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Home My WebLink AboutApplication and WC, TOWN OF YARMOiJ'I'H BOARD OF AEALTH APPLICATION FOR LICENSE/PERMIT-2017 �� *Please complete form and attach all necessary documents by Decembcr 16�2016. Failure to do so will result in the return of your applicahon pac et. ESTABLISHMENT NAME: • O� - (d '�(� LOCATIONADDRESS: Io�Sa �Co7�.5UUTH ARrnvrt�/ oa�tiK��..#:s��-�3� -�S// MAII.,ING ADDRESS: 3�?lo lL e S i lY1 R i/�l ST I-I_yA A1 N iS 11�f�- L7�Z l'oa/ E-MAIL ADDRESS: 5A'�C)/�GG � C!�22L )� G[�M ' OWNER NAME: :�Y �'Y1�l� CORPORATION NAME(IF APPLICABLE): / MANAGER'S NAME: ��f =I�Y)R'Sl� TEL.#: �`�; -� '� �/�/' MAILING ADDRESS:��l.p L�1�"i M T �i i�"�/Anin(,�S M LE �l�l�i POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated S =� � Pool Operator(s)and attach a copy of the certification w this form. � � � 1. 2. _ �, ("�i'1 Pool operators must list a minimum of two employees currently certified in standard First Aid and Community � -,,-, C Cardiopulmonary Resuscitation(CPR),having one certified employee on premises at ali times. Please Iist the � �� employees below and attach copies of their certifications to this form.The Heatth Department will not ase paet --� � � years'records. Yoa must provide new copies and maintain s file�t yonr place of business. 1. 2. 3. 4. �. �� FOOD PROTECTION MANAGERS-CERTIFICAITONS: _ � . 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 wpies of certification to this application. The Health Department will not ase past years'records. , � You must pmvide new copies and maintain a file at your establishmen� �- W 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 Atlergen certification, as defined in the State Sanitary Code for Food Service Establishments,105 CMR 590.009(G)(3)(a). Piease attach copies of cer6fication to this application. The Health D�partment will not ase past years'records. Yon must provide new copies and maintain a file at yoar establishmen� 1. 2. HEIlvILICH CER"I'IFICATIONS: All food service establishments with 25 seats or more mvst have at least one employee train�in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedwes below and attach copies of employee certifications to this form. T6e Health Department_a�ill not use past years'_records. You must provide new copies And maintain a file at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY IADGIlYG: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# `B&B S55 CABIN S55 MOTEL. $110 1NN S55 CAA�dP SSS _SWIMNIlNG POOL Sl t0ee. �T.ODGE E55 =TRAII,ERPARK $105 WHIRL.POOL S110ea. FOOD SERVICE- LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PF,RMIT# LICENSE REQ UIRED FEE PERMIT# 0-100 SEA7'S 5125 _CONTiNENTAL S35 NON-PRO�Tf xi0 >100 SEATS �200 COMMON VIC. S60 �NHOLESALE S80 —RESID.KTPCAEN S80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMl'C# LICENSE REQU[RED FEE PERMIT# =<25,OOOsq.ft. SI50 �['�,� =�RO�ZEN�SSERT�S40 �fOBACCO ��t1�105 _�'��3 NAME CHANGE: f15 AMOUNT DUE _ '�(oO.UC� **'•'PLEASE TURN OVER AND COMPLETE OTAER SIDE OR FORM"*** 3ol+F-1 5-ta�f-0 2 � P,o t�'i'P-lS-{d3I-a 2 ADNIINISTRATION Under Chapter 152,Section 25C,Subsection 6,the Town of Yarmouth is now requirred to hold iss�ance or renewal of any license or peruiit to operate a business if a person or company dces not have a Certificate of Worket's Compensation �nsurance. 