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HomeMy WebLinkAboutApplication and WC� 1 �'! ' ' �7+'6.�LT . � � TOWN OF YARMOUTH BOARD OF HEALTH �������� � � APPLICATION FOR LICENS ` `� MAY O 5 �jj1� • "'� * Please complete form and attach all nece � ` mber 16 2016. � Failure to do so will result in the re o app ica ion ac1d��ALTH DEPT. � � ESTABLISHMENT NAME: r L� TAX ID: - �' � I LOCATION ADDRESS: � S�. c� TEL.#: S - /-l1 MAILING ADDRESS:_ �C} L�C. Sc�/ [,v,i,y����, yl•v�¢ �z,� �3 � E-MAIL ADDRESS: �U r�� vyr,l ✓q�� �, OWNER NAME:��-� i2.rzZ..a-Q�fy TYl.0 CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: ,1 C7�, {�v�f-it rtit,,� TEL.#: 9 7� -3"�S-S`�f�2_ MAILING ADDRESS: / 'm�/G.,�,� s� . /�� WlA . G2 /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. II i 2 � 3. 4. i 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. i You must provide new copies and maintain a file at your establishment. � 1. 2. PERSON IN CHARGE: j Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. � 1• 2. ALLERGEN CERTIFICATIONS: f 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, i i r 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• 2. � 3. 4• � RESTAURANT SEATING: TOTAL # � ; i OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE P I;.Iv�IT�� B&B $55 _C�P $55 1MOTEL $I10 ([ 7 I� $55 SWIMMING POOL$110ea. _LODGE $55 =TRAILERPARK $]OS _WHIRLPOOL $110ea. FOOD SERVICE: � LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _>100 SEATS $200 —CONTINENTAL $35 NON-PROFIT $30 ' _COMMON VIC. $60 WHOLESALE $80 RETAIL SERVICE: —RESID.KITCHEN $80 LICENSE REQUIRED FEE , PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <2�,000 s .ft. $150 >25,000 sq.$. $285 VENDING-FOOD $25 — q _FROZEN DESSERT $40 _TOBACCO $110 NAME CHANGE: $�s AMOUNT DUE _ $ ��O,,OO *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** t���l�-1.�0 '���1��'G f � � 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 COMP. AFFIDAVIT SIGNED AND ATTACHED E i 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 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 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. 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. i 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 Deparirnent 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 RETLTRN 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 COMMENCEMENT. RE�TOVATIONS MAY REQUIRE A SITE PL ' DATE: 5 S SIGNATURE: ' , PR1NT NAME& TITLE: ,� e S P.P �N�����Q• W G�— Rev. 10/12/16 � - • � The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations � ' ` 1 Congress Street, Suite I00 ' Boston, MA 02114-2017 . � www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legiblv Business/Organization Name: S� �f�, j/L,�ti,�,_,�, �� ��. �� � /314.r.F�'l��iL.%��� 1 Address: � j L � City/State/Zip: �_ O�w) Phone #: �J'7k—3"7S—.S�6 Z 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. ❑ RestaurantBar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no �. � Office and/or Sa1es(incl. real estaxe,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.❑ Health Care 4.❑ We are a non-profit organizaxion,staffed by volunteers, �" � � � with no employees. [No workers' comp. insurance req.] 1 . Other V•"r�-�--�-� *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 themseives,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#1. � I I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. j Insurance Company Name: � � I Insurer's Address: � i City/State/Zip: Policy#or Self-ins. Lic.# 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 C 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 E 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 pai s a enalties ofperjury that the information provided above is true and correc� i Si atwe: Date: � � Phone#: �! �]�— 37� —,��G Z Official use only. Do not write in this area,to be completed by ciry or town officia� . � C�ty or Town: PermitJLicense# ; 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#• www.mass.gov/dia r r ; c�� CERTtFICATE OF LlAB1L ��f�+���i fTY iNSURANCE lo zs �.