The URL can be used to link to this page

Home My WebLink AboutApplication and WC1 ....��4 b. ia . ......-'1sa3 � � TOWN OF YARMOUTH BOARD OF HEALTH � � APPLICATION FOR LICEN T . -� �qN � � 2p17 � � `'°` * Please complete form and attach all nec �` � �� ` e ber 16 2016. � � � � Failure to do so will result in the r o "' a �� i ��i '�� pa � - �� ° °_��`�'� ESTABLISHMENT NAME: -� C TAX ID: — � ' LOCATION ADDRESS: � (�tz�'° T L.#: � — ' MAILING ADDRESS: b E-MAIL ADDRESS: C *_ C O OWNER NAME: E-' � CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: TEL.#: �� — � 6 MAILING ADDRESS: � o �� cs�� i 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 o er r p ato s must list a minimum of two employees currently certified in standard First Aid and Communit � Y Cardiopulmonary Resuscitation (CPR), having one certified employee on premises at all times. Please list the em lo ees below and attach co ies of their certifications to this form. The Health De artmen will n t ot use ast ears'records. You must rovide new co ies and maintain a file at o r p p u lace of business. Y P P Y P l. 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. l. 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. l. 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. 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. 3. 4, 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 $55 CAMP $55 SWIMMING POOL$110ea. _LODGE $55 _TRAILERPARK $105 WHIRLPOOL $IlOea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 _CONTINENTAL $35 NON-PROFIT $30 >100 SEATS $200 _COMMON VIC. $60 WHOLESALE $80 RETAIL SERVICE: —RESID.KITCHEN $80 LICENSE REQUIRED FEE PERMI # LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �<2�,OOOsq.ft. $$50 " —Z _FROZENDESSERT$$40 �TOBAC O-FOOD$$10 �?j� _�L.�rV NAME CHANGE: $ts AMOUNT DUE _ $ ��g� '�� *****PLEASE TURN OVER AND COMPLETE OTHER SID�OF FORM***** �jot�F�(S—(cr�-02. (�0��-IS� [a 86—6Z ! 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 COIVIP. 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 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 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. PO�OL 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: 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. OUTDOOR COOKING: 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 COMMEN EM NT. RENOVATIONS MAY REQUIRE A SIT _.------- DATE: SIGNATURE: PRINT NAME & TITLE: Cc.y�b �/'C� l'l� Rev. 10/12/16 � The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations . - ` 1 Congress Street, Suite I00 ` Boston, MA 02II4-20I7 � www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Iaformation Please Print Le�iblv Business/Organization Name: 8 tJ� 2�' i��l,� �—�(�'f C � Address: (�� (,'{ 11� City/State/Zip: S� (�►��►�Cd`f/�j 67�� Phone #: ��`'��Z3 Are you an employer? Check the appropriate bog: Business Type(required): 1.❑ am a employer with employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ RestaurantBar/Eating Establishment 2. I am a sole proprietor or partnership and have no �, � 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.❑ 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 ; no employees. [No workers' comp. insurance required]* 11.❑ ealth Care 4.❑ We are a non-profit organization, staffed by volunteers, ,(,r n with no employees: [No workers' comp. insurance req.] 12. Other �� Cj I I V, 1 ; *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. ; **If the corporate officers 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 w rkers'co pensation insura e for my employees. Below is the policy information. ; Insurance Company Name: � �L ^ �l,l`� �C� ; Insurer's Address: ��S �G� � 3 rf ' City/State/Zip: SbLt�-� �Qn�-i�S /%�.