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Home My WebLink AboutApplication and WC . e� � i'�o�n.,'«�IL�� .5 � �� TOWN OF YARMOUTH BOARD OF HF�,A�.�T�I � APPLICATION FOR LICE��A�'� 1 �1� DEC 0 5 2016 ,,. �e �-r;:.it...: R, .,.� ..�F..��. �......,. * Please complete form and attach all n��ss,, : ��n�;,t��De mblel� � ' Failure to do so will result in the ret�o�our application pac e . T ESTABLISHMENT NAME: '"f' 1'�� S ti2Z� TAX ID: � LOCATION ADDRESS: ��{-'r 1'1�� 1�tJ ��-- 1�*��Zy�p i�T1�'TEL#• -v'�rJ S��"�-33�'� MAILING ADDRESS: E-MAIL ADDRESS: � V Ce ►�� t7�� r/1�1l�1� ��-f ' OWNER NAME: �T�"L��,/�_ L�✓�1/ �1 t7�S CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: TEL.#: S�-8'�9- � MAILING ADDRESS: C� G�L � 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. — — - —-- � ._.�.v - — -- �----- _ -- _ � __ - ------ -_ ----_ — _ �. _ - - � 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. j 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 1N 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 f provide new copies and maintain a file at your establishment. ; 1 1. 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 li�t 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 �le at your place of business. ( 1. 2, 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY '` _ T AT!'�iST/"'��. _ { T: _—__.._ ...—_—__--_' i '____.. _. �__ 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 $110ea FOOD SERVICE: ' �CENSE REQUIRED FEE P T LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 -�a� —CONTINENTAL $35 NON-PROFIT $30 >100 SEATS $200 �COMMON VIC. $60 ��SS =WHOLESALE $80 ( —RESID.KITCHEN $80 ' RETAIL SERVICE: ' LICENSE REQUIRED FEE PERMIT# 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: $i s AMOUNT DUE _ $ �g S.OO *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** Qo�{�,.t4-6�$-p3 ��,w_ } L svw 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 1NSURANCE ATTACHED � OR _ � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED i , Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK i APPROPRIATELY IF PAID: I � 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 j 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 t 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. � - . _: .. � ,_ , _FO�H�RVICE _ _ _ __ 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 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: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. - - _ -�---�-- — _ __ .. -1 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: SIGNATURE: ! PR1NT NAME & TITLE: Rev. 10/12/16 i � i i • � � The Commonwealth of Massachusetts Department af Industrial Accidents Office of Investigations ' ` 1 Gongress Street, Suite I00 Baston,MA 021I4-2017 � www mass gov/dia : _ Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legiblv � Business/Organization Name: �{� �� Z. Z� ', ^ I Address: � �' /� ��" ' , .._,., City/State/Zip: Phone#: �5 t��' 7 7l � -�i� � � ; Are you an employer? Check the appropriate boz: Business Type(required): 1.[��am a employer with Z employees(full and/ 5. ❑ Retail ; i or part-time).* 6. ❑ RestaurantBar/Eating Establishment � ' .-� ice an or a es incL reai"estate, auto,—etc:}— ! employees working for me in any capacity. [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 a 152, §1(4), and we have 10.❑ Manufacturing ; no employees. [No workers' comp. insurance required]* ll.❑ Health Care ' 4.❑ We axe a non-profit organization, staffed by volunteers, � with no employees: [No workers' comp. insurance req.] 12.❑ Other i *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. � **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an i organizafion should check box#L C i I am an employer that is providing workers'compensation insurance for my employees Below is the policy information. Insurance Company Name: �� l G.� � I i i Insurer's Address: ; City/State/Zip: Policy#or Self-ins.Lic.# 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 ; �_ �„A,,,,r„ �� snn pQ��_�n€�,��-i�grise��s�zell--as-r,��l penal#ie.�i�the faxm of a STOP_WC2�K QR:1�ER andafine_—___— r-_ .._�_...,. 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 correc� Si�nature: Date• Phone#: 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 Clerk 4.Licensing Board 5. Selectmen's Office ' 6. Other i Contact Person• Phone#• I www.mass.gov/dia f f i VDAC a ZURICH WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY TYPE AR INFQRMATION PAGE WC 00 00 01 ( A) POLtCY NUMBER: (6ZZUB-0762N00-8-16) REI�WAL OF (6ZZUB-0762N00-8-15) INSURER: AN�RICAN ZURICH INSURANCE CONIPANY NCCI CO CODE: 17965 , 1. ' INSURED: PRODUCER: ' 1lARETIN��, ST'�V_E DBA____ CHAt�ION INS AGENCY INC _ . _ TAKIS PIZZA P.O. BOX 355 547 MAIN STREET ROUTE 28 4�ST YARMOUTH MA 02673 WEST YARMOUTH MA 02673 ' Insured is AN INDIVIOUAL Other work piaces and iderrtification numbers are shown in the schedule(s) attached. ' 2. The policy period is from 05-22-i s to p5-22-t 7 12:01 A.M. at the insured's mailing address. 3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy appiies to the Workers Compensation Law of the state(s) listed here: MA .� o� �= B. EMPLOYERS LIABILITY INSURANCE: Part Two af the poifcy applies to work in each state listed in _ item 3.A. The limits of our liabiliry under Part Two are: m-- �_ Bodily Injury by Accider�t: $ 10000o Each Acciderrt o_ Bodily injury by Disease: � 500000 paicy Lim1t � B�iily injury by Disease: $ 100000 Each Emptoyee �_ C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here: � _ _ �� COVERAGE REPLACED BY ENDORSEAAENT WC 20 03 06B , �� ,— � a; o� � i .� D. This policy includes these endorsemerrts and schedules: ; i a� SEE LISTING OF EI�ORSEMENTS - EXTENSION OF INFO PAGE ' o� = 4. The premium for this�licy will be dstermined by our Manuais of Rules, Ciassifications, Rates and Rating m— P{ans. All required ir�formation is subject to verification and change by audit to be made AI�IUALLY. ' � =Zs ; DATE OF ISSUE: 04-18-16 WC ST ASSIGN: MA ' OFFICE: ZURICH-ORLAN 809 I PRODUCER: CHAGNON INS AGENCY INC 73CC�(2 � o2esao � - r �