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Home My WebLink AboutApplication and WC . � �, � _� � ��E3�'�� TOWN OF YARMOiJTH BOARD � '� �" "'� �CT � 6 �� APPLI�ATION FOR LICENSEJPE�, - 18 �'� '. 2017 �' *Please complete form and attach all necessary cum��cember 1 S 201 . �� Failure to do so will result in the return of your applicarion pac et. �A�TH DEPT. ESTABLISHMENT NAME: • �� LOCATION ADDRESS: TEL.#: MAII,ING ADDRESS: `� � E-MAIL ADDRESS: C�Y`C�� -`f1 `�- OWNER NAME: Y(��z_��5� CORPORATTON NAME APPLIC�BLE): �'1 L.CCY' MANAGER'S NAME: � 'S TEL.#: �� 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 tkris form. L 2. Pool operators must list a minimum of two employees currently certified in standard First Aid and Community Cazdiopulmonary Resuscitation(CPR),.having one certified employee on premises at a11 times. Please list the employees below and attach copies of their certifications to this ferrs.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 PROTECTION MANAGERS=CERTIFICATIONS: All food service estabiishments are required to have at least one full-time employee who is certified as a Food Protection Manager,as defined in the$tate Sanitary Code for Food Service Establislunents, 105 CMR 590.000. Please attach copies of certificarion to this application. The Health Department will not use past years'records. You must provide new copies and mai in a file at your establis6ment. i. 1��1 a.�/1�1��n. `�sp� ,nc�z o--� .-�..,� PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. l.�j�� P�N� 2. ,v�u.� ✓��L.�� ALLERGEN CERTIFICATIONS: All food service establishments aze required to have at least one full-time employee who has Allergen certification, as defined in the State Sanitary Code fdr Food Service Establishments,105 CMR 590.009(G)(3)(a). Please attach copies of certification to this application. The Health Department will not use past years'records. You must provide new copies and maintain a file at your establishmen� 1.�/\�Z��1 rC�7t.7�Y��Z 'U-- 2.�� J� `�c��'� �_ � HEIMLICH CERTIFICATIONS: � All food service establishments with 25 seats or more mus[have at least one employee trained in the Heimlieh Maneuver on the premises at a11 rimes.;Please list your employees trained in anti-choku►g procedures below and attach copies of employee certifications to this form. The Health Department will not use past years'reeords. You must provide new copies and maintain a fde at your place of business. 1.�1 c�,�V�� `_7 2. �1✓� z ��/l,� � 3. c� 4.�$a�,�1t�.Gc ;InS��1" RESTAURANT SEA G: TOTAL# ��"C5 OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $110 ^1NN $55 CAMP $55 _SWIMMING POOL$110ea LODGE $55 TRAILERPARK 5105 _WHIRLPOOL S1IOea FOOD SERVICE: LICO N�E Q� D a 2 PERMIT f! !LICCONTINENTAL D S35 PERMIT# LICNON-PRO�T�D $30 PERM[1'# �>100 SEATS $200 ��DZ 1COMMON VIC. S60 �OZ- �ID KITCHEN$80 ✓"�� 1��3 ' RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# ;LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# Q y <50sq ft. S50 >25,000sq ft. 5285 VENDING-FOOD S25 =QS;OO sq.ft $150 �ROZEN DESSER�f S40 _TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE _ $ �O.O� *+***PLEASE TURN OVER AND CON7PLETE OTHER SIDE OF FORM*'••• + ADMINISTRATION Under Chapter 152,Secrion 25C,Subsection 6,the Town af Yarnnouth is now required to hold issuance or renewal of any license or pernut to operate a liusiness 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 COMPLET�D 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 nenewal or issuance of your pernuts. PLEASE CHECK APPROPRIATELY IF PAID: YES i/ NO MOTELS Al'�D OTHER LOD�GING ESTABLISHMENTS 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 b� able to demanstrate_that they maintain a principal place of residence elsewhere.Transient occupancy shall generally refer to continuous occupancy of not more thau tlrirty(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 ttansient. 