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Home My WebLink AboutApplication and WC ' -, � TOWN OF YARMOUTH BOARD OF HEALTH �� ; � APPLICATION FOR LICENSE/PERMI - Ol ,:C�,_ I�AR Q ] z0f] - o,,,. �, ��, * Please complete form and attach all necess ,, , `: � � � e`` er 2016. �� Failure to do so will result in the retur� yo `�l�ti '�� DEPT. '� ESTABLISHMENT NAME: __Sf�f�K l3�-�S �� TAX ID: Z 7--S3G�'8'"/ 3 LOCATION ADDRESS: S � jv TEL.#: MAILING ADDRESS: O �! � � E-MAIL ADDRESS: 'o e r OWNER NAME: .Io CORPORATION NAME (IF APPLICABLE): .�c�.n I3c.� MANAGER'S NAME: ea-a`�-c..,�-G� h�,��-wv9- TEL.#: 97�f'—3"75----S�v Z MAILING ADDRESS: I� 0 r°�i�c ��1 !,v. Lnti�,w� «a �� 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. l. 2. 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. 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.�`�`n� �� 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. C�1 /'I `S 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 provide new copies and maintain a file at your establishment. 1. �.�t�t�ctt I�t..G�_ .ti 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 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. l. ��' � 2. � 1.�� 3. �o q., , h �. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&B $55 CABIN $55 MOTEL $110 —r� $55 CAMP $55 SWIMMING POOL$110ea. _LODGE $55 _TRAILER PARK $105 _WHIRLPOOL $110ea. ' FOOD SERVICE: LICENSE REQUIRED FEE P RMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# � 0-100 SEATS $125 ��J�� CONTINENTAL $35 ��, NON-PROFIT $30 >100 SEATS $200 TCOMMON VIC. $60 =��-'=�=1✓ —WHOLESALE $80 RETAIL SERVICE: —RESID.KITCHEN $80 LICENSE REQUIRED FEE PERMIT# LICENSE REQU�RED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<25,000 sq.ft. $$50 �Z5,000 sq.ft; $285 VENDING-FOOD $25 _FROZEN DESSERT $40 =TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE = $ �S 5• OO **x**PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** Loak�,t5—('lr2—b�— f c , i a ADMINISTRATION ` { E 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 ta�ces 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 ar 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 thirly(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 i 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 far 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. 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. CATERING POLICY: Anyone who caters within the Town of�armouth 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.�armouth.ma.us under Health Department, Downloadable Forms. ' i FROZEN DESSERTS: i 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 COOHING: 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 AN�APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUT A SITE PLAN. ' DATE: j J( �/7 SIGNATURE: �� PRINT NAME& TITLE: J G s� Rev. 10/12/16 � � The Commonwealth ofMassachusetts Department of Industrial Accidents ` Office of Investigations ` ' 1 Congress Street, Suite I00 Boston, MA 02X 14-2017 � www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Apulicant Information Please Print Legiblv Business/Organization Name: S ; � Address: � �� t�t�j 1 I ' City/State/Zip: Phone #: �J'?��3 7�' —S�p-i Are you an employer? Check the appropriate box: Business Type(required): 1.� I am a employer with�p employees(full and/ 5. ❑ Retail � or part-time).