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Home My WebLink AboutApplication and WC � ; .� �4��-� r`�� ,.. � :�� °" TOWN OF YARMOUTH B Q�,HEALTH . � APPLICATION FOR LICE `� F ' T- 17 DEC � 2 2Q�6 � .�. a.. � . * Please complete form and attach all n��sar�d m�n s �De em 6. Failure to do so will result in the return of your applicatio =� T � ' ESTABLISHMENT NAME: t S 1 D t �.o'f''T'� (.�-� S TAX ID• ; LOCATION ADDRESS: I�S 5�v-�-H- µn(�F' �� TEL.#: �l)$��g_�S 33 i ' MAILING ADDRESS: �411'1� ! E-MAIL ADDRESS: ��c� �� ,o OWNER NAME: �� e��0.� � CORPORATION NAM F APPLICABLE):�/qq�o��. V i LLR Cs�' (�'A►.�ao �'sso r"� �T i�r� � MANAGER'S NAME: o�c� � TEL.#: MAILING ADDRESS: �e�,rnA 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. � 1=ti �- � � _ _ -— --— _ -- -- - - --- - _ _ _ _ _ _ -- — � Pool erators must list a minimum of two employees currently certified in standard First Aid and Community Cardiop monary Resuscitation (CPR), having one certified employee on premises at all times. Please list the employee elow and attach copies of their certifications to this form. The Health Department will not use past years' reco s. You must provide new copies and maintain a file at your place of business. i � 1. 2. i 3. 4, I , a i `,FOOD PROTECTION MANAGERS - CERTIFICATIONS: j ' 11 food service establishments are required to have at least one full-time employee who is certified as a Food P tection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Ple e attach copies of certification to this application. The Health Department will not use past years'records. You ust provide new copies and maintain a file at your establishment. i ' 1• 2. PERSON CHARGE: Each food e tablishment must have at least one Person In Charge (PIC) on site during hours of operation. � 1• 2. � _ ___ - ALLERGEN C TIFICATIONS: All food service e ablishments are required to have at least one full-time employee who has Allergen certification, as defined in the St te Sanitary Code for Food Service Establishments, 105 CMR 590.009(G)(3)(a). Please attach � copies of certificatio to this application. The Health Department will not use past years' records. You must provide new copies d maintain a file at your establishment. 1. 2. HEIMLICH CERTIFICA ONS: All food service establishm ts with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at 1 times. Please list your employees trained in anti-choking procedures below and attach copies of employee certi cations to this form. The Health Department will not use past years' records. You must provide new copies d maintain a file at your place of business. 1. 2. 3. 4 RESTAURANT SEATING: TOTAL# _ ��,� OFFICE USE ONLY _ LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE P$ T B&B $55 _C�P $55 1 MOTEL $I 10 ��Z� I� $55 SWIMMING POOL$110ea. _LODGE $55 =TRAILER PARK $105 _WHIRLPOOL $110ea. FOOD SERVICE: - LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _�100 SEATS $200 —CONTINENTAL $35 _NON-PROFIT $30 _COMMON VIC. $60 WHOLESALE $80 RETAIL SERVICE: —RESID.KITCHEN $80 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: $is AMOUNT DUE _ $ ►►p,pp *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** 13ok�L—IS—I2�6-02 � , � ` 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. 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 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 E�cise, 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. PUOL 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 ar covered within seven(7)days of ' closing. . ,, � - : - _ _ _. _ : FO�� SERi�I�E _ _ . _,._ �_..� __, . . . _�_._ __ ___ 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 obta.ined 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 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 COOHING: 'i 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 COMME C MENT. RENOVATIONS MAY ,, A S PLAN. ' DATE: �� Cv SIGNATURE: PR1NT NAME & TITLE: ().�2Q ►1R r��-4 0 Rev. 10/12/16 � � � The Commonwealth of Massachusetts - Department of Industrial Accidents ' � Office of Investigations ' ' ' 1 Congress Street, Suite 100 ; Boston, MA 02I14-2017 ' � www.mass.gov/dia VUorkers' Compensation Insurance Affidavit: General Businesses Apnlicant Information Please Print Le�iblv � Business/Organization Name: ; ; � Address: 1,��, c�t,6-�'�e �'!'�'y� - City/State/Zip: , -� 2 Phone #: ��'�'—,.�9��S�� A ou an employer? heck the appropriate box: �usiness Type(required): l/� I am a employer with�employees (full and/ 5. ❑ Retail � or part-time).* 6. ❑ RestaurantBar/Eating Establishment —Z �J-�-am a sole proprie�or o�p�ers ip a i -- ----- -- - --- __-- 7. Office and/ar Sa1es(incl. real 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 c. 152, §1(4), and we have 10.❑ Manufacturing ino employees. [No workers'comp. insurance required]* 4.❑ We are a non-profit organization,staffed by volunteers, 11.❑ Health Care � 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 o�cers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#l. � I am an employer that is providing workers'compensation insurance for my employees. Below is the po[icy information. � Insurance Company Name: i Insurer's Address: i 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 €�ne tz�te�1,540.C�9-ai:d,�or ene-�ear i��r:��n;as-ws��-as c,�v-�l�ena�t�-in the fa�of�-STO�W��RD��-_�-f�� _ 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 ce� 'y, he pai nd penalties of perjury that the information provided above is true and correct. Si ature: Date: �-Z � � Phone#: —� ,j Official use only. Do not write in this area,to be comp[eted by city or town officiaL City or Town: Permit/I.icense# Issuing Authority(circle one): 1. Board of Health 2.Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone#• www.mass.gov/dia i . ,_ n �� NOTICE _, . � " � NOTICE T� � W � O W f� _._.._. ...'._.- � � E.�rPLo � - � To . �� ~` EMPLOYE _ �� ES , '��M Sv�y� The Co�nrnonweal : �� o� M�ssach�setts D�PARTIYiENT OF INDUSTI�IAI, ACCIDENTS 1 Congres� Street, Suite 14Q, Bo�ton, Massacl�usetts 02114 — 2017 617-727-49Op _ http://�vwvv.st�;t�,ma.us/dia _ _ _ As_required by Massachu�etts General Law, Cha ter 152, Sections 21, 22 c�i 30, this will give you notice that I(we) have provided for payrnent to our in�u ed empl-oyees unc�er th�-a��ve m�ntianect chapt�r by msuring with: THE TRAVELERS INSURANCE COMPANIES ; NAME OF INSURANCE COMPANY P.O. BOX 1450 MIR ORO M� 0 344-14�0 . ADDRESS OF INSURANCE COMPANY (IEU�-2�3L94-5-16) Q�-�7-1� 'F(J Q�-�1 -17 POLICY NUMBE�t �,, EFFECTIVE DATES� � PO BOX 424 �� BRIGHT AGENCY INC s �`�� MILFORD MA 017570424 �� NAME OF INSURANCE AGENT ADDRESS PHONE # o� o� SEASIDE RENTAL ASSOCIATION 135 SOUTM SHOF2E DRIVE o� SOUTH YARMOUTH MA 02664 �� EMPLOYER ADDRESS � __ � ___ _ _�______ � EMPLOYER'S WORKERS COMPENSATI�N OFFICER (IF ANY) � - DATE , N`= � MEDICAL TREATMENT o= "� The above named insurer is required in cases of personal injuries arising out of and in the course of �= employment to furnish adequate and reasonable hospital and medical services in accordance with the Q� provisions of the Worl�ers' Compensation Act. A copy of the First �eport of Injury rnust be given to the v� injured employee. T'he ernployee may select his or her own physician. Tlie reasonable cost af the services prov�ded by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably ' connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the NAME OF HOSPITAL AI�DRESS 000eo9 w�e�,�,s T� BE POSTED BY EMPLOY��