� THIS CERTIFICATE IS {SSUEQ kS A MATTER OF II+�QRMATION ONLY ANp CONfERS NO RC6HTS UPON THE CER1'IFICATE HOLDER THIS CERTIFICATE DOES NOT AFFIRMATFVELY OR NEGATIVE�Y AMENp, FJ(TEND OR AI,.TEFt TME COVERAGE AFFORDED 81f 7HE POUqES BELOW. TNtS CERTIFlCATE OF INSURANCE DbES N4T CONSTITUTE A GONTRACT BETWEEN 7HE iS3U1NG INSURER{Sj,AUTHQRLZEp REPRESEMATIVE OR PRODUCER,AND THE CERTIFlCAIE HOLDER. �MPOR7'ANT. �f the ceRfficate hWder is an ADDITtO AL INSUFtED,ifie policy(ies)must be endorsed. If SUBROGATION i5 WAI1/ED,subject to the terms and con�itions oPthe p�q�icy,certain poUeies rr�y re�ire an endflr�empnt. A stat�merjt on tfiis certifiqte does not confer rl�1s to U�e certificate holder in lieu of such eMorsement(�. U peowea� Choice Insura,r�ce "^"'�: . t�1�''02]GY� I11C. PHONE _. .._ .._...._, _ ___ _ 376 Summer Street • 978 4 -4853 ' �x ; (978) 345-ioo� Fitchburg. MA 01420 n��ss: choiae@choiea-i.nsurance.com INSURERj3}AFPOROfNGCpVER,qC,�_E _ NAfC• i�.suR�a:NorGuard Tnsuranoe Co. �HsuR+�o � �n�+x�x a: � Sandbar Management, Tnc. - _ _ � r _ Cape Cod Ir�.flatable Park rHsuRasc:__ � _.� .._.�--_..._--_ __ . __._._.._._.__._w_ . _._______ PO Box 4$1 �Nsu�e�a_;. _ � West Yarmouth, MA 02673 �wsu.R�e:.__ __ .. _ _____� _ . . INSt1RER F: ; COVEFtAGES CER71FlCATENUMBER: REVISION PIUMBER: THiS 15 TO CERTIFY 7NAT THE POLIC�S OF INSURANCE USTED BEi.OW HAVE BEEN{SSUED TO THE INSURED NAME7�AHQVE PpR THE POI.IG'(A8210� i INDICATED. N07WITMS7ANDING ANY REQUtREMENT,TERM OR C4NDITION OF ANY CON7RAC7 OR OTHER DOCUMENT WITH RESPEC7 70 WHICH TFIIS ; CERTIFICATE N}AY BE ISSUQ�OR MAY PERTAIN, FHE INSURANCE AFFOf�ED BY T}�E POLICIES DESp21BED HEREIN {5 SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CdNDITIONS OF SUCH POLICIES.LlMII�SHOWN MAY HAVE BEEN REDUCED BY PAID CIARNS. j _ _ . ._.__�___ _ ;A�$II�__.�_ ._ _ ._____ R_ _. � LTR 'IYPH OR INSURANCE ,F P'SUZ�Y EFF P �4�'EX'�s _ """., _. - _ .�_- --._ _ POLCY NUI46ER M1f1D/Y MIA p�YYyy LiNIT3 i ; GENERALLIABILIIY � � � ' ' EACH pCCURRENCE g �COMMERCIALGflNERALLIABIU7Y ' ' OAMAGE70RENTED _ . 7 PRENISEC j�gorraxrencel_ S ` I CIAIMS�AADE ( j OCCUa ' - - ' t - � .MED EXP(Ary ore pasm) S ! � . � , ` 4PERSQN4L&ADVINJURY S�_ . � ._._w�.____.._ . . __ _.._ _._- - _� i � GENERAI ACiC3REGATE 5 J GEN'LAGGREGATEIIMITAPPUESPER ` ' ` -' r �POIICY� _` PRO- '�� � � PRO�UCTS_-COMPiUPAGG i . __ __ ,_ � S I AU70M0$ILE LIASIUTY O IN L LIMI ANYAUTf7 1 � � F jEaacd n} � g i I � �DiLY IIVJURY(Per person) S I � UTOSWI1E0 SCHECUl.ED � ; m _ _ Y _ 1'A�����0 f i + 800i1,Y INJURY(Per a;ciCanq�8 ' �_HIREpAUTOS � PRbPERTY DAMAGE a ! � i I 1Pereccirdent1- _ ._.._ _.____.. _ . _ . ____.._.. _ , , � I UNBI�LLA LIA9 OOCUR ' ( �' � I EACH OCCURRENCE S E7(CESS LIAB CLAIMS•MA4E -` - - _ _ ._____ ... .__ � r...__ �. .'_.._. . _ � �AGGREGATE . S DEO R N � _ .__ _ _-- . _ . .__. A WORKE'RB COMPENSA7WN � S nr+o�P�oreas•uneiunr � Is�WC768346 io/x/i& io/i/i�i , +� ATU- OTH- ANYPRQPRIEtOWt�RRTNERIEXECU7IVE YIM C_ _I�RYtIWLS. ._ , »_ .� _. _ _._.. OFF�CE(7INiEMBER EXCLIAEp? � N!A� � �,E L EACH ACd CEN1' _ �4 �.�OOO�CIOO �IJlanda�ry fn t3kj ; �E L DISEq$E-Eq Ep,iPLOY � 11 p041000 �D�S�RIPTlON�sOAERA710NS beMw � � i 'EL.DISFASE-PqLICYLIMiT S I. OOO OQO I ! � ° � � i � I OESCRiPTtONOFOPERpT10NS/LOCA710N31VEHICLE$(t�ttaehACpf20101,Atld�ionalRerteAcaSchedute,tfmorespaceiarequretl) ' CERTI�iCAT�HOLDER CANCELLATION &kOtJLb ANY OF THE ABOV6 pESCR}BED POUCIES BE CANCEI,1,Ep BEFORE ThIE EXPIRA7fON DATE TtiEREpF, NOTICE WILL Bf DELIVERED IN AOGORDANCE WITH THE POLiCY PROVfSIONS. AU'fHOFmZED REPI�SENTA7NE I t Brian A3,lai,n �1988 2040 ACORD CORPORATION. AH rights reserv�ed. AGORD 25(2Q10/OS) The�CORD name and logo are register�d marks of ACORD Phone: Fax: EMail: