HomeMy WebLinkAboutApplication and WC � � TOWN OF YARMOUTH BOARD OF HEALTH
� � APPLICATION FOR LICENSE -2Q�. .; �ti,`�=- � -- -�'�='
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* Please complete form and attach all neces `nt���e e be -.1(r 6 �
cket.:._, _ �l1 h -
Failure to do so will result in the ret .' of y ;: a�p�i�at�Qr�,p � �
ESTABLISHMENT NAME: rm . ` z1� TAX ID.
' LOCATION ADDRESS: ��..�r �2g TEL.#:c5C7A''-77�•0� �l
MAILING ADDRESS: ��r��„_.-
E-MAIL ADDRESS: �y�Lr�@ ,���!' ,�o ,�•�
OWNER NAME: „ -
CORPORATION NA (IF APP ICABLE):
MANAGER'S NAME: ___�� }�, zl,=} TEL.#: �r�"• � (� " v�lC7
MAILING ADDRESS: �a.,.�.,�,
POOL CERTIFICATIONS:
The pool supervisor must be certified as a P 1 Operator,as required by State law. Please list the designated
Pool Operator(s) and attach a copy of the ification to this form.
1. 2.
Pool operators must list a mi ' um of two employees currently certified in standard rst Aid and Community
Cardiopulmonary Resuscit 'on (CPR), having one certified employee on premise at all times. Please list the
employees below and att copies of their certifications to this form. The Healt epartment will not use past
years' records. You ust provide new copies and maintain a file at your ace 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 certificatiori 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. C.l Co f}' �(')�.J"'1 � 2.
PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
, , �
1. �� �,1� � 2. Q- �
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. 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.
1._ UQI�, �t��� 't' 2. /'Z.��`�ti i� ��7'
3. ;��rn �.�'Z►-- �6�..�~:c► 4. �_��. �lstr: �C
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
INN $SS CAMP � $55 SWIMMING POOL$110ea.
_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 l 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# '
_<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 _ $ 3 0�O O
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*****
8 0.�F-t5-(Soo-OZ
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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 ATTAC�IED STATE WORKER'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR
CERT. OF 1NSURANCE ATTACHED �
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth taxes and liens must be paid priar 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 ar
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 , j
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. '
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: I
. 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.
4
OUTDOOR COOKING:
Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited.
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NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR R.ESPONSIBILITY 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 Y THE BOARD OF HEALTH PRIOR
TO COMME CE ENT. RENOVATIONS MA UIRE A E PL N. �
DATE: SIGNATURE: ' I,
PR1NT NAME & TITLE: �,-,��,'�
' Rev. 10/12/16
�
i�'� (Policy Provisions: wc o0 00 00. B)
� 59
� INFORMATION PAGE
�� W4RKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY
INSURER: T�IN CITY FIRE INSDRANCE COMPANY
ONE HARTFORD PLAZA, HARTFORD, CONNECTICC7T �6155
NCCI Company Number: 14974 1��
Company Code: � HARTFORD
suffix
LARS RENEWAL
POLIGY NUMBER: 08 WEC NN5968 r�i��
Previous Policy Numbsr: os w�c NN5968
HOUS IPTG CODE: SB
1. Named Insured and Mailing Address: �ST YARMOUTH CONGREGATIONAL
(No., Street,Town, State,Zip Code) C��
383 MAIN STREET
FEIN Number' WEST YARMOUTFI, MA 02673
State Identification Number(s):
UIN:
The Named Insured is' NON-PROFIT ORGANIZATION
Business of Named Insured: Cx[�tCxEs AND OTHER xousEs oF w
Other workplaces not shown above: 383 rtArrr STREET
WEST YARMOUTH MA 02673
2. Policy Period: From l0/01/16 To io/ol/i�
12:01 a.m.,Standard time at the insured's mailing address.
Producer's Name: FITTs INSURANCE AGENCY INC
2 WILLOW STREET SUITE 102
SOUTHBOROUGH, MA 01745
Producer's Code: o8ao26
Issuing Office: THE HARTFORD
301 WOODS PARK DRIVE
CLINTON NY 13323
(800) 962-6170
Total Estimated Annual Premium: $1,2 0 9
Deposit Premium:
Policy Minimum Premium: $282 MA �INCLUDES INCREASED LIMIT MIN. PREM.)
Audit Period: ��� Instailment Term:
The policy is not binding unless countersigned by our authorized representative.
Countersigned by ��"'� '���"�'"'�� 0 8/13/16
Authorized Representative Date
Form WC 00 00 01 A (1) Printed in U.S.A. Page 1 (Continued on next page)
Process Date: os/i3/i6 Policy Expiration Date: 1o/oi/i�
�'
• INFORMATION PAGE (Continued) Policy Number: os .wEc rrxs�6s
3.A Workers Compensa#ion Insurance: Part one of the policy appiies to the Workers Compensation Law of the
states listed here: �
B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A.
The limits of our liabilil.y under Part Two are:
Bodily injury by Accident S1,o 0 0,o 0 o each accident
Bodily injury by Disease $1,000,o0o policy limit
Bodily injury by Disease $1,o 0 0,o 0 o each emptoyee
C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here:
ALL STATES EXCEPT ND, OA, WA, WY, US TERRITORIES, AND
STATES DESIGNATED IN ITEM 3.A. OF THE INFORMATION PAGE.
D. This policy includes these endorsements and schedule:
WC 00 04 22B WC 20 03 03D WC 20 06 02 WC 00 04 14 WC 20 03 01
! WC 20 03 02A WC �20 04 O1 WC 20 04 05 WC 20 06 OlP,
4. The premium for this policy will be determined by our Manuals of Rules,Ctassifications, Rates and Rating
Plans. All information required below is suaject to verification and change by audit.
Premium Basis
Classifications Total Estimated Rates Per Estimated
Code Number and Annual $100 of Annual
Description Remuneration Remuneration Premium
8868 109,800 .79 867
RELIGIOUS ORGANIZATION PROFESSIONAL
EMPLOYEES & CLERICAL
INCREASED LIMITS PART TWO (9812) 2.00 PERCENT 17
TO EQUAL INCREASED LIMITS MINIMUM PREMIUP4 (9848) 58
TOTAL PREMIUM SUBJECT TO EXPERIENCE MODIFICATION 926
MA - MERIT RATING CREDIT (98$5) .950
PREMIUM ADJUSTED BY APPLICATION OF EXPERIENCE MODIFICATION 880
SMALL DEDUCTIBLE 500 (9663) 1.90 PERCFNT -16
TOTAL ESTIMATED ANNUAL STANDARD PREMIUM 880
EXPENSE CONSTANT (0900) 250
MASSACHUSETTS DIA ASSESSMENT 5.600 PERCENT 46
TERRORISM (9740) 109,800 .030 33
TOTAL ESTIMATED ANNUAL PREMIUM 1,209
Total Estimated Annual Premium: Si,209
Deposit Premium:
Policy Minimum Premium: 5282 MA (INCLUDES INCREASED LIMIT MIN, PREM.)
Interstate/Intrastate Identification Number: / 000017863
NAICS:
Labor Contractors Policy Number: g�C; s66i
UIN:
N0. OF EMP: 000003
Form WC 00 00 01 A (1) Printed in U.S.A. Page 2
Process Date: 08/13/16 Poliay Expiration Date: lo/o1/i�
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