HomeMy WebLinkAboutApplication and WC�
� TOWN OF YARMOUTH BOARD OF HEALTH �`
� APPLICATION FOR LICENSFJPERMIT-Z017 r
� •Pl�se complete form and attach all necessary documents b
Failure to do so will result in the retum of yow applicaUo��
� ESTABLISHMENT NAME: • — / / �
LOCATION ADDRESS: $S/ R��7�' 7 S TEL#• Gi76�,�i z8�
MAILMG ADDRESS:
E-MAIL ADDRESS: d Q ro ce r�a 7 co„-tca.sf..w
OWNER NAME: � dv.� /'lli9Jr.�.,�e�
CORPORATION NAME(IF APPLICABLE): Gss' i// L,..-E Z'.r�r•'
MANAGER'S NAME: �',�.fr�laC �'.oSr'rlv�wiot�rea TEL.#: r'o/Z`�grZB�
MAILING ADDRESS: $�7 �'o�L� ��- '�,vst.adcS^�J ���
POOL CERTIFICATIONS: �/</j
' T6e pool supervisor�mt be certi8ed ss a Poo!Opentor,as reqeirsd by State i��v. Please list the designated
j Pool Operawr(s)and attach a copy of the cectificatioa to ttris form.
I. 2,
Pool operators must list a minimum of two employees curnendy certified in standand First Aid and Community
Cardiopulmonary Resuscitation(CPR),having one certified emp loyee onp at ali dmes. Pkas�list the
employces below and att�h copies of t�ir certifications to tWs form.The H��Department w�lt Bot uee past
! years'recorda Yon mwt provide ne�v copia aad mainhin a fik at yoar place oi buaineaa.
L 2.
3. 4.
FOOD PROTECTTON MANAGERS-CERTIFICATIONS:
Ail food service establishments are tequired to have at least one full-time employee who is certified as a Food
Protection Manager,as defineci in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. �
O ,e�„a
Please attach copies of cectification to this application. 1'he Hakh Depnrt�ent�vill eot use paat yeus'recorda. , n z.
Yau muat provide Bew copia nnd maiotain s 81e st yo�r ahbin6meew � ��
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1. c��o� �JT.rs/�rylZ�Lj 2. � ,� �i'3
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PERSON IN CHARl3E: � � ��� '
Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. �
1. �C �sf� 0���'f'/lo/�dYr..Ca 2,�� /,�
ALLERC3EN CER'!'IFICATIONS: ,� ,
All food service establishments ere required to have at le:ast one fWl-time employce who has Allergen certification,
as defined in the State Sanitary Code for Food Seivice Establishments,105 CMR 590.009(Gx3�a). Please auach " �r,
copies of certificatioa W this application. Thc Halt�Departmeat will not uae psat yeara'raorda You mnst
provide new copiea aad maintajn a 8k at yoar esbblishmeat.
,�1. ✓�IDr� /�'�s�i��+�. 2.
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HEIMLICH CERTIFICATIONS: �l/�- +_�i
All food service establislunents with 25 seats or more must have at least one employee hained in the Heimlich �-�
Maneuver on the premises at atl times. Please list your enployees Uained in anti-choking procedures below and � ' -��
' attach copies of employee certifications to this form. T6e Healtb Dsp�trtment wIl1 not nse past yeara'records.
Yoa amrt provi�k aew copks aad�t�#e a�e at yonr pboe of biulaae.
;
1, 2. ;
3. 4.
