HomeMy WebLinkAboutApplication and WC � TOWN OF YARMOUTH BOARD OF HEALTH
APPLICATION FOR LICENSElPERMIT-2017
*Please complete form and attach ail necessary docwnents �
Failure to cb so will result in the return of your applic�ahon pac�e�
ESTABLISI�IIv1ENT NAME: 1 c �
LOCATION ADDRESS: t0 i Sa,.�1. SI�.�.. D�:r.. S. Y..�«..,,,it. TEL#•Soa-3j,! •92Z!
Iv1AILING ADDRESS: f+�.aa
B-MAILADDRESS:_in�'.[ s�r�.e,wb+rs��...nss.w�,e..�
. OWNERNAME: _SvrFeemver lwc.
CORPORATION NAME(IF APPLICABLE): S.+�{�c a w+b tr 1�+c.
MANAGER'SNAME: Btea�' =w+$eld. TEL.#: Sot �31t4 -�440
MAILING ADDRESS: /1i S_ S6sr� Jr S 1����re.a�6 Mw �?1[�/
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POOL CERTIFICATIONS:
The pool supervisnr most be certified ns a Pool Operator,as roqnired by State law. Plea�list the designated
Pool Operator(s)and attach a eopy of the certificatt'on to this form.
L gRbY INCovD 2. .�oS�+i� T„✓aol�
Pool operatars must list a minimum of two employees cumently certified in standard First Aid and Comnnuaity
Cau•diopulmonary Resuscitation(CPR),having one certified employee onpremises at all times. Please list the
employees below and attach copies of their certifications to this fotm.The Health Depprtment will not use past
yesrs'reeorda Yoa mnat provide new copies and msiabia s Sk at yow pl�ec of b�aimess.
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FOOD PROTECTION MANAGERS-CER'TIF'ICATIONS:
All food service establishments are required to have at least one fiill-time emplayee who is certified as a Food m ti i �
Protection Manager,as defined in the State Sanitary Code for Food Service Establishments, 1Q5 CMR 590.000. D n �
Please attach copies of certification to this application. The Hcalth Depsrtment will not nse past years'records. � : � �
You mast provide new copies and maintain n$le at yonr establishment. � -►
1. t`�,.�A �v �
2. N�� �i �? t�
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PERSON IN CHARGE: '
Each foad establishment must have ai least one Peison In Charge(PIC)on site during hours of operation.
1. N�Q 2. �.t�/k ,��.�:
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ALLERGEN CERTIFIGATTONS:
All food sexvice establis�hments are iequired to have at least one fiill-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 this a�rplicahon The Health Department will not use past years'recorda You mnst � �
provide new copies�ad maiutaie a fi�e at yonr establiahmen�
1. Nl/�h 2. N �A � '
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HEIMLICH CERTIFICATIONS: � ��;°
All food service establishmeuts with 25 seats or more.must have at least one einployee tcained in the Heimlich "' "x'�``' t
Maneuver on the premises at all times, Ple,ase list youremp loy�trained in anri-choking procedures below and
attach copies of e�nployee certifications to this fomi. The Health Department will not use gast yars'records.
Yom m�at provide new copies xnd m�intnin a file at your place of business.
1. 1�1��01 2,
3. 4.
RESTAURANT SEAITNG: TOTAL# N�/a ��,,L.•�������,�� �
Loncnvc: OFFICE USE ONLY � �''�'���� -0� ;
L[CENSE REQU[RED FFE PERMi'p il L[CENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE P # �
�s ss"s cnsna sss �Mo�, suo 23 ,
us cn�rn sss .�swn�n�mac rooL suo�. ��
�� SSS ='IRAILERPARK S105 _WHIRLPOOL S110ea
FOOD SERVICE: �
WCENSER�Q UlltED FEE pERMiT# LICENSE REQUIREp FEE pERMIT# LICENSEREQ UIRED FEE PERMIT#
0-IOQSF.A'I'S s125 _COMTNENfAi. S35 NON-ARO$IT S30
>(00 SEATS 5200 COMMON VIC. S60 �'WHOLESALS S8t1 ;
RETAII.SffitVICE: —RESID.[fITCHEN S�
LICENSE REQUIRED FEE PERMI'P N LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
<30sq R S50 >25 000 R 5285 VENDING-FOOD S23
=<LS,OOOsq.ft. St50 �RUZENT�ESSERT S40 _I'OBACCO SI10
�v�►tE cxnxc�: sis AMOUNT DUE = S�C20.DD
�ra�xPLEASE TURN OV< AND COMPI.ETE OTHER SIDE OF FORM**:ar
,
ADMINISTRATION
Under Chapter 152,Section 25C,Snbsection 6,the Town of Yarmouth is now required to hold issuauce or renewal
of any license or permit to operate a business if a person or compeny does not have a Certificate of Wocker's
Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANGE
AFFIDAVIT MUST BE COMPLETED AND SIGNED,UR
CERT.OF INSURANCE ATTACHED�
OR
WORKER'S COMP.AFFIDAVTT STGNED 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 lunitations of Motel or Hotel use,Transient occupancy shall be
lnnited to the temporary and short term occupancy,ordinarily and customarily associated with motel and hotel use.
