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Home My WebLink AboutApplication and WC I TOWN OF YARMOUTH BOARD OF HEALTA APPLICATION FOR LICENSE/PERMIT-2017 *Please complete form and attach all necessary documents by e�e r�. �, Failure to do so will result in the return of yoar applicatton pac et. 4'��;� ESTABLISHMENT NAME: LOCATION ADDRESS:�3 �u s.�i rfs .v�.y TEL.#:,S'P8-.�"'9 y-..�ja d MAILINGADDRESS: /on G'�� e-�c� �?d,+iclin8„Jy�'�F_�nG�. .�IA �.�.5'.S3 E-MAIL ADDRESS: f'��c c.,q r2 r,u 5� �'�✓�"!�i Z a N.�s�T OWNER NAME• ��-r�r� �!�r.o rr,�',�;� . CORPORATION NAME(IF APPLICABLE}• C` vi �- v, G ?e � � ;i MANAGER'S NAME:�'TL�vSa� ./�r [�'A2 Ti�i`� L.#:,s''o8-Y� ' � � n �` � MAILiNG ADDRESS: s�o �csr's'�U ��s.0✓•��"�/T �.�,�o� ,�!�� t��"S"3 �� .V � �.'�� i:�� POOL CERTIFICATIONS: ; � ,� `� Thc pool snpervisor mast be certified as a P�l Operator,as required by State law. Please list the designated � ''� o Pool Operator(s)and attach a copy of the certification to this form. =� � ��v€ l. 2. Pool operators must list a minimum of two empioyees currendy certified in standard First Aid and Community Cardiopulmonary Resuscitation(CPR),having one certifced employ�on premises at all times. Ple.ase list the employees below and attach copies of their certifications to this forra.The Health Department will not nse psat years'records. Yoa must provide aew copies and maintain a file at yoar place of basiness. 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 Protxtion Manager,as deSned in the State Sanitary Code for Food Service Establishments, 105 CMR 594.000. �:.� Please attach copies of certification to this application. The Health Departraent wil!not use past years'recorda. ;;;..�.,,,.:,z., �.�yYou must provide new copies and maintnin a file at yonr establisl�ment �, ;<� 1.�°7x✓/�s /'�G �.ol��-iv�i __2.,�viG e�t��" �C C�.�v�--�l��r :;'"-�i '� m PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. i. o z C n, � z. �A��,Q. !i, ll.o ALLERGEN CERTTFICATIONS: All food service establishmenis ate required to have at least one full-time employe.e who has Allergen certification, as defined in the State Sanitary Code for Food Service Establishments,105 CMR 594.009(Gx3xa). Please attach copies of certification to this applicatioa The Health Department wil!not ase past years'records. Yon mast provide new copies and maintain a�ile at yoar establishment. 1.V/� ✓�s �c- �Ae2`T/�y 2. HEII�iLICH CERTIFICATIONS: N/ A11 food service establishments with 25 seats 6r m�ore measi have at least ono employee trained in the Heimlich Maneuver on the premises at all times. Please list your enployees trained in anti-choking procedures below and attach copies of empioyee certifications to this form. The Health Department wi11 not nse past years'records. You muat provide new copies and maintain a fle at your place of basineas. 1. 2. 3. 4. RESTAURANT SEATING: TQTAL# � OFFICE USE ONLY LODGING: LICENSE REQUIREA FEE PERMIT# LICENSE REQUIRED FEE PERMIT q LICENSE REQUIRED FEE PEILMIT# B&B SSS CAB1N $53 MQTEL SIlO 1NN S35 CAMP SSS =SWIMMINGPOrJL$IiOea. _7..ODGE SSS =—`TRAILER PARK 5105 _WHIItLPWL 8118ea.