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Home My WebLink AboutApplication and WC ;, � �� TOWN OF YARMOUTH BO�,Iti� OF�EA.�TH F. DEC 1 4 ?O�6 � � APPLICATION FOR LICEN , ��. � T '� �`� �; � �"°` * Please complete form and attach all nec�� ; ��s � ce ��I�EPT. Failure to do so will result in the return of your application packet. ESTABLISHMENT NAME:_ .'7��L�V�✓ S�"DRL TAX ID: � LOCATION ADDRESS: �y y t��n/ �5�-i-R��T G��St �J�nmov� TEL.#: r�-v��-yri� MAILINGADDRESS: A�7F �� }fi3o�/� ^''�3 ' E-MAILADDRESS: 'yy)��,,,,.,c� Y�"/hQo� C'ew� OWNER NAME: /�1')U�T TS/n'1 C/��J1�1-f�y CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: /�U�-��m C 1�'UJj y-R� TEL.#: �8 3l07�D 72I MAILING ADDRESS: /��t,/ {�A-//1/ ��'� ��}-. Z�1 �J-`/�-,e�o vT� n�� z � 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. � _ _ -- _ �-- __ ---- � Pool operators must list a minimum of two employees currently certified in standard First Aid and Community i 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. 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�le at your establishment. l. 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 i provide new copies and maintain a file at your establishment. ' 1. 2, i 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 list 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 file at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY ��r -- — , LICENSE REQUIRED FEE PER1viIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $I10 I� $55 CAMP $55 SWIMMING POOL$I l0ea. _LODGE $55 _TRAILERPARK $105 _WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 _CONTINENTAL $35 NON-PROFIT $30 ' >100 SEATS $200 _COMMON VIC. $60 WHOLESALE $80 � RETAIL SERVICE: —.RESID.KITCHEN $80 � LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# f <50 sq ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 + �<25,000sq.ft. $150 ��Cf =FROZENDESSERT $40 �TOBACCO $110 � � I NAME CHANGE: $IS AMOUNT DUE _ $ 260.00 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** g0 k4 F-15- L 0�O�Z ! . �j/OYI�r��'�� i l L .) ADMINISTRATION � I 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. 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 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 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 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 closin . g '' . ___ __. , _ _ _ ,. _� �_,� _,,� ____ FOOD SERVICE 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. ; i 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. 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: f o� (p SIGNATURE: �I�I 1�a�i-=- G�S'�---�� / PRINT NAME& TITLE: �'1 U/�TS I 1'� C)-f��U��y b t�Nc.�, I� Rev. 10/12/16 � . � � The Commonwealth of Massachuset�s Department of Industrial Accidents Office of Investigations ' 1 Congress Street, Suite I00 Boston,MA 02114-20I7 y www.mass.gov/dia Workers' Compensation InsuranceAffidavit: General Businesses Applicant Information Please Print Legiblv Business/Organization Name: 7- rL Eyc��J Sd��2� Address: �� /Yl Ai N �- ��Z 8 City/State/Zip: W LS7" M oz6 Phone#: �510�.� `77�—�}��y ' Are you an employer? Check the appropriate boz: Business Type(required): ' 1.[� I am a employer with �t7 employees (full and/ 5. ❑ Retail , or part-time).* 6. ❑ RestaurantBar/Eating Establishment ' -- i e proprie or or p ners ip an nave no �. 0 Office and/or Sa1es(incl.real estate, auto, etc.) � employees working for me in any capacity. [No workers' comp. insurance required] 8• ❑ 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]* 11.❑ Health Care ' 4.❑ We are a non-profit organization, staffed by volunteers, with no employees: [No workers' comp. insurance req.] 12.❑ Other *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 organiza6on should check box#1. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: �Y) I TS U I .5 U 1'►') 1 `I"� i1�0 /N.Su(�/�N�E �oM �N� D F� �MC�i (G�� Insurer's Address: G�l 7'y PL�C� C.