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Home My WebLink AboutApplication and WCi , �, rf-�.C,�,`W 1" TpWN OF YARMOiTTH�OAR� F ALTH �T�'' O HE � A�PLICATION FOR LICENSE/PERMIT-2017 •Please complete form and attach all necessary documents by December 16 2 16. Failure to do so will result in the retum of your applicaUon pac cct. � ; ESTABLISHMENT NAME: + � : LOCATION ADDRESS: T�L•#; .- '�rlS MAILING ADDRES : E-MAIL ADDRESS: OWNER NAME: CORPORATION NAME F PLICABLE): MANAGER'S NAME: ��„#; — MAILING ADDRESS: POOL CERTIFICATIONS: � O � The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated r � Pool Operator(s)and attach a copy of the certificarion to this form. T N �� 1� �►.� �1'I��v o� z.�o�v��me�,�_ � �,:; �� .� � �..�� Pool operatars must list a minimum of two employees currently certified in standard First Aid and Community -{ v� � Cardiopulmonary Resuscitation(CPR),having one certified employee on premises at all rimes. 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. L 2, � 3. 4, " —� � ��: � �.��,.:7 FOOD PROTECTION MANAGERS-CERTIFICATIONS: �'°��' All food service establishments are required to have at least one full-tune employee who is certified as a Food -u Protection Manager,as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certifica6on to this applicaUon. The Health Department will not use past years'records. a You must provide new copies and maintain a file at your establishment. �� r► L 2. �` ,�- " �`. . PERSON IN CHARGE: � Each food establishment must have at least one Person In Charge(PIC)on site d�ing 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(Gx3xa). Please attach copies of certification to tlus application. The Health Department will not use past years'records. You must provide new copies and maintain a 51e at your establishment. 1. 2. � HEIMLICH CERTIFICA'T'IONS: 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 enployees trained in anti-choking procedures below and attach copies of empioyee certifications to tIris form. T`he Health Department wilt not use past years'records. You must provide new copiea and maintain a file at yonr place of business. 1. 2. � 3. 4 RESTAUR,ANT SEATING: TOTAL# LODGIlVG: OFFICE USE ONLY ` LICENSE REQU[RED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# ` �B S55 CABIN S55 M07'EL 5110 �(� � _I,ODGE SSS _TRAILERPARIC Ss05 1VHIRLPOOL�L$1�1�„-"�� FOOD SERVICE: € LICENSE RE iJIRED FEE PERMIT f! LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMfI'k a�s��s a2� —CONTINENI'At. S35 NON-PROfIT S30 _COMMON VIC. E60 —1�VHOLESALE a80 RETAIL SERVICE: —RESID.KITCHEN $80 LICENSE REQUIItEp FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQU[RED FEE PEItMIT# =Q5,000 ft, gj5p �ZS>000 ft. 5285 VENDING-FOOD S25 �• =FROZEN�ESSERT S40 =1'OBACCO 5110 � NAME CHANGE: f 15 AMOUNT DUE _ � f��,�}� 4 •*'**PLEASE TURN O'VER AND COMPLETE OTHER SIDE OF FORM**•** �b� �o�SP��-Eac�o--o�, ; � � � � � � r ' 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.AFFIDAVI'I'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 LODGWG ESTABLISHMENTS TRANSIENT OCCUPANCY: Far purposes of the limitaGons 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 tban ninety(9U)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 Deparhnent to schedule the inspecNon three(3) days prior to opening.PLEASE NOTE:People aze NOT allowed to sit in the pool area until the pool has been inspected and opened. POOL WATER TESTIIVG: 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. Piease contact the Health Department to schedule the inspection three(3)days prior to openmg. 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 ta the catered event. These fom�s 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 priar io opening and monthly thcte�er,with sample resu#s submitted to the Health Department. Failure to do so will result in the suspension ar revocarion 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 COOKING: ' i Outdoor cooking,prepazation,or display of any food product by a retait or food service establishment is prohibited. i � � NOTICE:Permits run annually from January I to December 31. IT IS YOUR RESPONSIBILITY TO RETURN , THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 16,2016. i , i ' � ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW I ; I EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR I ' TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A STI'E P N. . DATE: � � SIGNATURE: ' PRINT NAME 8c TITLE: 1� ; k Rev.10/l2/16 C ' � . � � � The Commonwealth of Massachusetts Depart»:ent oflndustria[Accidents . Offue of Investigations 1 Congress Street,Suite 100 Bosion,MA 02114-2017. www.mass gov/dia Workers' Compensation Insurance A�davit: General Businesses Aualicant Information Please Print Legiblv Business/Organization Name: ol� , ��D �'�O�,�fJ�T��1T�t� �Dr�li�mi v1 a�ms Address:3�O ��G�� ar�b'� City/State/Zip: Phone#: 'J 0�''r1"L�'��a 5 Are you an employer?Check the appropriste boz: Bnsiness Type(reqnired): , 1.[� I am a employer with�_employees(full and/ 5. ❑Retail or part-time).* 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. [No workers' comp.insw�ance required] 8. ❑Non-profit 3.❑ We are a corporation and its oft'icers have exercised 9. ❑Entertainment their right of exemption per a 152,§1(4),and we ha.ve 10.0 Manufachuing no employees.[No workers'comp.insurance required]* 4.❑ We aze a non-profit organization,staffed by volunteers, 11.[]Health Care with no employees. [No workers'comp.insurance req.] 12.[�Other�'A 'MY applic�►t that chxks bwc#i must also fill out tha section below showing thes workecs'compensation policy inforntation. «•If the cwrpotate officets have exanpud rhem4elves,but tfie c�rporadon has otha�employees,a work�s'�mpensation policy is required ead such aa rnganization should chedc box#l. I ane an employer that is providing workers'compeasation insurance for my enep[oyee� Below Is the polic.y infor»ratlon. Insurance Company Name: C � `��, C��, �• Insurer's Address: ��,�j ��1�OV 6� 1'��• �"'��'�_ k�X��,� o�t�o j c;riis�z�P:� � Policy#or Self-ins.Lic.# �1��0�U�"��7 7 ��" �D'"[�D Expiration Date:�D� ' �?' � 7 ! � Attach a oopy of the workers'compensallon policy declaration page(showing the policy anmber snd ezpiration date). ; � Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penal6es 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 Investigadons of the DIA for insurance coverage verification. � I do hcreby certify,usder the patns aad ofperJury that the inforniaKore provJated above�s true and correc:� �{ / y ��one#• SD�-'R ^- � ��.� � . � Oj,ficial use only. Do not wriite in ihis area,to be co�npleted by city or town officiaL City or Town: PermitlLicense# ; Issning Anthority(circle one): 1.Board of Health 2.Bnilding Department 3.:Gitq/Town Clerk 4.Licensing Board 5.Selectmen's Office 6.Other Contact Person• Phone#• � � www.mms.gov/dia � 4 I i � voAc �' WORKERS COMPENSATION ace aroup AND EMPLOYERS LIABILITY POLICY TYPE AR INFORMATION PAGE WC 00 00 01 ( A) POLICY NUMBER: (6562U6-4477P70-6-16) RENEWAL OF (6562U6-4477P70-6-15) INSURER: ACE AMERICAN INSURANCE CON�ANY NCCI CO CODE: 12165 1. INSURED: PRODUCER: HORSE POND CORP DBA HALCYON MILLER MCCARTIN INC CONDOMINIUMS 973 IYAI�IDUGH ROAD, 2ND FL 300 BUCK ISLAND RD PO BOX 1990 WEST YARMOUTH MA 02673-2590 HYANNIS MA 02601 insured is A CORPORATION Other work places and identificatfon numbers are shown in the schedule(s) attached. 2. The policy perlod is from 02-14-16 t0 02-14-17 �2.�1 A.M. at the insured's mailing address. 3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers Compensation Law of the state(s) iisted here: MA ,� _ o� e�� .,,_ B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state Ifsted in + item 3.A. The limfts of our liabfifty under Part Two are: ^= Bodily InJury by Accident: � �00000o Each Accident � � Bodlly Injury by Disease: $ t o00000 policy Limft ! ,�._ Bodily InJury by Dise�se: S i o00000 Each �mployee o� ! �-- C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here: — � COVERAC� REPLACED BY EI�ORSEN�NT WC 20 03 06B �� i � i .�� ; �� D. This policy inciudes these endorsements and schedules: � �� ; o� SEE LISTING OF Ef�ORSEMENTS - EXTENSION OF INFO PAGE � i � 4. The premium for this policy wfll be determined by our Manuals of Rules, Classffications, Rates and Rating ` _ Plans. All required f�ormation Is sub)ect to verification and change by audft to be made ANNUA��Y. � .� DATE OF ISSUE: 02-09-16 WC ST ASSIGN: MA ; OFFICE: ORLAt�O DA ACE 24M i PRODUCER: MILLER MCCARTIN INC 73M2Y � � o�zo2o ' � i E � r � � VDAC � 0. , � acearoup WORKERS COMPENSATION ( AND �EMPLOYERS LIABILITY POLICY TYPE AR INFORMATION PAGE WC 00 00 01 ( A) � ; , POLICY NUMBER: (6S62UB-4477P70-6-16) � CLASSIFICATION SCHEDULE: PREMIUM BASIS ESTIMATED RATES ESTIMATED TOTAL ANNUAL PER$100 OF ANNUAL CLASSIFICATIONS CODE NO REMUNERATION REMUNERATION PREMIUM � R SEE EXTENSION OF INFORMATION PAGE - SCHEDULE(S) SIC-CODE: 7349 NAICS: 561720 ------------------------------------------------------------------------------------ STANDARD TOTAL ESTIMATED ANNUAL STANDARD PREMIUM $ 3294 PREMIUM DISCOUNT NONE 0900-20 EXPENSE CONSTANT 338 TERRORISM 50 TOTAL ESTIMATED PREMIUM 3682 TAXES AND SURCHARGES 185 ' . DEPOSIT AMOUNT DUE 3867MP ' I � .r II A/R (WCIP) # � I Minimum Premlum: $ 284 EMPLOYERS LIABILiTY MINiMUM: $ 75 i � 1 I ST ASSIGN: MA DATE OF ISSUE: 02-09-16 WC OFFICE: ORLANDO DA ACE 24M PRODUCER: MILLER MCCARTIN INC 73M2Y