The URL can be used to link to this page

Home My WebLink AboutApplication and WC TOWN iUF YARMOUTH BOARD OF HEALTH APPLICATION FOR LICENSE/PERMIT-2018 � *Please complete form and a#tach a11 necessary documents by D,� ecemlier 1 S 2017. � Failure to do so will result in the return of your applicattori pac c�— ESTABLISHIvIENT NAME: � SC� - LOCATION ADDRESS: (�F 02 TEL.#: - - G�O MAILING ADDRESS:303 i S % le E-MAILADDRESS: �C @(�. 2 pldii'►ds.Con., OWNER NAME: �WC,� U� CORPORATION NAME(IF APPLICABLE): MANAGER'S NAME: WQ 'fCR. �t. WIr►� Z.S TEL.#: S� - �o -�G�t'CLO MATLING ADDRESS: O m p � � -n-r t*] POOL CERTIFICATIONS: r' The pooi supervisor must be certi5ed as a Pool Operator,as required by State law. Please list the designated = � � Pool Operator(s)and attach a copy of the certificafion to this form. p 0 e � 1.—N�A" 2. ,� � ►T r � Pool operators me�st list,a minimum of two employees cwrently certified in standazd First Aid and Coaununity Cardiopu(monary Resnscitation(CPR),having one certified ex�p lcayee on premises at all times. Please list the employees below and attach copiea of iheir certifications W 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. 3. N/� 4. �:.�.�� ' FOOD PROTECTION MANAGERS�CERTIFICATIONS: `" All food service establishments are reguired 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 i�is application. The Health Department will not nse past years'records. �,, � Yoa mast provide new copies and maintain a fik at your establishmen� � �� ; i. wQt�„2 w��1��s a. C3P.bbt� t�1,2oc.c�-r,c,�iar.� ��"� ; � PERSON IN CHARGE. � � �� Each food establishment must have at least one Person In Charge(PIC}on site during hours of operation. ' ��.Watt�,� wl�q,�les ; a.Pebbic Na�u-I-i,cn�'a,v� ALLERGEN CERTIFICATIONS: All food service establishments aze reqiiired to have at least one fuli-time employee who l�as Allergen certification, as defined in the State Sanitary Code fdr Food Service Est�ablishments,105 CMR 590.009(G)(3xa). Please attach copies of certification to this application. The Health Department will not nse past years'records. You mnst provide new copies and maintain a file at your establiahmen� 1.h1Gi.I�Pt� C. wln�,�nI�S 2. . HEIIvILICH CERTIFICATIONS: All food service establishments with�5 seats or more miust have at least one employee trained in the Heimlich { Maneuver on the premises at a11 times.;Please list your employees trained in anti-chokujg procedures below and attach copies of employee certificationS to this form. The Health Department will not nse past years'records. You must provide new copies and maintain a fde at yonr place of businesa. i. ..s 2.�� H �ufu,�,'ar► 3. MqfthPW '1'�:l 4.�4Q Lt/,tLr� � � RESTAURANT SEATING: TOTAL# �B�0 ; Loncnvc: ' OFFICE USE ONLY LICENSE REQUIRED FEE PERMIT# !LICENSE REQUIRED PEE PERMl'f# LICENSE R&QUIl2ED FET PERMIT# B&$ E55 CABIN $55 MOTEL 5110 INN S55 —CAMP SSS =SWIbIlvIING POOL S110ea —^L.ODGE SSS TRAILERPARK s103 _WHIRLPOOL S110ea FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# �LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# >l�SEATS 5200 ��" �g NON-PROFiT S30 _ �q �COMMON VIC. S60 .�o� —_��.s° � N� �ON�F-1�1-o�rZ RETAII.SERVICE: ' LICENSE REQUIlZED FEE PII2MIT# ;LICENSE REQUIRED FEE PERMIT#. LICENSE REQUIRED FEE PERMIT# �O y <50sq ft. SSO ' >25,000sq�ft. 5285 VfiNDING-FOOD S25 j =Q5>OOOsq.R SISO :_FROZENDESSER3'S40 =TOBACCO S110 � NAME CHANGE: S15 , AMOITNT DUE = S �.(pO.00 ! •••"PLEASE TURN OVER AND COMPLFTE OTAER 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 person or company does not have a Certificate of Worker's Compensation Insurance. THE AT'TACHED STATE WORKER'S COMPENSA'TION INSURANCE AFFIDAVIT MUST BE COMPLE'TiED AND SIGNED,OR CERT.OF INSURANCE ATTACHED OR � I WORKER'S COIti+IP.AFFIDAVTT SIGNED AND ATTACHED �' Town of Yannouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES_�L NO , i MOTELS AND OTHER LOl)GING ESTABLISHMENTS I i 1'RANSIENT 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�cupants met��ve and b� 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(9U)days within any six(6)month period. Use of a guest unit as a residence or . dwelling unit shall not be considered t#ansient Occupancy that is subject to the collection of Room Occupancy Excise,as defined in M.G.L.c.64G ar�$30 CMR b4G,as amended,shall generally be considered Transient. PO�LS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to oper�ing. Contact the hIealth Department to schednle the inspection three(3) days prior to opening.PLEASE NOTE:Peopie are NOT allowed to sit in the pool area imtil the pool has been inspected and opened. . POOL WATER TESTING: The watier must be tested for pseudomonas,total coliform and standard plate count � by a State certified lab,and submitted to the Heaith Departrnent three(3)days prior to openiag,and quarterly � thereafter. POOL CLOSYNG:Every outdoor in gound 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 Deparhnent 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 uf Yarmouth must notify the Yarmouth Health Department by filing the • reqwred