��R �Q}ST �7l I �U'• I-��}S��L L �V E S�"E S4 C.-.C3 - $ f Ty p� ��t�s �X �52oy � Z S �� Ci /State/Zi > � Policy#or Self-ins. Lic.# G(J�p �Jr'z S�d�- Expiration Date: I "' � ^ �1$ , 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 � - fi�e up-ta-�-3�St� � - '� � � , � � � '�rv�e�a'itiz�i�r�ir��orm of a � tc ana a nne_ of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. � I do hereby certify, under the pains and penalties ofperjury that the information provided above is true and correct. � Si�nature: ��-�-� Date• � c�— I t'1"'t� Phone#: � 1/ � Official use only. Do not write in this area,to be completed by city or town officiaL � � I City or Town: Permtt/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3.City/Town Clerk 4.Licensing Board 5. Selectmen's Office ' 6. Other i Contact Person: Phone#: � www.mass.gov/dia A Memoer af 6 • � iivS�.�Rr��,'CE >3r i�L1F M S IG �' WORKERS COMPENSATION AND EMPLOYERS LIABILITY ' INSURANCE POLICY—INFOf�1AATION PAGE � ; INSUREI� POLICY NO: WCP8525402 � MITSUI SUMITOMO INSURANCE COMPANY OF p�OR POLICY NO: WCP8525402 AMERICA 1 NCCI Company No: 19089 Account No: J500001001 Interstate/Intrastate Rsk Identification No: 1 FEIN/Taxpayer ldentification No: � Unemployment No: ITEM 1. NAMED INSURED AND MAILING ADDF�SS: PRODUCER NAME AND ADDRESS: MLTATSIM CHAUDHRY AON RISK SRVC SW/FRNCHS 7-11 DBA: 7-ELEVEN NO. : 2464-25933D CITYPLACE CENTER EAST 444 MAIN STREET 2711 N. HASKELL AVE. , STE 800 L.B.8 WEST YARMOUTH MA 02673 DALLAS TX 75204-2999 PRODUCER NO.: 0030500 LEGAL ENTITY: INDIVIDUAL OTHER WORKPLACES NOT SHOWN ABOVE: (See Workers Compensation Classification Schedule) ITEM2. POLICYPERIOD: From: O1-01-2017 To� 01-01-2018 Effective 12:01 A.M. Standard Time at the Insured's mailing address. ITEM 3. COVERAGE: A. Workers Compen$ation lnsurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers' Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits of liability under Part Two are: ' Bodily Injury by Accident: $ 500, 000 each accident 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 states designated in Item 3A and ND,OH, WA, WY D. This Policy includes these Endorsements and Schedules See Schedule �Forms and Endorsements. ITEM 4. PREMIUM: The premium for this Policy will be determined by our Manuals of Rules, Classifications, Rates and ' Rating Plans. AII information required on the Workers Compensation Classificatian Schedule is subject to ' verification and change by audit. See Extension of Inforrr�tion Page. ', Total Estirrrated MinimumPremium , $ 229 Annual Prerr�um: $ 2, 416 Audit Period:ANNUAL Expense Constant: $ 338 Terrorism risk insurance is included at 44 additional charge. ' Issued At: LOS ANGELES ' Date: 11-14-16 Countersigned by ' i � WC 00 00 01 A(414) � Includes copyright material of the National Council on Compensation Insurance, k�c_ used with its permission. � O Copyright 1987 National Council on Compensation�surance, Inc.All Rights Reserved. � i wsuaFn r.nav, � � � A.Memoer of � � �r ��<��:�E�r�.._. _ '_, ,::�_i�: MSIG � ; I Pblicy Number � WCP8525402 � .I COM PANY SIGNATU F� PAGE i MITSUI SUMITOMO INSURANCE COMPANY OF AMERICA (A New York Stock Company) MITSUI SUMITOMO INSURANCE USA INC. (A New York Stock Company) I Home Office: 560 Lexington Avenue, 20th Floor New York, New York 10022 (212) 446-3600 Admnistrative Offices: 15 Independence Boulevard Warren, New Jersey 07059 (800) 388-1802 Policyholders may use the telephone numbers shown above for any purpose. IN WITNESS WHEF�OF, the Company has caused this policy to be executed and attested. Except where prohibited by law or regulation, this policy shall not be valid unless countersigned by a duly authorized representative of the Company. `�`- ��-r.-�,.�c�1 f.,��!'�.,�•��t�-- Presid�t �� Secrehary MITSUI SUMITOMO INSURANCE COMPANY OF AMERICA ' MITSUI SUMITOMO INSURANCE USA INC. WC 99 06 07(Ed. 05-14) Page 1 of 1 �O 2014 Mitsui Sumitomo Insurance Group,all rights reserved ', i � IN URED COPY ��,'