� FOOD SERVICE: LICENSE REQUIRED FEE P�'�� #�(,� LICENSE REQUIRED FEE PERMtT# LTCENSE�p UIRED FEE PERMIT# ,LO-l00 SEA1'S SIZS ��.,,�-�-�J _CON7'INENTAL S33 NQN-PRO�1T S30 _,>I00 SEATS 5200 `COMMON VIC. S60 �SID.1T'CHEN 5�80 RETAIL SERVICE: LiCENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT tl LICENSE REQUIRED FEE PERMIT# <50sq�ft. S50 >25,000sq�ft. 5285 VENDING-FOOD S25 _<25,000 sq.R SI50 ='FROZEN DESSERT S40 `1'OSACGO SI l0 NAMECHANG�: Si3 AMOUNTDUE = S �Z�,QQ •••e*PLEASETURNOVERAND��ar:aa gat-�F��39�O� , ADMINiSTRATION Under Chapter 152,S�tion 25C,Subsection 6,the Town of Yannouth is now requi�+ed to hold issuance or renewal of any license or permit to operate a husiness if�person or company does not have a Certificate of Worker's Comgensation Insucance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST SE CUMPLETED AND SIGNED,OR CERT.OF INSURANCE ATTACHED OR WORKER'S COMP.AFFIDAVIT SIGNED AND ATTAGHED Town of Yarmouth taxes and liens must be paid prioz to r�newal or issuance of y4nr perauts. PLEASE CHEGK APPROPRIATELY IF PAID: / YES J NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purpose.s of the limitations of Motel ar Hotel use,Transient occupancy shall be limited to the temporary aacl short t�m occupancy,ordinarily and customarily associated with motel aud hotel use. Transient occupa�ats must have a�d be able to demonstrate that they maintain a pri�ipat plsce of residence elsewhere.Transient occapancy shail generally refer to continuous occupancy of not more than thirry(30}days,and an aggregate of not more than zunety(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 coll�tian of Room Occupancy Excise,as defined in M.G.L.c.64G or 830 CMR 64G,as amended,shatl generally be considered Transient. POOLS POOL OPENING:AII swimming,wading and whirlpools which have been closed for the xason must be inspected by the Health Departmentpnor to ope�un� Contact the Health D ent to schedule the inspection three(3) daya prior to opening.PLEASE NOTE:Peopte are NOT atlowe�t in the gaol area until the pool has been inspected and opened. POOL WATER TESTING: The water must be tested for pseudomonas,totai colifarm and stendard plate count by a State certified lab,and submitted to the Health Degartment thr�(3)days prior to opening,and quarterly thereatier. POOL CLOSING:Every ouidoar in ground swimming pool raust be drained or covered wiilvn seven(7)days of closing. FOQD SERVICE SEASQNAL FOUD SERVICE OPENING: All foai service establishments must be inspected by the Health Depart�nent prior to opening. Please con#act the Health Deparhnent to schedirle the inspection three(3)days prior W opening. CATERING POLICY: Anyone who caters within the Town of Yarmouth mast notify the Yarmouth Heattti Department by filing the reqwred Temporary Food Service Application form 72 honrs prior to the catered event. These forms can be obtainal at the Health Depaztment,or from the Town's website at www.yarmouthxna.us under Health Deparhnent, Downloadabie Farms. FROZEN DESSERTS: Frozen desserts must be tested by a State certified lab prior to opening and monthly thereafter,with sample resutts submitted to the Health Department. Failure to do�will result in the suspension or revocation of your Frozen Dessert Permit untii the above tem�s have been met. OUTSIDE CAF�S: Qutside cafes(i.e.,outdoar seating with waiter/waitress service),must have prior approvat from the Board of Heatth. OUTDO(3R COOKING: ' Outdoor 000king,preparation,or display of any food praduct by a retail or food service establishment is prohibited. NpTICE:Penmiits run annually from January 2 to December 31. IT IS YOUR RESPONS�II.ITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQiJIRED FEE(S)BY DEGEMBER lb,Zd16. ALL RENOVATTONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAII�iTING, NEW EQUIPMENf,ETC.),MUST BE REP(?RTED TO AND APPROVED$Y THE BOARD OF HEALTH PRIt�R TO COMMENCEMENT. RENQVATIONS MAY RE UIRE A SITE PLAN. DATE: /L - a �/Ia SIGNATURE:� �" PRINT N.AME&TI1'LE: G �� [tcv.10/12/i6 � The Commonwealth of Massachusetts Deparb�ent of Indus�iriarl Accid�nts 4,,�'ice oflnvestigations 1 Con,gress Stree�Suite lOt1 Boston,lKA 4211�2017. www.rnars�gowldia Workers' Compensation Insurance Affidavit: Geaeral Businesses Annlicant Informstion Please Print Le�ibiv Business/4rganization Nazne: — i �� T L.a . l`L .