RESTAURANT SEATIlVG: TOTAL#
toncn�c:
OFFICE USE ONLY
LiCENSEREQt1IRED FEE pERMI7'g LtC��QUIRED s S PERMITY LI M�LREQUIRED i E� PERMIT+Y
�� s s CAMP f55 _SWII�tiNG POOL SI IOea
_I.ODGE SSS _7RAILER PARK 5103 _WHIRLPOOL f i l0ea
FOOD SEItVICE:
UCENSE UQtE� FEE if LlCENSE REQ(ARED FEE PERMIT N LICENSE REQUIRED FEE PERMIT M
�aiao�rs sus ��j ooxrn�rrr�, s�s �5? �Po�s°� �
_>�ooseaTs s2oo �corKa[oxvic. s6o
RETAIL SERVICS: —�ID.KTfCHEN S�
LICENSE 1tEQU1RED FEE PERMIT# LICENSE REQUIRED fEE PERMIT a LICENSE REQUfRED FEE PERMIT N
<SOsq R. f50 >25 000 8. f283 VENDIWG-FOOD S25
=<23,000 aq.R SISO � �RdZEN�ERT S40 =TOBACCO
5110
NAMECBANGE: s�s AMOUNTDUE - �'�'�� �
i
�rirsPL��TURN OVER AND COMPLETE OTHER S1DC OF FQRM����• �
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� ADMINISTRATION
j Under Chapter 152,Section 25C,Subsection 6,the Town of Yarmouth is now roquired to hold issuance or renewal
� of any license or permit to operate a business if a pecson or compeny dces not have a Certificate of Worker's
� Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE
a AFFIDAVIT MiJST BE COMPLETED AND SICNED,OR
;
CERT.OF INSURANCE ATTACHED �
OR �/
WORKER'S COMP.AFFIDAVIT SIGNED AND ATTACHEIT
Town of Yarmouth taxes and liens must be paid prio�r to renewal or issuence of your permits. PLEASE CHECK
APPROPRIATELY IF PAID: /
YES r� NO
MOTELS AND OTHER LODGING ESTABLISHMEIVT&
TRANSIEIVT OCCUPAI�ICY: For purposes of the liuutations of Motel or Hotel usee,Transient occupancy sl�ell be
limited w the temporary and short term occupancY,ordinarily and customazily associatod with motel and hotel use.
Trausient occupants must have and be able to �monstrate that they maintain a}xincipal place of residence
elsewhere.Transient occupancy shall generaily refer to continuous occupancy of not more tl�an thirty(30)days,and
� an aggregate of not more ihan ninety(90)days within any six(6)month period. Use of a guest unit as a residence or
dwelling�mit shall not be aon4idered transien� Occupancy that is subject to ttie callecui�of Room Occupancy
Excise,as defined in M.G.L.c.64G or 830 CMR 64G,as ameaded,shal!generally be considered Transient.
POOLS
POOL OPEHING:All swimming,wading and whirlpools which have been closed for the seagon must be inspected
by the Health Department pr�or to opening. Contact the Health Department to schedule the insp�n thrce(3)
diya prior to opening.PLE,ASE NO�:People are NOT allowed to sit in the pool area unUl t�he pool has been
inspected and opened.
POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count
b�y�r certified lab,and submitted to the Health Deparhnent three(3)days prior to opening,and quarterly
POOL CLOSING:Every outdoor in ground swimming pool must be drair►ed or cavered within seven('n days of
closing.
FOOD SERVICE �
SEASONAL FOOD SERVICE OPENIIYG:
All foad servia establishments must be inspxtod by the Health Department prior to openiag. Plesse contact the
Health Department to scl�dule the inspection thc+cc(3)days prior to opening.
CATERING POLICY:
Anyone wtw caters within the Town of Yarmouth must notify the Yarmouth Health Depertment by fi' the
required Temporary Food Service AppGcaiion form 72 hows prior to the catered event. These fottns c��n be
obtained at the Health Depart�nent,or from the Town's website at www.varmouth.maus�nder Health Dep�tmeat,
Downloadable Forms.
FROZEN DESSERTS:
Frozen desseits must be usted by a State certified Iab prior to opening and monthly thereafler,wiW sample results
submitted to the Heatth Depact►nent. Failure to do so will result in the�or revocation of your Fru�
Dessert Permit until We above terms have ban met
OUTSIDE CAF�S: '
Outside cafes(i.e.,outdoor seating with waitex/waitress service),m�st have prior approval&om the Board of Health.
