department will not use past �,r p ',�;
years'records. You must provide new copies and maintain a 51e at your place of business. rr� r'*� �;;
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1. 2. � �' �
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FOOD PROTECTION MANAGERS-CERTIFICATIONS: � o� �� ;
All food service establishments are required to have at least one full-time employee who is certified as a Food t
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. E .
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PERSON IN CHARGE: ;�>�,<
Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. �:
°—�^ � /� � _'
1. IG?.f`.fil'1 1�!t.�.�U�aL 2. �
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ALLERGEN CERTIFICATIONS: J -�
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 �S-'
copies of certification to this application. The Health Departmeat will not use past years'records. You must ~�� "
provide new copies and maintain a file at your establishment.
l. � P� (�et'� �`� 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. T6e Health Department will not use past years'records.
You must provide new copies and maintain a 51e at your place of business.
1. �Q.C.`lE�.li �—►�'�7`J 2.
3. � 4.
RESTAURANT SEATING: TOTAL# 1��
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
B&B $55 CABIN $55 MOTEL $110
INN $55 CAMP $55 SWIMMING POOL$110ea.
�,ODGE $55 _TRAILERPARK $105 WHIRLPOOL $110ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PE T# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE P RMIT#
_0-100 SEATS $125 � _CONTINENTAL $35 �NON-PROFIT $30 �__,LQ3
_>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 >25,000sq ft. $285 VENDING-FOOD $25
=<25,000 sq.ft. $150 =FROZEN DESSERT $40 —TOBACCO $110
NAME CHANGE: $15 AMOUNT DUE _ $ C n.��
"""""PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM"***"
►�ON�F-������-01
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 STAT'E WORKER'S COMPENSATION INSLJRANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR
CERT.OF INSiJRANCE ATTACHED
OR ,,/
WORKER'S COMP.AFFIDAVIT SIGNED AND ATTACHEDp
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 sha11 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 OPEI�TING:All swimming,wading and whirlpools which ha�e 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 wunt
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 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 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.yarmouth.ma.us under Health Deparhnent,
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 ha�e prior approval from the Board of Health.
OVTDOOR COOKING:
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, MOT'EL 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 S TE PLAN.
DATE: �,�/f��IG� SIGNATURE: �
PRINT NAME&TITLE: "Rl�t',�►�d�-���1��
Rev.10/12/16 Za 9837 2
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FROM:T0:5087904298 11/28/201615:33:12#089 P.005/006
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� � � . The.Commonwealth oflVlassachusetts .
� Departmenf of Indristrial�ccidents
� � 1 Congress Street,Suite I00
.j , . . . Bosiorc,MA 02I1�2017 . . � . ..
� www rriass.gov/dia . . .
� � • Workers'Compensaiioa Insarance Affidavi�General Businesses.
�� � TO BE F1LED WITS T�PERMTITIlVG AUTHORTTY.. .• •
� A licant Information � � � � � Please Print Y1 � 'b
� Business/Organiza.tion Name:�/�,�� � W U l I�►'U�i��'(�
�R g� ,peQ►�l s�- � .
Address:
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� City/State/Zip: � �/l�l��.S� !"�l'C OZ�P�I Phone#: J�(7� —'��S (OZ`�0 .
� Are you an�employer?Check the appropriate boi: � Busiaess Type(required):
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� 1.�_I am a.employ.cr with 2: . O empl�ees:(full and/ � Retail ,. . : . .
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_ . . ...� :...:_... �_.... . ._ ... _
` or part-ivme).* � : � �e'sfaurantlBar7Eating Establishmant ': _....
�j 2.❑ I am a sole proprietor or partnership and have no 7, �p•��.�a/or Salrs(incl.real esta#e,auto,etc.)
• employees worldng for me in any capacity.
� [No workers'comp.insnrance required] 8. (�Non-profit • ,
� 3.[� We are a corporalion and its officers have exercised 9. [�Entertain.ment .
a �their ri�it'of exemption per c,152,§1(4),and we have • 10.0 Maaufacturmg �
� no employtes.[No workers'comp.ins�aace requiredJ* 11.[]Health Care �
{ 4.❑ Wt are'a'non-p'rofit organization,staffed by volimtaers,
� with no employees.[Na work'ers'�omp.insurance req.] .�12-�Othea' �
� � #Aay applidant that checks box#1 must also fill out the section below showiag their oValcers'�6ompeasatian pclicy ciform�tion.
, *+Tf the cccporate ofScccs bave�exempted themselves,but du cocporation has offiet dmplayea,n worktts'.eompeasthon policy is reqimad aad sueh aa
� or�nimtion should theck boz'#1. . � � � ' . • . •. . •..: .. . . . , � , • .
� Iamartemployerthatisprovidin�wor�s'ce�s �� eu'/ ceja��Iat es B �`istfiepblicy�irifo�v���V1��J�
� Insurance Compaay Name: � �A ��► r n.
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� ��r�sAd��: ���2� L�,IC,e�rn� � �1v-e, • S�-e • o �
� c��is�z�, �V�..�1�1 0�� �1. 3� 1�{
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� �ov�#ors���.L��.# �7 �Ju.i��.1��3033-2�tb �.�.�,�onn�: lo• 15- Zo(�-
� Attach 9 cop�+of the�vbrkers'comperisation policy.declaraiaon.page.(showing tIie policy number aad eacpiratioa date).