� � finn�.��S �... IT—' Address: �-3 r.��;� s '��Tr1 �_ .�ar�d��', �.v., , City/StatelZip: Phone#: �S"� -�`?'"� ! o v Are aa employerT Che�k the appropriate iwz: Business'i'ype{reqaired): 1.�I am a emplayer with�_employees{full ar►cl/ 5. (�Ret�il or part-dme).'` 6, ❑RestaurantrBar/Eating Establishment 2•❑ I am a sote proprietor ar partnership and have na 7, �p��a/or Sales(incl,t�eal estate}suto,etc.) employees working for me in any capacity. [No workers'comp.insurance required] 8. Q Aion•profit 3.❑ We are a corporatian and its afficers have exercis� 9. ❑Entertainment their right of exemption per c. 152,§1(4�and we have 1 fl.�Manufacturing no employees.[No workers'comp.insurance r�uired]* 4.❑ We are a non-grofit organization,staffed by volunteers, 1 L[]Health Gare with no employees.[No workers'comp,insurance req.] 12.(�Other 'Auy epgiic�t tha�chodcs box#t must also fiIl o�the saxia�beiow showing their wadaers'c�satia��wiicy informffiian. s sIf the caipoiate o#�cers have exemptal themseIves,but the co�poaation has other eu�loYees.s worlcers'campc�Policy is required mid such aa orgartizatio�n sltould check box#1, I am an�y�er tJiat�s pravid�'ieg x►orkers'compcnsat�ax ins�urance jar my emplayee�. Below u the poltcy�formation. Insurance Company Name. ��2-"T�1�,�(1.�� )� � Insur�r's Adclre�s: `�� c�o � ��j� c�rirs�P: _.��N-rc�� ; N � t 33 3-5 Policy#or SeL€-ins.Lic.# l� c��C_ L� c�3 3 0�- Expiration Date: .�" �� Attac�a c,opy of the workers'compensat3on policy declar�tion p�ge(shawing the policy nnmber and ezpiixtiom date� Failure to secure coverage as required u�r Section 25A of MGL c. 152 can lead to t3�e imposition of criminai p�enaities af a fine up to�1,500.00 and/or one-year imprisanment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$254.00 a da.y against the violator. Be ad�ised that a cogy of this statanent may be forwarded to the(}ffice of Investig�tions af the DIA for insurance coverage verificatian. I do Jkertby ctrtify,u�the palns and penalties o.1'�P�isry tAwt tbe�nformatlore pravtded abau�Ts trt�e and corrsec� i 7 r ��" ��`�.l� _P_hone#: �� `'�'�`� - �1"? Dfficia!use only. Dv not wr�e ln tltis area,tv b�e coniplded by ctty or town officiat Cit,y or Tawn: Permit/Iacense# Iseaing Authority(circk one): 1.B�wtrd af Health 2.Buiidiug Department 3.City/Town Cterk 4.Licensiag Board S.Selectmen'�Qifice 6.Q�er Coatact Persan• I'boae#• www.m�.gov/dia 32 �PoltcY�ovisions_ �� o0 00 0o B) 03 - LF tNFORMATIpW pqGE �'� WORKERS COMPENSATION AND EMpLOYERS LIABtLiTY p INSURER: �TFORD ACCIDENT 1� I�jE�I� COMP.�y �LICY ONE HARSFORD PLAZA, HARTFORD, CONNECTICUT 06155 NCCI Company Number: 10448 �mpany code: 5 THE - HARTFORD O'BRIEN � G�gBONS /nsurance Centar USE OUR CONVE�IIENT Dqry�N�pOW WORC�GH�ND�- P.O BOX 1 Og4 �D.�ggp� MASSACHUSEI'Tg 01673 �__— (SOB)74�75p4 FA7(#752-4017 Suffix POLICY NUMBER: oe WEC LF0332 �s �NEWi� Previous Palicy Number: os wEC LF�332 06 �- Named I�1SV��J and Nl��n9 Add1�SgINSIINSETEFRII T CO., (No.,Street,Town.State Zi INc. = P Code) FEIN Number: P� BOX 570 M��T B��H� N1A 02553 State identifiqtion�Number(s); The Named Insured is: CORPORATION Business of Named Insured: GIFT BASKETS - RETAiL Other workplaces not shown above: SE$ ATTACHED SCHEDUi,gg 2• Policy Period: F�om 05/Ol/16 To 05/0l/1� 12:01 a.m.,Standard time at the insured's mailing address. Produce�'s Name: O'BRiEN & GIBBONS