OUTDOOR COOIQNG:
Outdoor coolcu►g,preparadon,or display of any food product by a retail or food service establishment is pwWb�ted.
NOTTCE:Pernuts 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 ESTABLISHIu�NT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT,ETC.),MUST BE REPORTED TO AND AP VED BY THE BO OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY REQ E PLAN. '
DATE: `/ SIGNATURE:
PRIlVT NAME 8c TITLE: ��,.i��"' �� '
w�.�a�yi6
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� Th�Co�weoltb of Massochase�s
IJeparlm�nt of I�edus�triol Acclde�s
O,�'ict of Inv�sti,gatiows
1 Congnss S'd+ee�Suite 100
Boston,MA 0211�2017
www�,rws�gov/dia
Workers' Compeasstion Inaarance A#�idxvih General Bnsiaes�es
Annlicant I�f'or�adon Ple�ae Print Lesiblv
Business/Organization Name: � ��� � ��� -sv 2�
Address: 25�� ��v� 2�
�yao�ozt.r
City/State/Zip: U�'G �� Phone#: fo'l? 6r6T/P�
An yoa an empbyer?CLecic tie sFProPrbbe boz: BBsine�Typ�(re9�irod).
1.�I am a employer with �Z employees(full andJ 5. ❑Re�ail
or p�rt-time).* 6. e'RestaurantrBar/Eating Establishment
2.❑ I am a sok P�P�;�'��P and t�sve no 7. ❑O�ee aad/�Sales(i�l.real estat�,auto,etc.)
anployees working for me in any cap�city.
[No workers' comp.insurance requiredJ 8. ❑Non-profrt
3.❑ We are a corporation and its officers have exexcised 9. ❑Entertainment '
their right of exemption per a 152,§1(4�,and we have 10.Q Manufacturing
no employees.[No worlcers'comp.insurence roquired]' 11.Q Health Care
4.❑ We are a non-profit organization,staffed by volunteas,
with no anployces.(No workers'comp.insurance re�.J 12.�Other
•My appliant d�at droda bmc Nt must alro 6110+�t6e aaxioo belo+v sha�vin6 their wodoas'oort�p�on PolicY iafamation.
••If d�e coiporue ot�oeis have exemptod�hes,Mt tbe eorporation has other mq�loyaes,a w�aioeis'oom�n Poliry ia eequired eod anch aa
or�aair�tian should c6ect baac N L
I wu e�a�loya tJlrot Ps provicGing�wrkas'cao�p�ex�obToa�w+wree jor�ry tn�loye+es� Below ls d�e polfcy iwj�di�w.
Inswance Company Name: ���/�
��•g A�: 3 �_
c;�y�s�p; <�,� �/� � '�6
Policy#�Self-ins.Lic.# w,�G � �O 7 �y0 7�� Expiration Date: ���1/�
Attac6 a capy of the wrorkera'compe�tion polky declacatior W�e,(showing the poNcy namb�sad apirattot data�
Failure to socure coverage as rcquirod under Saxion 25A of MGL c. 152 can lead W the unposition of criminal penal6es of a
fine up to�i,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a S'I'OP WORK ORDER and a fine
of up w SlSQ.00 a day again4t the violator. Be advised that a copy af this smtement may be forwarded to the Office of �
Inves6�ations of�e DIA for insurance coverage va�ifi�on.