Transient occupants must have and be abie to demonstrate that they maintain a principal place of residence
elsewhere.Transient occupancy shall generaliy refer to continuous occupancy ofzat more t�anthirty(3U)t�ys,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 consideied transien� Occupancy that is subject to the collection of Room Oocupancy
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 whirlpooIs,which have been closed for the season must be inspected
by the Health Department .rioP pE L o�P�ntact the Health�W schedale the inepection three(3)
days prior to opening. L A NOTE: ple are NOT a11ow to s�t in the pool area until the pool hss been �
inspeeted and opened. �
POOL WATER TESTII�iG: The water must be tested for pseudomonas,total coliform and standacd plate count
t�hyera�Staeter cerrified lab,and submitted to the Healffi I�parmnent three(3)days prior to opening,and quarteriy
POOL CLOSIlYG:Every outdaor in ground swimming pool must be drained or covered within seven(�days of
closing.
FOOD SERVICE '
SEASONAL FOOD SERYICE OPEMNG:
All food service estahlishments must be inspected by the Heaith Department prior to opening. Ple�se contact the '
Health Department to schedule the inspection tLree(3)days prior to openuig.
CATERING POLICY:
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Depattment by filing the
reqwred Temp� Food Service Apptication form 72 hours prior to the catered evem. These forms cau be
obtained ai the H�th Department,or from the Town's website at www.yanmouthma.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 da so will result in tbe suspension or revocation of your Frozen
Dessert Permit until the above teims have been met
OUTSIDE CAF�S:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior app�roval from the Board of Health
� OUTDOOR COOIQNG:
i Outdoor cooking,preparation,or display of any food product by a retail or food savice establishment is prehibited.
;
NUTICE:Pernrits run annually from January 1 to Uecember 31. IT IS YOUR ItESPONSIBILTTY TO RETURN
THE COMPLETED RENEWAL APPLICATiON(S)AND REQUIRED FEE(S)BY DECEMBER 16,2016. �
� �
� ALL RENOVATIONS TO ANY FOOD ESTABI.ISHMENT, MOTEL OR POQL (i.e., PAINTING, NEW I
i EQIJIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR I
' TO COMMENCEMIId'T. RENOVATTONS MAY ' dII�A S—ITE P
DATE: ►• � SIGNATURE:
PRIIVT NAME 8c TTTLE: �t �^�.,G o(�(��,� :
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From: 1�/29t2076 �2:52 #508 P.002/003
WORKERS C4MPENSATfON AND EMPtOYERS LtABIUTY lNSURANCE POLICY
INFORMA?'fON PAGE
AJ.M. Mutual lnsurance Company
54 Third Avenue, Burtington, �asaacbusetts 0�803-09T0
(80qj 876 2T6S NCC�[vo 2s��
POLiCY NO. AV1NC.4pp- 1 20tBA
PRIOR NO. qW�..�pQ.7Q2 �_ '�q
ITEM �
1. The losuted: Su�nbs�Inc
DBA: �
AAailing add�s: 10T Sou1h Shote Drivs FEIN:'=*"$
South YBrtrwuth�MA 02864 .
�ega!Entity Type: Cor�tion
Other w�lcplaces rwt shown above: Ses Location .
2. The policy period is from 07/01R016 to Q7p1i2Q17 12:Q1 a.m.star�rd dn�at tt�e ir�sut+ed's maNfa�g eddreas.
3, A. Warkers Compertsatbn Irtsurance:i�sat Orte of the pdicy a�lies to U�e Work�s Cor�ensation Law of the
stetes tisted hete: MA
B. Empbyers'liabitity insurar�e:Part Two oi�e policy appi�es to vvoric in each state Nsted in item 3.A.
The limits of Gab�ty under Part Two sre: 8odily lnjuty by Acadent S 500.OW each aociden!
Bod�y�njuiY bY Disease S 500.0� policy limd
Bod�y lnjury by D�ease S 500.000 each employee
+
C. Otfier States Insurarwe: Coverage Replaoed by Endarsement WC 20 03 OB B '-
D. Thts Poliey indudes thgse Endtxsements and Sdtedulea: SEE SCHEDULE i
• j
4. The prerr�urn for Uus policy wi�be det�mir�d by our Manuals of Rutes�Classificatians.Rates and Rating Plans. �
Aa infonnation required below is subjed to verification and char�ge 6y sudit. ;
Classiflcati�s Premiurn Basis Retes �
i �
Cods Estim�ed Pet 3100 Estintatad
Pla. Tote4 Arwwal � Artiwai +
• � RBR111M(it10f1 R8f1fYnOfitlOfl PfAt�F�li i
i .. _..._.._.. _�..._.. __ �_._._—__--—�— -------- - -- -- �
INTRA 120204 i
INTER SE Ct�4SS CODE 3CHEOv __ _ _ _ ____ .------- �
; ,
:
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#
AAinimum Prernium S29'1 Ta�Eatimated Anrnial Premium s4,439
G4V� GQV Deposit Premium $4.g88 ;
STATE CLASS
� �q gp� St�e AsaessmentslSurd�arges
33,963.00 x 5.750096 �g
;
� /���
This policy,inctuding a�endorsements,is I�eby aountersi9n�b!' �. `-.�� Qg�08/2Qt6
� �— i
i
Service Oftice: HUB Infiemstionei New England LLC
54 Third Avenue 299 Ba�rdyab St�t
Bu�lington MA 01803 Wiin�n�tpn,(�1A 01887
WC 00 00 Ol A(7-11 j
�iu�ed a�k�s�°�Ws Irada�d Cow�eM on Compnption haurana,
� The Commonweallh ofMassachusetts
Deparhnent of Indr�ial Accide�ts
4,�'ice of Investigmtions
' 1 Congress SYree�Suite I DO
BostoA,MA 02114-2017
www rnas�gov/+dia
Workers' Compensation Insnrance A,f�'idavit: General Businesses
Applicant Information Please Print Le�iblv
Business/Organization Name: S uc�c��►,�s�f lN'�-
Address: �D� sov� SMs�e. Dw v�..
City/3tateJZip: �. Y�,,,,�,,�-► M/a Phone#: 50$ �39 8 —°122$
Are you an employer?C6eck the appropr�ate boz: Bnsiness Type(reqaired):
1.� I am a employer with ?A employees(full and/ 5. ❑Retail
or part-time}.* b. ❑Restaurautl$arlEa�ag Establis�u�aent
2.�] I am a sole proprietor or partnership and have no �, �pff��/or Sales(incl.real e.ctate,auto,etc.)
employees working for me in any ca.pacity.
[No workers' comp.insurance required] 8. ❑Non-pmfit
3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment
their right af exemption per a 152,§1(4),and we have 1 p.���,��g
no employees. [No workers'comp.insurance required]*
4.❑ We are a non-profit organization,staffed by volunteers, 11.Q Health Care
with no employees. [No workers' comp.insiu�ance req-1 12.(�.Other
`�Y aPPlic�t that c�ecka bmt#i must also fill art the se�tion below showing their workas'compensati�policy infoxmation.
•sIf the c�po�be offioers have exempted themselves.but t�o�po�atian has otha employoes,a vw�ers'compensa�ioi►Polic,y is required�such an
organizatia�sLould check box#1.
I am an a�ptoyer that�r pmvldin workers'co�xpensat�on i�suraRce for i�ey employee� Below is the potky i�fornmt3o�r.
IN
Insurance Company Name• .�.M M v•�vA1� �.�t SiJ fAnL s. C.ciAs..�,c��
Insurer's Address:� Sh,.�1,`A:r.4
city/State/Zip: �cl;n�,.firn MA O�8�3
Policy#or Self-ias.Lic.# Expiration Date:
Att�ch s copy of the workers'compensation policy declaration page(showing the policy nnmber and ezpiration date).
, Failune w secure coverage as required u�uier Section 25A of MGL c. 152 can lead to the imposition of eriminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the fornt of a STOP Wt?RK ORDER�d a fine '
of ug to$250.00 a day against the violator. Be advised that a copy af this statement may be forwarded to the Office of ;
Investigations of the DIA for insur�tce coverage verification.
I do hereby certify,u�the padns and P�ofP�.��Y fhat the informallon prov�ded above is bue wed conec�
� —��• ��I�.a i��
��#: So8 •3qy-89 t�
O,f,�c�al use oKty. Do not w�tte�tku orea,to be cornpleted by cFty or town offu�
City or Town: Permit/L'rcense# "'
Zssaing Antl�ority(carcle o�e):
1.Board of HeaitL 2.Baildiag Department 3.CityiTown Clerk 4.Licens�ng Board 5.Selectmen's Ot�ce
6.Other
Coatact Peraon: Phoae#:
• www.maas.gov/dia