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. POaLS POOL OPENING:All swimming,wafling and whirlpools which l�ave been closed for the season must be inspected by the Health Department prior to operiing. Contact the I�ealth 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 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 g�ound 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 Hea1th 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 af 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 fnom the Town's website at www.varmouth.ma.us under Heaith Department, Downloadable Forms. FROZEN DESSERTS: Fmzen desserts must be tested by a Statie certified lab prior to opening and monthly thereafter,with sample results subxnitted to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Pernut until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating witti waiter/waitress service),must have prior approval from the Board of Health. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food pmduct by a retail or food service establishment is prohibited. NOTICE:Permits run annually from January 1 to December 31. TT IS YOUR RESPONSIBILTTY TO RETURN THE COMPLETED RENEWAL APP�.ICATION(5)AND REQUIRED FEE(S)BY DECEMBER 15,2017. ALL RENOVATIONS TO ANY FOIOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPI�RTED TO ROVED BY TF�BOARD OF HEALTH PRtOR TO COMMENCEMENT. RENOVATIONS MAY A I LAN. DATE: 1 b I��JI��r- SIGI�ATURE: PRINT NAME&TITLE:�v�si�,can.�� I Rev.10/11Jt7 /�Ak' The Commonwealth of Massachusetts �� -`�� Department of Industrial Accide�ts 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 Le�iblv Business/Organization Name: (� � Q ��, -�Y��n_�'1 Address: �� cZc._ t..e� City/State/Zip:��,��a�L��..S p��Phone #: �Sv`�'> ��2• ��(�2 Are you an employer?Check the appropriate box: Business Type(required): 1.� I am a employer with��ertiployees(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.❑ Manufacttzring 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.❑ Other *Any applicant that checks box#1 must also fill out the section betow showing their workers'compensation policy information. **If the corporate o�cers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization shouid check box#1. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: i�{\�� SQ��,vG�n� v�,;��P_ �'�n�� Insurer's Address:�, (��X� Q��jc1 _7'7 — � 7 �? City/State/Zip:�r�9 �,rt�h- -� �(Y�� . �Z,� � Policy#or Self-ins.Lic.# C7��h �U�� (�Cl I 1� Expiration Date: � �i ►�t�_ Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of l��GL 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 ' , under the pain and penalties of perjury that the information provided above is true and correc� Si nature: r Date: L�I � �~ Phone#• ��b� ��l2�Z, - �C1(,.�� Official use only. Do not write in this area,to be completed by city or town officia� City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health Z.Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: www.mass.gov/dia � NOTICE _ N4TICE h � TO TO M r � � x a EMPL��EES �� w�� EMPLO�EES C`'G'9M s�0"` , The Commonwealth of Massachusetts DEPARTMENT OF INDIJSTRI�.L ACCII�ENTS 1 Congress Street, Suite 100, Boston, Massachusetts 02114-2017 617-727-4900 - http;//www.state.ma.us/dia As required by Massachusetts General Law, Chapter 152, Sections 21, 22 &3Q,this will give you notice that I (we)have provided for payment to our injured employees under the above-mentioned chapter by iiisuring with; MA Retail Merchants WC Group Inc. NAME OF INSURANCE COMPANY PO Box 859222-9222 Braintree,MA 02185 ADDRESS OF INSURANCE COMPANY 014005032709117 1/Ol/2017 - 1/Ol/2018 POLICY NUMBER ' EFFECTTVE DATES Rogers`& Gray Insurance Agency 434 Route 13� Soutli Deniiis, MA 02660 NAME OF INSURANCE AGENT : ADDRESS PHONE# Old Yarnlouth Inn 223 Mai�St�eet Yarmout�aport, MA 02675 _ EMPLOYER ADI�RESS � EMPLOYER'S WORKERS' COMPENSATION O��ICE�2(IF ANY� DATE MEDICAL fiI�.�ATMENfi The above na}ned insurer is required in cases of p�rsonal injuries arising out of and in the cotiirse of empl�yinent fio furnish adequate and reasonable h�spital and medical seiYvices in accoxdance with the provi�;ions of the Worlcers' Compensation Act. A copy �f the First Report of Injury must be �iven to the injured empinyee. The employee may select his Qr her o�vn physician. The reasonable cost of the se�- vices'�rovided by the treating physician will be paid by the insurer, if the treatment is necessary and reaso>>ably connected to the worlc related injury. �n case�requiring hospital attention, employees are hereb'y notifi�d that the insurer has arranged for such att�ntion at the C � � �--c��.,-;�� - NAIVXE OF �75PITAL ; ADDRESS TO BE POSTELL� BY� EMPL�YER