I do Ikeneby curijy, palns and P�� ofP�1�1'tJkat tAie Injon�adon provldtd obove Ls true oad cwnrcx
/ Z� l
�#: l'!7 6� /z�
O,�'Iclo!ase arly. D�o not wri�r ln tkls ane,to bt on�ettd by city ar towr�oJj9ciaL
;
City or Towta• P�it/Lic�ae#
I�aie�AntSority(eirck o�e):
l.Board of Hesiti� 2.Baildi�Depsrtmeat 3.Ctty/Town Cla�k 4.I�n�Board S.3deetmen's Otfiae
6.Ot�er
Co�bct Penon: pr�#;
www.au�a.�ov/dia
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�.��4 STANDARD WORItERS COMPENSATION
AND �iPLOYERS LIABILiTY POLICY
INFORMATIdN PAGE - RENEWAL OF WC 4 30764072
�:��� ...�� ��' � �1`�r ;Tfl-" �_� �'�1s����. __ �_� ___ � ._� ��,��.,
WC 4 30764072 06/O1/16 06/01117 CONTIldIIJTAL CASIIALTY CO 070390580
� ��� ���d1K�� a�� � �� ��9e11t� � =� �� � ��;
�_ ,z _ .. �_xr . - . - _
ITEM Chill Line Inc S&S/BROWN &�BROWAT OF CT, INC.
1. 87 TONELA LANE
BARNSTABLE, MA 55 CAPITAL BLVD. , STE. 102
�CKY HILL CT 06067
02630
FEIN NUMBER: NCCI CARRIER CODE NO: 10243
I' OTHER WORR PLACES NtYP SHOWN ABOVE: SEE ATTACHED SCHIDIILE(S)
YOU ARE A - CORPORATIONI5
2. POLICY PERIOD- 06/01/16 TO 06I01/17 12:01 AM STANDARD TIME AT THE
INSIIRIDS MAILING ADDRESS.
3A. PART ONE OF THIS POLICY APPLIES TO THE WORRERS COMPENSATION LAW AND ANY
OCCiTPATIONAL DISSASE LAW OF EACH OF THE STATES LISTID HERE:
MA.
3B. PART TWO OF THYS POLICY APPLILS TO EMPLOYERS LIABILITY INSIIRANCE FOR WORR
IN EACFi STATE LISTED IN ITENI 3A: THE LIMITS OF LIABILITY ARE:
BODILY INJURY BY ACCIDENT $100,000 EACH ACCIDENT
BODILY INJiTRY BY DISEASE $500,000 POLICY LIMIT
N BODILY INJIIRY BY DISEASE $100,OQ0 EACH EMPLOYEE
0 3C. PART THREE OF TAIS POLICY APFLIES TO OTHER STATES, IF ANY, LISTED $ERE:
g ALL STATES EBCEPT AK, ND, OA, WA, WY ANb STATES DESI6NATED IN
IT�! 3A OF THE INFORMATION PAGE.
3D. THIS POLICY INCLIID�SS TFIESE ffi�iIDORSEMENTS AND SCHEDULES: STE ATTACIiEQ SCHBDIILES
---------------------------------------------------------------------------------
4. THE PRF�IIUM FOR TIiIS POLICY WIItL BE DETLRMINED BY OIIR MANUAL OF RIILES,
CLASSIFICATIONS, RATES, AND RATING PLANS. ALL INFORMATION REQIIIRED BELOW IS
SUBJECT TO VERIFICATION AND CFIANGE �Y AIIDIT.
ADJUSTMENT OF PREMItTM SHALL BE MADE: A`r POLICY EXPIRATION
CLASSIFICATION OF OPERATIONS • EST ANNUAL
PREMIUM
SEE ATTACHID � $1,103
PREMIUM DISCOIINT 0
« SBPENSE CONSTANT 338
TERRORISM PREMIIIM 29
� MINIMDM PRE�IIIJM $219 TOTAL ESTIMATED ANI3UAL PREMIIIM $1,470
= TOTAL STATE TAXES/ASSESSMEAiTS/SiTRCHARGES $63
� TOTAL ESTIMATED COST $1,533
� DEPOSIT PREMIIIM $1,470
�
s
� ACCOUNT NDMBER: 3019092053
� DATE OF ISSUE: 04l07/16
-- POLICY ISSt7ING OFFICE: FARMINGTON
= COITNTERSIGNID BY
� DA2E AIITHQRIZED AGENT
� WC000001 P-33398-E tED. 6l87)
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