Tempo Food Service Ap�lication form ?2�►ours prior to the catered event These forms can be obta�ned at the H�th Depaitment,ar�om the Town's website at www.yannouth.ma.us under Health Departimetrt, Downlaadable Forms. FROZEN DESSERTS: ' � Frozen desserts must be fested by a Statie certified lab prior to opening and monthly thereafter,with samgte results submitted to the Healfh Departrr►ent 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 witli waiter/waitress setvice),mtist have prior approval from theBoard of Health � OUTDOOR COOKING: � Outdoor cooking,prepararion,or display of any food product by a reta�l or food service establishment is prohibited. i i ; � NOTICE:Pernuts run annually from J�nuary 1 to December 31. IT IS YOUR RESPONSIBILITY TO RET[JRN � TI-IE COMPLETED RENEWAL APP�.ICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15,2017. ; ALL RENOVATIONS TO ANY FO�DD ESTABLISHMENT, M01'EL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPII�RTED T0 AND APPROVED BY Tf�BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVAT.IONS MAY REQUIRE A STfE PLAN. DATE: I��I�'�� SIGI�ATURE: '�l./ ��, ' PRINT NAME&TI'TLE: ��i [ �� I �s,Use&�PropatrTaocA000wWpt x�.ia�vn i i � � �� The Commonwealth of Massachusetts `��;;,,�,r � Department of Industrial Accidents " ? Office of Investigations ' ' ' 1 Congress Street,Suite 100 Boston,MA 02114 2017 www mas�gov/dia Workers' Compensation Insurance Affidavit: General Businesses i A licant Information Pleas P ' e rmt Leablv Business/Organization Name: q� (L�-� r,'J' � P,�,h ��,pp50 � Address:_ (� �,�,°�Lt.i .��PVI�� City/State/Zip: ��,-�'��,�/1�Q�3 Phone#: sa g- $�p 2-�l�l.�'10 Are you an employer?Check the appropriate boz: Business Type(required): 1.� I am a employer with 55 employees(full and/ 5. �Retail orpart-time).* 6. � Restaurant/Bar/Eating Establishment ! 2.❑ I am a sole proprietor or partnership and have no �. � Office andlor Sales(incl.real estate,auto,etc.) � employees working for me in any capacity. [No workers'comp.insurance required] 8• 0 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]* 11.0 Health Care 4.❑ We are a non-profit organization,staffed by volunteers, ; with no employees. [No workers' comp.insurance req.] 12•Q Other ' *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. x*If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an , organiza6on should check box#L I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: SQ'�Qj� N(�,'1'1�a/1Q�. C,G(,��(��{ CQQ�/� Insurer's Address: I��Z SG�/�Ll�i�� IwCCG( City/State/Zip: S'�= �f�t�S f�(� �D��'(,.P Policy#or Self-ins.Lic.# LpG�s��7 Expiration Date: �I t� �` I $ 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 and penalties.of perjury that the informatron provided above is true and correc� Si¢nature: W✓ i�t7t�lJ� Date• (��/�J� �� I Phone#: � �s� 2��p��p0 i Official use only. Do not write in this area,to be completed by city or town of,j`'iciaL City or Town• Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmeds Office ' 6.Other Contact Person• Phone#• www.mass.gov/dia � � SAFETY NATIONAL CASUALTY CORP Workers'Compensation and Employers'�iability 1832 SCHUETZ ROAD Insurance Polic ST. LOUIS,MO 63146 Polic Period (888)995-5300 Polic Number From To LDC4055593 08/O1/2017 O8/O1/2018 12:01 A.M.Standard Time at the address of the Insured as stated herein Transaction Renewal Issue Renewal of:LDC4055543 1. Named Insured and Address A ent 11845 ABRH, LLC WILLIS OF TENNESSEE, INC. 3038 SIDCO DRIVE P O BOX 305025 NASHVILLE, TN 37204 NASHVILLE, TN 37230-5025 Telephone: (615) 872-3000 j Customer S Carrier# 917057680 LLC Additional Locatians if applicable:See attached Location Schedule 2. The Policy Period is from O8/O1/2017 to 08/01/2018 12:01 a.m.Standard Time at the Insured's mailing address. ' 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: AL AZ AR CA CO CT FL GA IL IN IA KY LA ME MA MN MS MO NE NH NM NY NC OK OR RI SC TN UT VT VA WV B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident S 1,000,o0o each accident Bodily Injury by Disease S 1,000,00o policy limit Bodily Injury by Disease S 1,000,o0o each employee C. Other States Insurance: Part Three of the policy applies to states,if any, listed here: All states except ND, OH, PR, VI, WA, WI, WY and states designated in Item 3.A. D. This policy includes these endorsements and schedules: See attached Schedule of Forms and Endorsements. 4. The premium for this policy will be determined by our Manuals of Rules,Classifications, Rates, and Rating Plans. All information required below is subject to verification and change by audit. SEE EXTENSION OF INFORMATION PAGE Minimum Premium Total Estimated Annual Premium NYCCPAP Adjustment � Expense Constant j Assessments and Taxes _ Premium Discount Deposit Premium _ This is a Three Year Fixed Rate Policy Premium Adjustment Period: � Annual _ Semiannual _ Quarterly _ Monthly � Countersigned this Day of , Authorized Representative (ssued Date: 0 9/18/2 o i 7 ISSUI�9 OffICe: Safety National Casualty Corporation i WC 00 00 01 A 02 96(WC 99 04 03 in California) i