* 6. Q RestaurantlBar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no �. � O�ce and/or Sales(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 I( no employees. [No workers' comp. insurance required]* 11.❑ Health Care 4.❑ We are a non-profit organization, staffed by volunteers, I 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 o�cers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization 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: C � . ' Insurer's Address:_ 3 71 G�G'��'Iu.� � City/State/Zip: �;,�1;��i.t/�,t�t� �, 0/�Z7� . , Policy#or Self-ins. Lic. # S 1�"(i(J�i '?�0 �3�-f,6 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 fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify,un r the pains and penalties of perjury that the information provided above is true and correct. Si ature: Date: 3� (o Phone#: �7�� — 3 7.�—�4GU Z Official use only. Do not write in this area,to be completed by city or town officia[ City or Town: permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Offtce 6. Other Contact�erson: Phone#• �vww.mass.gov/dia '`'''�� CERTfFtCATE OF LIABlLITY INSURANCE °"�`'�'°"'Y"Y"' 10 28/16 YHIS CERTIFICATE IS IS3UED A3 A MATTER OF 11��2MATION Of�,Y AND CONfERS NO RtGHTS UPON THE GfiRTtFlCATE HOLDER TtMS CER'i'iFIGAIE DOFS Nd7 AFFIR�NATNELY OR NEGATNELY AMEND, EXTENp OR A1.7ER 7ME COVERAGE AFPt7RDED BY 7HE POUCIES BELOW. THtS CEFLTIFlCATE OF INSt7RANCE DOES NOT GON$TITUTE A CONTiiACT BETVYEEN THE ISSUING INSURER(Sj,At1TNORIZED REPRESEMATIVE OR PRODUCER,AND THE CERCIFlCATE Ht7LDER. iMPORTANT: !f the certiflcate holder�an ADDITIO AL INSURED,the policy(ies)must be endarsed. if SUBR�GATI�N iS WAtVED,subject to the terms and condiUo�s ofthe policy,certafn policles rnay rsquire an er�orsement. A statement on thiscertifiqte does not confer rtghts to tl�e csrti5cate halder in lieu of such erid�semen s). PROOUCER NAIY�:._ --,__ . _._ .__._ C$03.C6 IIl$lI�'79TiC� F�GJ�ACy� IAG. PHONE - _--. ._ _ . _ _ _._ 376 Sunu�er Street 7 94 -4853 '�X <97$) 345-1007 Eitchbur�, MA. Oiq2p c��ss: choice@choice-insurance.coa► INSUIiERjS�AFi�pRDING COVERAGE _ � NAiCM ' �n�suR�a:NoxGuard Insuranca CO. � INS UREO T � . i1V�RER B� 4 Sancibar Management, Tnc. _ . _ _ _._ _ _ t _ Cap� Cod In.flatable Park �r�suR�c:_� � _ _______...___ _.___..�- --------. .._ _-----____ PO Box 481 �NsuRe�,o c_ . West Yarmo�th, MA 02673 �Nsur��tE:__,. _._ _. _ _____ � _ _ __ .._ _. INSURER F: ' COVERAGES CERTIFICATE NUMBER: RENISIOM NUMBER. THIS IS Td CERTiFY TNAT FHE POLICIES aF tNSURANCE USTED BR.OW h1AVE BEEN ISStJE�TO THE IMSUR�D NAMED A80VE FpR THE PQLIGY PERIOD INDICAT�, NOTWI7HS7ANDING ANY REQUIREMENT,TERM OR CpNDf710N OF ANY C�NTRAC7 OR QTtiER DOGUMENT WlTH RESPEGT 70 WHICH 7W15 CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFpRDED BY ThE POLICIES DESCRI$ED HEREIPI IS SUBJECT TO RLL THE TEE2MS, EXCLUSIONS AND CONDITIONS OF SUCH PQUCIES.LIMITS SHOWN MAY HAVE SEEN REDUCED BY PiVD CLAYMS. __. . _. __--- ,__ , ___ __.__ A .�___.__ lTR TYPEOFINSURANCE POIJCY t�lAIBER pM� ��T _ ._.___.__. _, u�___. ____._ �6ENERAL LIA81Lil'Y � j , .� ; ; �EACH OCCURRENCE S.__ �. ._.__ __ ; �COMMERCIALGENERALLIABIUTY � ' ;dAMAGETO RENTED �f � ` b arxeenieFc�,�._ S ,� . . . _._._ ' i ClAIM3-MALIE ( �QCCUR !�D EXP(Ary pne persanj $ ` � � �_ _�____..._. _ __ _ "._. .j . ... - t . 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