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 generaily 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 shaii not be oonsidered tiansient Occupancy that is subject to the collection of R�m Occupancy Excise,as defcned in M.G.L.c.64G or 830 CMR 64G,as amended,shall generally be considered Transient. POOLS POOL OPElvING:All swimtming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to openuig. Contact the Health Deparhnent to schedule the inspection three(3) days prior to opening.PLEASE NOTE:People are NOT allowed to sit in the pool area until he pool has been inspected and opened. POOL WAT'ER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, and submitted to the Heaith DepaRment three(3)days prior to opening,and quarterly thereafter. POOL CLOSING:Every outdoor in ground swimming pool must be drained or covered within seven(�days of closing. FOOD SERVICE SEASONAL FOOD SERVIC�OPENIIVG: All food service establishments must be inspected by the Health Departcnent 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 Yazmouth Health Department by filing the requu�ed Temporary Foad Service Application form 72 hours prior to the catered event. These forms can be obtau►ed at the Health Department,or from the Town's website at www.yarmouth.ma.us under Heaith Deparanent, - Downloadable Forms. FROZEN DESSERTS: Frozen desserts must be tested by a State certified]ab prior to flgening and monthly thereai�er,with sample re.sults submitted to the Heaith Department Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have b�n met. OUTSIDE CA,F�S: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health OUTDOOR COOI�NG: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. NOTICE:Pernuts run annually from January 1 to Dacember 31. IT IS YOUR RESPONSIBILITY TO RETURN i THE COMPLETED RENEWAL APPLICATION(S)AND REQUIItED FEE(S)BY DECE 16,2016. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL . , AINTING, NEW i EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE B OF HEALTH PRIOR ' TO COMivIENCEMENT. RENOVATIONS MAY REQUIRE A SI P DATE: Ti� CS° SIGNATURE: Pxn�rr Na��.E:--...i A Y �� O r��-�?'� xev.ia�v�e � � The C�rerma�wet�af�Ila�sssirchus� .13�p�e��rf�ndus�ri,a!'Accid�rnrts tJ�`icc of'Im�stigatio�s I�vn�re�c Stneet,Sxare IQl! Bn�on,� U�II�-?t!1 T �vww�govfub� V�or�cers'Compensati�n�nsaranc�A#fiidavi�: Generai B�inesses A lic�nt�'+ur�a�ion Fl�Pr�nt Businessl()rganiza�on Name: �/�� R 1 �� A�ss: I �o�. CJGt T� �� c��s�t�z�p;�S��.�lA�m.c�c�� '� °�i�:�#. 5b � —3 ��-�7� � � , Are yt►a sn employ�rT�6eck the apgropriste baz: ��TFf��I�i�� L E�f t am a�l+Qy�v�►itlt�,��glvye�.a{fu�I ancl! � ��, �]I�� or�tt time�.* 6. �Resfawrantl��rlEacting Fsta6lisi�ment 2>❑ I am a sr�le}�ropn�or or�rtneash�p and huve no 7. ❑Office andlor Saie�{incl.rea!estate,auto,et�-) �anplc�yees working for me in a�y r.ap�r.ity. [Na waarIcers'cflmp.insurance rec�tziz�dj 8. [��Ian-�ofit 3.[� We are a corpc�ratio�t artd it�offit�have ercercised 9. [�Eni�rtainm►ent their right of exemption per c_ I S2,§1(4},and we have 1{y.Q Man�scturing rx>ernployees.[No worker�'camp.insurance requireci�* 11.0 He�rh Cars 4.Q We ar�a�on-profit arganization,s�by vohmteers, 12.[�Other �"� �l�''n(?/� with na ernployees.[No warkers comp,insi.uanr�e�-1 `nnr appti�t dur a�ear�c#t mu�ai�o ftiu o�.We�i�atow�av�u�s wakas• � �+oli�y u��qon. *•If tt�c c�orate affioets have��ves,b�rt the Qo�pa�has ei�r ert�byees,a vv�kers' ` Po�cy�t��s�cl[� ' sho�td d�edc[w�c#i. �rcs �tl{lt Q/!I��,}�l`�tftt�f�tT+91►�(�li,�MNiI�iS'L1BRJ�RSiftt�ll�7/l"�ttk,'fOf"!�►�[p�� ,�'�tJM►IS�j1A�Cf►��`DT�lf. Inswanc�Company Name: �(T-1��- j� �d��L.. ��-C-(��1,�C.� �QLt.-{� ��a�: � � � ci�y�s�rz� �z? ��►��s��.L��.� '��a0�� ;�,�. � '3d ao 1 Attach s�of t!�work�rs*connp�tiou policy dedarat�a�(sia�the polxy nnmber a�e:pirstiou dste� Faileu+e m�cac>verage as r�uiretl u�der Secti�an 2�A of I�fG�c. I52 can Irad to the imposi�c�of ca�miraat pc.nalties of a fine up to S1,S�Oa.00 an�lor tme-year im�isanment,as well as�ivil penalties in�t�e forrn of a�Tt?P WC}RK 4RDER.and a fine of�t�o S25U.U0 a day agai�st t�e vialatar. Be dtat a copy oftixis�cmem may t�fcfr�va�w�Dffice of investigatia�s of thz DIA far insurance ca verrficatian. �do�rereby c�,#�t!!r� �'of�a'jury tkart t1�e,i�x,�t»�at�on��so�ded r��e Is ir�e attd ctrtrec� � � �e#: ��-�,-��i� -�o��V�J 4,�1 u�e rtnty, l�o�rot»�ite iat this ta he co b or tawn t► � �� Y� �� City or T�vrn- P�rmiULiceeae# �Ssning Authority(eir�Ie one); 2_84ard of He�l#� 2.$eilding I3epsrtment 3.City/Town Cieark d.I,ic�g Boa�rd 5,Seiec#men's t?�6ce 6,[fther C6�t�uCt Fer9aa. p�� www�.g�tdia UTICA NATIONAL INSURANCE GROUP WC 000001A 1 So Genesee street New HartFord, NY 13413 Issuing Company: Utica Mutual Insurance Company MEMBER OF UTICA NATiONAL INSURANCE GROUP WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY Information Page Policy Number: 4792033 1. The Insured and Mailing Address: Prior Policy Number: Jay Mart Inc DBA JayMart 326 W MAIN ST Producer: Oxford Insurance Agency P.O.Box 370 HYANNIS MA 02601 Oxford, MA 01540 Entity of Insured: Corporation Producer Number: 70177 Other workplaces not shown above: SIC#: 5411 insured's I.D.Number: 043518650 NCCI Comparry Number. 15717 Risk I.D.Number: 2. The policy period is from 09/30/2016 to 09/30/2017 12:01 AM Standard Time at tl�e 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. Empioyers Liability Insurance: Part Two of the policy applies to work In each state listed in ftem 3.A. The limits of our liability under Part Two are: Bodily Injury by Acadent $500,000 Each Acciderrt Bodily Injury by Disease $500,000 Policy Limit Bodily Injury by Disease $500,000 Each Employee C. Other States Insurance: Part Three of the policy applies to the states,if any,listed here: All States except those listed in Item 3.A, ND,OH,WA,WY D. This policy includes tl�e.se endorsements and schedules: 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 audi� Pr+emium Basis Rate Per�700 ❑See E�ctension of Information Page Code Estimated Annual Total est Annual of Classifications No. Remuneration Remuneration P��um Minimum Premium: S 229 MA E�ense Constant � Employer's Liab Minimum Premium: 5 Total Estimated Annual Premium ; 944 If indicated below,interim adjustments of premium shall be made: Deposit Premium $ gq4 Issuing Office: New Hartford, NY 13413 Date of Issue:0&16-2016 Countersigned by � r" 8-D-WC Ed.08-2008 Copyright 1988 National Counal of Comper►sation Insurance BILLING NO. 100938566