� ��G� I � � Policy#or Self-ins. Lic. #_ __ l�3 o�C`j 7�� 3 FS�[O Expiration Date: �� G �G'�� ; Attach a copy of the workers' compensation policy declaration page(showing the policy number a d egpiration date). i 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,under the pai s of perjury that the information provided ab e is tr e and correct. I� Si ature: Date: l ` Phone#: ��-� ��'�� Official use c�nly. Do not write in this area,to be completed by city or town officiaL 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 Office 6. Other Contact Person: Phone#: �tivw.mass.gov/dia � 1/11/2017 11:39 Bryden and Suilivan kas->Rte 28 Mobile t/1 ,i��1 RTE28-1 OP ID:KS '`�C'aRo� CERTIFICATE OF LIABILITY INSURANCE �a�{MM/Db/YW1� � ov�u2o�� THIS CERTIFKATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATNELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BEI.OW. THIS CERTIFICATE OF lNSURANCE DOES NOT CONSTITUTE A CONTRACT BETiNEEN THE ISSUING INSURER(S� AUTHORIZED REPRESENTATIVE OR PRODUCER,AND TH6 CERTIFICATE HOLDER. IMPORTANT: tF the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. ff SUBROGATION IS WANED, subject to the terms and cond'Rions of the policy,certain policies may require an endors�nent. A statemeM on this certificate does nat confer rights to the certificate holderin lieu of such endorsem s PRODUCER �" DennisOffice 9 den&Sullivan InsAgency � of�ennis Inc. ac r�e�e:508-398-6060 �ac n�,:608-394-2267 485 Route 134,PO Box 1497 aoo�ss: So.Denn is,MA 02660 iNsu�rt�s�n�oRoin�covew►c� wuc s Dennis Office n�su�a:TravelersCommerciai Lines msur�� Rte 28 Auto Services inc. ,,,��s: 601 Route 28 West Yarm outh,MA OZ673 �� q�SURER D: INSUR@2 E: MlSUR�F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN �SSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD iNDICATED. NOTWITHSTANDING ANY RE�UIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH TH�S CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POIICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS J1PID CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. L7R 7YPE OF INSURANCE POLICY NUA�ER MMIDD MMIDD �� COMMERCIAL GENERN.LIAB�rtY �qp{pC��p�p�E y CXAIMSMADE �OCQIt PREMISES Ea occurrerx:e S MED EXP(My one person) $ PERSOPI+�L&ADV INJI�Y S GEPR AGGREGATE l IMIT APPLIES PER: GENERAL AGGREGATE S POLICY ❑�a �lOC PROOL�TS-C�P/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY � C INED SINGLE UMIT a . Ea acadent ANY AUfO BODILY INJURY(Per person) $ All OVUNED SCHEWLED BODILY INJlN2Y(Per accideM) E AUTOS AIJTOS HIRED AUTOS �pg�EO Per accideM S S UMBRELLA LIAB OCCUR EACH OCCURRENCE E EXCESS LIAB �MS-ry1�pE AGGREGAIE L -- �D RETENTION ; S WORKERS COMPENSATIQPI X AND EMPLOYERS'LIABLITY STATUTE ER 14 ANYPROPRETORIPARTNERfDCEClJf1VE Y❑N!A UBZE�72��g 03l07/2016 0310712017 E.I.EACHRCCIDENT S ��,�� OFFICERIMEMBER EXCLUDED9 (Mundatory in NH) E.L.DISEASE-EA EMPLOYEE S �OO,OO If yas,describe under DESCRIPTION OF OPERATIONS bebw E.L.DISEASE-POIICY LIMIT ; SOO,OO DESCRIPTION OF OPERATIONS/LOCATIdNS!VEHICLES(ACORD 101,Addkionr RemarNs Schadule,may bs a2tachM if mars space is required) Moussa Kafal,corporate officer,has elected to exclude himselffor Worlcer Com pensatlon beneflts. CERTIFICATE HOLDER CANCELLATION YARMOUT SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, PIOTICE WILL BE DELNERED IN TOW�Of Yefr11 OUth ACCORDANCE WITH THE POUCY PROViSI0N5. Bucklsland Rcad A�p�p�P�s�,A,� WestYarmouth,MA 02673 �� n �""'—_"-_ r� ll� �1988-2014 ACQRD CORPORATION. Ail rights resenred. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD