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Home My WebLink AboutApplication and WC TOWN OF YARMOUTH BOARD OF HEALTH APPLICATION FOR LICENSE/PERMIT-2017 x�,''�� ` *Please complete form and attach all necessary documents by December 16 1016. °'�� Failure to do so will result in the return of your applicataon pac cet. ESTABLISHMENTNAME: T � r� LOCATIONADDRESS: �a,?al Q,{- �g S- �Cu'/'Ylvuy{•17 O?r(o�r�TEL#• 5�'$ 39� 1��{a �..1,;,�r� MAILINGADDRESS: l� laaun�s�-l- b�Ll[7L] p1L ✓i.uic.� M.14 O eKV ,,.�;-�� E-MAIL ADDRESS: OWNER NAME: � � � '�� , CORPORATION NAME(IF APPLICABLE): �p f �� C�c,,p►K.bs •'' ,�' MANAGER'S NAME: TEL.#: � MAII,ING ADDRESS: Ca.s t� POOI.CERTIFICATIONS� The pool supervisor must be certified as a Pool Qperator,as required by State law. Please list the designated = � � Pool Operator(s)and attach a eopy of the cerbification to this form, m �. 2. � � m � Pool operators must list a minimum of two employees currently certified in standard First Aid and Community 0 rv � Cardiopulmonary Resuscitation(CPR),having one certified employee on premises at all times. Please list the � o tTl 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 PROTECITON 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 Establislunents, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years'records. Yo�must provide new copies and maintain a file at your establishment. �wi� �C�� • � 2.1 �C7`�l/n � i t� PEIiSON IN CHARGE: �� Each food establishment xnust have at least one Person In Charge(PIC)on site during hours of operarion. <��S _ _ _. l.��n��u,ltara,r� 2.�;t_i_sl� n�4libr� 3�I�'!ia�h ALLE�tGEN CERTIFICATIONS: t-11 C��XY� � All foad service'esfabiishments 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 provid�new copies and maintain a file at your establishment. 1. 2. HEIM�ICH CERTIFICATIONS: All food service establishtnents with 25 seats or mare must have at least one employee trained in the Heimlich Maneuver on tlie premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of employee certificarions to this form. The Health Department will not use past years'records. You must provide new copies and maintain a file at yaur place of business. l. � 3. 4. RESTAURANT SEATING: TOTAL# . C� Loncuvc: OFFICE USE ONLY LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B�B S55 CAMP $55 � _W MMING POOL$1 l0ea. _LODGE =TRpILERPARK $I�OS _WHIRLPOOL E110ea FOOD SERVICE: LICENSE REQ UIRED FEE P IT LICENSE REQUIRF.D FEE P6RMIT# LICENSE REQUiRED FEE PERMIT# 10-100SEA7'$ 5125 �� _Cp��pi, �g5 NON-PROFIT S30 _>100 SEATS 5200 _COMMON VIC. $60 �_ 'WHOLESALB Z80 RETAIL SERVICE: - —RESID.KiTCHEN�80 LICENSE REQIJIRED FEE PERMIT'ti LI�ENSE REQtTTRF.Ci FEE PERMIT il LICENSE REQUIRED FEE PERMIT# ^�25.000sq.ft. 5150 . =FROZEN�ESSERTaSdO �Q =OBACCO FOOD$S2O5 NAMECHANGE: SIS _ AMOUNTDUE _ $ *"**sPLEASE TURIY OVER AND COMPLETE OTHER SIDE OF FORM"*++• �oH�F— f S—l3 6�f—o'z.. � ADMINISTRATION Under Chapter 152,Section 25C,Subsection 6,the Town of Yannouth is now required to hold issuance ar renewal of any license or permit to operate a business if a person or company does not have a Certificate of Woxker'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 xo renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY iF PAID: YES_� NO MOTELS AND OTHER LODGING ESTABLISI�VI�NTS 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 dweliing 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 POqL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Depardnent 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 azea until the pool has been inspected and opened. POOL WA'TER 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 SERYICE OPENING: All food service establishments must be inspected by the Health Department prior to opening. Please contact the ' Health Deparkment to schedule the inspection three(3)days prior to opening. CATERING POLICY: Anyone who caters within the Town of Yazmouth must notify the Yarmouth Health Department by filing the requ�red Temporary Food Service Apptication 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 Depart►nent, Downlaadable Forms. FROZEN DESSERTS: Frozen desserts must be tested by a State certifaed 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 Fmzen Dessert Permit wntil tlxe ab�ve terms have been met OUTSIIIE CA,�ES: ()utside cafes(i.c.,outdoor seating with waiter/waitress service),must have prior appmval from the Boazd of Health. i OU'I'DOOR C�OKING: � Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. 1>IOTICE:Permits run annually from January 1 to December 31. I'�'IS YOUR RESPONSIBILTf Y 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., PAINITNG, NEW i � EQUIPMENT,ETC.),MUST BE REP�JRTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR � TO COMMENCEMENT. RENOVATIONS REQUIRE A SITE PLAN. DATE:�16� I�1 SIGlv'ATURE: � PRINT NAME&TITI,E: ��.►0,«�6 aW� t , � , � , The Commonwealth of Massarhuseits D�epartment of Industrial Accidents Office of Investigations ' 1 Congress Sbee�Suite 100 Boston,MA 02114-2017. www.mass gov/dia Workers' Compensation Insurance Affidavit; General Businesses ADn�ic�at Information Please Print Le�iblv BusinesslOrganization Name: Address: City/State/Zip:` Phone#: Are you an employer?Check the appropriate box: Business Type(required): 1.❑ I am a employer with employees(full and/ 5. ❑Retail or part-time).*. 6. [] daestaurantBar/Eating Establishment 2.❑ I am a sole proprietor or partnership arAd have no 7, ❑ Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers' comp.insurance required] g• ❑Non-profit 3.❑ ._W�ar�a corporation and its officers have exercised 9. [I Entertainment their ri gt�t�f exeEnpfion per c. 152, §1(4),and we have 1 Q.❑ Manufacturing no�rr�ployees. [No wo�ers'comp.insurance required]* 11.�Health Caze 4.❑ We�re a non-profit organization,staffed by volUnteers, wit�no employees. [No workers' comp.insurance req.] 12Y(� Other •Any applica�at that chedcs box#1 must also fitl out the section betow showing tLeir workeis'compensation policy information. ••If the carpo;ate officers have exempted themselves,but the corporation has qthea employees,a yvorkers'compensation policy is required and such an arganizetion should checic boz#L' , . . ; I dm a�i�PinJjloyer C�irrt'is'provialing workers'compens,ation-insurance for my erKployee� Befow is tl�e po[icy fiiformat�on. Insurance Cvmpany.Name, Insurer's�Address: City/State/Zip: Policy#or Self ins.Lic,# _ Expiration Date: Attach a`copy of th�vvorkers'compensa�ion policy declaration page(showing the policy number and ezpirAtion date). �eure�$ure cov,erage as requireii under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a p ;500.00 and/or one-year imprisonment,as well as civil,penaTties ui the form of a STOP WORK ORDER and a fine of up'ta$250.00 a d'ay against the,violator. Be�advised that a copy�f this statement may be forwarded to the Off�of Investigations of t�e DIA for insurarice cc�verage verification. : ' I do�ere8,�certt;fy,under tlte pd�ns�tnil penalli�s of,perjkry that the ix,f'ormutlon provided above ts bue and correct. ` Siatature• _ Date Phone#: � Officiat,�se only:';Do not write in this atea,to be completed by city or to►vn o,�'kia� City or�'own: . �_ PermitlLicense# _ Issuing.A�uthority(circk one): , 1.Bosrd of Health 2.Bailding Depuctment 3.Ci�ky/Town Clerk 4.I.icensing Board 5.Selectmen's Office 6.Othe'r. . . Con#aat:Person• Phone#� � www.mass.gov/dia _ ,- _.. � . _. � ;,....; � , . ,. . ; . ..:., :.;: . • ; �s�; , .�: � . � TRAVELERS�� WORKERS COMPENSATION ONE TOWER SQUARE AND HARTFORD, cT obiss EMPLOYERS LIABILITY POLICY TYPE V INFORMATION PAGE WC 00�0 Ot ( A) POLiCY NUMBER: (IEUB-1 A37070-A-16) RENEWAL OF (IEUB-1 A37070-A-15) INSI��iER: THE TRAVELERS INDEMNITY COMPANY OF CONNECTICUT 1, NCCI CO CODE: 12637 I�ISURED: PRODUCER: POLAR EXPRESS LLC EDWARD F SULLIVAN INS i0 HARVEST HOLIOW DRIVE 507 HIGH ST HARWICli PORT MA 02646 DEDHAM MA 02026 Insured is A LIMITED LIABILITY COMPANY Other work places and identification numbers are shown in the schedule(sj attached. 2. The policy period is frorri 07-01 -16 t0 p�-0� -17 12:01 A.M. at the insured's mailing address. 3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers Compensation Law of the state(s) listed here: MA .� m— � �_ -E EMPLOYERS LIABIUTY INSURANCE: Part Two of the policy applies to work in each state listed in = ftem 3.A, The limits of our liability under Part Two are: o� Bodily injury by Accident: $ 10000o Each Accident o= Bodily Injury by Disease: $ 50000o policy Limit � Bodily Injury by Disease: � 100000 Each Employee �— �:: OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here: � � AL AR AZ CA CO CT DC DE FL GA HI IA ID I� IN KS KY LA MD ME MI MN �� MO MS MT NC NE NH NJ NM NV NY OK OR PA RI SC SD TN TX UT VA VT WI °� WV �� o� _ D. This policy includes these endorsements and schedules: �� o� SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE o� -_ 4. The premium for this policy wiA be determined by our Manuals of Rules, Classifications, Rates and Rating �_ Plans. All required informatfon is subject to verification and change by audit to be made ANNUALI.v: .� DA7�� OF ISSUE: 05-20-16 SM OFFICE: HUDSON/BOSTON 126 DIRECT BILL �RODUCER: EDWARD F SULLIVAN I�IS CRF87 ooie�e TRAVELERS�� WORKERS COMPENSATION ONE TOWER SQUARE AND HARTFORD, cT obiss EMPLOYERS LIABILITY POLICY EXTENSION OF INFO PAGE-SCHEDULE WC 00 OC nt ( A) POLICYNUMBER: (IEUB-1A37070-A-16) INSU�f R: THE TRAVELERS INDEMNITY COMPANY OF CONNECTICUT , 12637-MA Ii��ED'S NAME : POLAR EXPRESS LLC PREMIUM BASIS ESTIMATED RATES ESTIMATED TOTAL ANNUAL PER $100 OF ANNUAL CLASSIFICATION CODE REMUNERATION REMUNERATION PREMIUM LOCATION 001 01 FEIN 2�031�991 ENTITY CD 001 POLAR EXPRESS LLC 1279 �tT 28 SCiIlTH YARMOUTH, MA Q2664 SIC CODE : 5451 NAICS: 445299 RESTaiURANT NOC 9079 18764 1 .09 205 .� o� � �� — � � � o� o� o� �� o� _ � o� � c� „� MA 'MANUAL FREMIUM $ 205 � --- ----. - ------ ------------------------------------------------------------------- o� EXPERIENCE MODIFICATION: NONE MODIFIED PREMIUM $ NONE o� TOTAL ESTIMATED ANNUAL STANDARD PREMIUM 205 � LOSS CONSTANT (0032) 20 ^� EXPENSE CONSTANT(0900) 250 � TERRORISM (9740) 6 .� MA WC SPECIAL FUND AND TRUST FUNQ 12 TOTAL ESTIMATED PREMIUM 493 DEPOSIT AMf�UNT DUE 493 � DATE JF ISSUE: 05-2n-16 SM SCHEDULE N0: 1 OF LAST aq*e�e TRAVELERS�� WORKERS COMPENSA`�tON ONE TOWER SQUARE AND HARTFORD, cT 06183 EMPLOYERS LIABILIIY �'�L1CY TYPE V INFORMATION PAGE WC 00 00�1 ( A) POLICY NUMBER: (IEu6-1 A37070-A-16) CLASSIFICATION SCHEDULE: PREMIUM BASIS ESTIMATED RATES ESTIMATED TOTAL ANNUAL PER$100 OF AIdNUAL CLASSIFICATIONS CODE NO REMUNERATION REMUNERATION pREMIUM SEE EXTENSION OF INFORMATION PAGE - SCHEDULE(S) SIC-CODE: 5451 NAICS: 445299 STANDARD TOTAL ESTIMATED ANNUAL STANDARD PREMIUM $ 205 LOSS CONSTANT 20 PREMIUM DISCOUNT NONE 0900-20 EXPENSE CONSTANT 250 TERRORISM 6 TOTAL ESTIMATED PREMIUM 481 TAXES AND SURCHARGES 12 DEPOSIT AMOUNT DUE 493 Minimum Premium: $ 217 DATE OF ISSUE: 05-20-16 SM OFFICE: HUDSON/BOSTON 126 PRODUCER: EDWARD F SULLIVAN INS CRF87 COUNTERSIGNED-AGENT