Failure to seoure coverage as required imdea Sectioa 25A of 1vYGL c.�152 oan lead to the impositioa of erimiaal•penalties of a
fine up to$1,500.U0 and/or one-year�prisonment,as weTl as civil pcnalties in the form of a STOP WORK ORDER aad a fine
� ofup to 5250.00 a�day against tbe violator. Be'advised tliat a copy of�Uis'st�#emerit maj►be'furwazded to�the Office of
� Investigations of the DIA foi iasurance coverdgo verificatioa. � .
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'I do hereby c.ert�fy,under e pains' d penal�es of perjury that the ircformatinn pravided above is frue and corred
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�� � � So� �-1'IS �.Coz4 u .x 3_0� .. � . . . �
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� Phone#'
� Offzcial use oxly. Do no1 write in ihis areg to be cnmpleled by c.ity or tawn official .
� � ' . .
� Permit/I.icense# � • ' '
� City or Town• • ' �
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� Issning Authority(cirde one): `. . .. � .
� 1.Board of Health 2.Building�eparhment 3.Crty/Town Clerl{ 4.Licensing Board 5.Selectrnea's O�ce.
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' 6.Other �
� � .
� Contact Person: Phone#;
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.,�� �� www.mass.gov/dia
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VDAC
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TRAVELERS J WORKERS COMPENSATION
AND
EMPLOYERS LIABILITY POLICY
T1(PE AR lNFORMATION PAGE WC 00 00 01 ( A)
POLICY NIIMBER: (7PJU8-7H73p33-2-16) '
NEw-1 e
INSURER: TRAVELERS PROPERTY CA5UALTY CDMPANY OF AMERICA
,�. fVCC!CO CfJDE: 13579
INSURED: PRODUCER:
N
CAPE CflD CHILD DEVELOPMENT ROGERS & GRAY INSURANCE
PROGRAM INC 434 ROUTE 134
83 PEARL STREET SOUTH DENNIS MA 02660
HYANNIS MA 4260i
InsUred 1s A CORPORATION
Other work places and identification numbers are sf�own In the schedule(s) attached.
2. 7he policy period Is from 10-15-16 to 10-15-17 12:01 A.M. at the insured's mailing address.
3. A. WORKEAS COMPENSATION INSURANCE: Part One of the policy applles to the Workers
Compensation Law of the state(s)listed here:
MA
m.= B. EMPLOYEAS LIABILITY IN5URANCE: Part Two of the policy applies to work in each state Itsted ln
�� item 3.A. The Ilmfts of our liability under Part Two are:
�w—
= Bodily Injury by Acc(der�t; $ 50000o Eaoh Acciderit
_ Bod(ly 1n)ury by Disease: $ 500000 policy Llmit
�= Bodlly Injury by Disease: $ 50000o Each Empioyee
a=
_.� C. OTH�R STAFES iNSURANCE: Part Three of the policy applies to the states, if any,listed here:
i
^� COVERAGE REPLACED BY EiVDaRSEMEM WC 20 03 06B
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= D. This poiicy lncfudes these endorsemerits and sciiedules:
,�
o� SEE LISTING OF END�RSEMENTS - EXTENSION OF INFO PAGE
a�
= 4. The premium for thls pollcy wiil be determined by our Manuais of Rules, Classifiications, Rates and Rating
� Plans. All required informat�i.on is subject to ver�ficatlon and change by audtt to be made a,lvrvuA��Y.
DATE OF ISSUE: 10-24-16 HS ST ASSIGN: MA
OF�ICE: DIRECT ASSIGNNlENI' 70i
PRODUCEA: RO�ERS & GRAY INSURANCE 73JiZH
CO2083
.
VDAC
,
TRAVEL�RS�� WORKERS COMPENSATION
AND
EMPLOYERS LIABII.ITY P�UCY
� TYPE AR lNFORMATION PAGE WC 00 00 01 ( A)
� POLICY NUMBER: (7PJU8-7H73033-2-16)
CLASSIFICATiON SCHEDULE:
PREMIUM BASIS
ESTIMATED �T�S ESTIMATED
TOTAL ANNUAL PER$100 OF ANNUAL
CLASS[FICATIONS CODE NO AEMUNERATION REMUNEFATION pREMIUM
,,
SEE EXTENSION OF INFORhfATION PAGE - SC�-IEDULE(S)
S I C-CO DE: 4111 NAI CS: 485999
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STANDARD
TOTAL ESTIMATED ANNUAL STANDARD PREMIl3M $ 101783
PREMIUM DISC�UN7 NONE
0900-20 EXPENSE CaNSTANT 338
TERR�RISM 1978
TOTAL ESTIMATED PREMIUM 129545
TAXES AiVD SURCHARGES 5643
DEPOSIT AMOUNT DUE 135188
A/R (WCIP) #
Minimum Premium: $319 EMPLOYERS I.YABILITY MIMMUM: $5a
ST ASSIGN: MA
DATE OF ISSUE: 10-24-16 Fi5
OFF�CE: DIRECT ASSIGNMENT 701
PAODUCER: RDGERS & GRAY INSURANCE 73JRH