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Home My WebLink AboutApplication and WC R�CEIVEL� d � TOWN OF YARMOUTH BOARDt� '�k APPLICATION FOR LICENSE/P, ,� � C}CT "� � �Q 17 � � *Please complete form and attach all necess um�s +201 . HEAISN DEPT. Failure to do so wili result in the retum of your applicaUon pac et. ESTABLISHMENT NAME: �f u�' f l�4 N - LOCATIONADDRESS: 559 QT6�4 V�FQ�uai�+ Pde'r TEL.#: 508 -3Go?�"19'1�l' MAILING ADDRESS: SR.v�L E-MAILADDRESS: .��vA.vcs� 6J Ga:�►G/�ST• �LT OWNER NAME: -T��►'t ��/.�.t/o t- CORPORATION NAME(IF APPLICABLE): .?GCA G l.L MANAGER'S NAME: W A Giv�/L Gv N G A G.✓'LS , TEL.#: SD$ - 36?-�9'?? MAILING ADDRESS: 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. 1. /�,�� 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�heir certifications to this form.The Heaith Department wilt not use past years'records. You must prov�de new copies and maintain a file at your place of business. �. �vl� 2. 3, 4. FOOD PROTECTION MANAGERS-CERTIFICATI01V5: 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. 1. I�in�►�T2 '�'�+a.�vc,r= 2. WAG�vt2. Gon�caL.vt.S PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. 1. �cih.�Ti2� �va,v�r' ' 2. w�t b N�� Go n�C.t LvtS ALLERGEN CERTIFICATIONS` All food service establishments are required to have at least one full-time employee who has Allergen certification, as flefined 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�le at your establishment. 1. 0 �� r2 � r'va.vor' 2. r�va.�.uc+c.. Go�v�.a�vE.S HEIMLICH CERTIFICATIONS: All food service estabtishments with 25 seats or more nnust have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your atnployees trained in anti-chok�ng 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 fite at your place of business. 1. �.c�AG.�4�2 ��oLvtS 2. Au4a.[Y Qoe�a�� 3. �4C.[..v /Nc.1L(.•4.uetf 4. RESTAURANT SEATING: TOTAL# 3 � ' OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED! FEE PERMIT# LICENSE REQUIRED FEE PERMIT.# B&B $55 CABIN $55 MOTEL $]10 —INN $SS CAMP $55 SWIMMINGPOOL$ll0ea =�,ODGE $SS =PRAILERPARK $105 _WHIRLPOOL $il0ea FOOD SERVICE: ' LICENSE REpU[RED FEE P RMIT# LIC6NSE RF.QUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT!! �0-100SEA�'S $125 l�001 CONTINENTAL $35 NON-PROFIT S30 BO�'F�(p►�S? >100 SEATS $200 �COMMON VIC. $60 � ��D.KITCHEN $80 RETAIL SERVICE: ' ' �Z UCENSE REQUtRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50sq ft. S50 >25,000sq�ft. $2$5 VENDING-FOOD S25 =<25,OOOsq.ft. $150 �ROZENDESSERT S40 _TOBACCO $I10 NAME CHANGE: S15 AMOITNT DUE _ $ (�'�J.�O **"*°PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***+* 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 persqn or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STA'�'E WORKER'S COMPENSATION INSiJRANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR CERT.OF INSURANGE ATTACHED��S OR' WORKER'S CO1viP.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 1/ NO MOTELS AND OTHER LOI�GING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limi�ations 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 thirry(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 whirlpoo2s which have been closed for the season must be inspected by the Health Department prior to opening. Contact the�Iealth 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 Eor 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 estsblishments 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 Deparhnent by filing the required Temporary Food Service Applicadon 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 CAF�S: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Boazd 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 15,2017. ALL RENOVATIONS TO ANY FOOD ESTABLISH;MENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO ANIa APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE P � DATE: /!� SIGNATURE: �...�� PRINT NAME&c TITLE: �M �T 4NOir (�j f�ilJ �1��., Rev.10/12/17 � The Commonwealth of Massachusetts �'�� Department of Industrial Accidents Office of Investigations 1 Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Lesiblv Business/Organization Name: fbC�► L L.G D B/.� V.Q�nu�'�!��2�4 l3�► ��'�/ �- Address: 5 S ct 2 T' 6� City/State/Zip: yq�au�'N FbQT, �YJA, Oa1G9cS- Phone#: bo8 - 36a — 7Q 77 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. ❑Restaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and 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.❑ 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 organization,staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.0 Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. *'If the coiporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#1. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: Insurer's Address: 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 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify,under the pains a dpenal s ofperjury that the information provided above is true and correct. � Si ature: � Date: /o /C Phone#: sp$ - 3 (o?- ?`j �?'7 Offzcial use only. 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#: www.mass.gov/dia • 7RAVFl.ERS� WORKERS COMPENSATION � AND EMPLOYERS LIQBILITY POLICY TYPE AR INFORMATION PAGE WC 00 00 01 ( A} POUCYNUMBER: (6t�lB-7H82900-6-i6) NEW-16 IN5URER: TF� 'iRAVELERS INDEMNITY C�ANY OF At�RICA �. . NCCI CO CODE: 13439 INSURED: PRODUCER: �OCA LLC bSA PI22AS 8Y EVAN DOWLING & Ot�IL INS 450 STATIOtV AVENUE 973 IYAt�UGH RD SQUTH YARMOUTH MA 02664 HYAI�IIS MA 026Qf Insured is A LIMiTED LiABiLiTY CONPANY Other work piaces and identif�ation numbers are shown in the sct�edule(s) attached. 2. The pdicy period is f�om t 2-30-i s to t 2-3o-t� 12:01 A.M. at the Ensured's mafHng address. 3. A. WORKERS COMPENSATtON tNSURANCE: Part Or�e�the pdtcy appfias to the Workers Compensation Law of the siate(s) listed here: MA _ .�� e� s� : � B. EAAPI.OYERS LIABttlTY INSURANCE: Part Two o#the�ticy appiies to work in each state listed In item 3.A. The Iimits of our IiabMity under Part Two are: �� Sodily InJury by Accbern: S 500�0 Each Accidertt e� Bod�y InJury by Dfsease: S 500000 polcy UmJt � BodAy lnjury by Disease: g 50000o Each Employee � ,� C. OTNER STATES INSUAANCE: Pan Threa of the{�licy applies to the�aies, ff any,listed here: � � COVERAGE REPIACED BY ENDORSEMENT WC 20 03 068 � � . o� � ` �. This poticy fndudes these endorsements and schedt�es: a �� SEE LISTING OF Et�ORSENENTS - EXTENSZtM{ dF ZC�#3 PkC� � o� -� 4. The premium for this policy wdl be deter►nined by our lUlanua�s of R�es, passifications, Rates and Rating � Pians. Ali required lnbrmation Is subjec�t0 ver#'�cation at�d c#�ar�}e by audii to be made AN�AlALLY. .� DA7E OF ISSUE: Ot-oa-t 7 AK ST ASSIGN: Mt► OFFICE: �LAWDO Ii�US AFF 161 PRODUCER: DOWI,ZNG 8 ONEIL INS 22�GR 002