INS AGENCY INC 52 HIGHI,AN7� STREET WORCESTER, MA p1609 Pr�ucer's Code: 061629 Issuing Office: THE HARTFORD 301 WOODS PARIC DRIVE CLINTpN (800) 962-6170 I`n' 13323 Totai Es#hnated qRR�al Premium: $3,893 �eposit Premium: Po�icy Minimum Premium: $280 MA (iNCLUDES INCREASED LIMIT MIN. PREM.) Audit Period: �7AL The policy is not binding unless countersigned by ou�r a+uth nied epresentative. Countersigned by ��"`�'� C Authorized Represen#ative o3/12/ls Date Form WC 00 00 01 A (1) Printed in U.S.A. Process Date' 03/12J16 Page 1 (Con6nued on ne�page� � Policy Expiratton Date• 05/01/1� INFORMATION PAGE (Continued) Policy Number: os w$c LF0332 3.A Workers Compensation insurance: Part one of the policy appiies to the Workers Compensation Law of the states listed here:MA B. Employers Liability Insurance: Part Two of the poticy applies to woric in each state list�ed in item 3.A. The limits of our liability under Part Two are: Bodity injury by qcxident $500,o0o each accider�t Bodity injury by Disease $5oo,o00 ��y��m� Bodily injury by Disease $soo,o0o each employee C. Other States Insurance; part Three of the policy applies to the states, if any, tisted here: ALL STATFS EXC$PT ND, OH, WA, WY, US TERRITORIES, AND STATES DESIGNATED IN ITEM 3.A_ OF THE INFORMATION PAGE. D. This policy includes these endorsements and schedule: WC 99 00 05 WC 00 03 O8 WC 00 04 22B WC 20 03 03D WC 99 03 OOD SEE ENDT 4. The premium for this po�icy will be determined by our Manuals of Rules,Classifications, Rates and Rating P1ans• Ali information re uired be�ow is sub ect to verification and chan e b audit. Premium Basis Classifications Totat Estimated Rates Per Code Number and Estimated p��p�� Annual �100 of Annual Remuneration Remuneration Premium (SEE ATTACFIED SCHEDULES) MA RATE DEVIATION PREMIUM CREDIT (_20) (9037) INCREASED LIMITS PART TWO (9807) 1.00 PERCENT -840 TO EQUAL INCREASED LIMITS MINIMI7M PREMIUM (984$) 34 T�T�' PRF�MIUM SUBJECT TO EXPERIENCE MODIFICATION I6 MA - MBRIT RATING CREDIT 3,408 (9885) .950 PREI"IIIIM ADJUSTED BY APPLICATION OF EXPERIENCE MODIFICATIOP7 TOTAL ESTIMATED 11NNL7piI, STANDARD pREMIUM 3.238 EXPENSE CONSTANT (0900) 3,238 MASSACHUSETTS DIA ASSESSMENT 5.750 PERCENT 33$ TERRORISM (9740) 229 291,700 .030 gg TOTAL ESTIMATED ANN[7AI, pREMIUM 3,893 Tota!Estimated Annual Premium: $3,893 Deposit Premium: Policy Minimum Premium: $280 MA (INCLUDES INCREASED LIMIT MIN. PREM.) InterstateAntrastate Identification Number. / 000484685 Labor Contractors po�icy Number: NAICS: SIC: 5947 Form WC 00 00 01 A (1) Printed in U.S.A_ p�ge 2 Process Date: 03/12/16 Policy Expiration Date: os/oi/1� SCHEDUlE OF OPERATfONS This Schedule of Operations forms a part of the policy effective on the inception date of the policy unless another date is indicated below: INSURER: HARTFORD ACCIDENT AND INDEMNITY COMPANY Company Code: 5 Policy Number: oe wEc LF0332 Schedule Number: oi-2o-o3 Effective Date: o5/oi/15 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Location Address of operations covered by this schedule: SUNTSET FRUIT CO. , INC. 23 WFIITES PATH SOUTH YARMOUTH MA 02664 NAICS: FEIN: UII3: SIC: NO. OF EMPL: 4. The premium for this policy will be determined by our Manuals of Rules,Classfications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Premlum Basis Classifications Totai Estimated Rates Per Estimated Code Number and Annual $100 of Annual Description Remuneration Remuneration Premium 8001 27,700 1.60 443 FLORIST - STORE - & DRIVERS 'Countersigned by Authorized Representative Form WC 99 00 05 (1) Printed in U.S.A. Process Date: 03/12/i6 Policy Expiration Date: os/ol/i