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Home My WebLink AboutApplication and WC ' � • ��'ae�o � TOWN OF YARMOUTH BOARD OF HEAL�'� , NOV Q,? ?O�j APPLICATION FOR LICENSE/PE 2 � 'Uy � H� `' * P lease comp lete form an d attac h a 1 1 necessary do� en ,� a ecember �F'7: Failure to do so will result in the return of y app ication packe�. . � Y�zv�a uT1-f ESTABLISHMENT NAME:��Sr coN��e��q71ov�9�efli2cKra� TAX ID• LOCATION ADDRESS: 3 29' MA (�l1 S i �°A2Nl�c�(TIf Pa�i NL4 TEL.#: SO� - 3 6 2- 6 4 7 7 MAILING ADDRES S: 3 2�T rl.(A-��J s 7"'� YA I'L�10 l�l� �27- M�9 �26 75' E-MAIL ADDRESS: �'� C-7�2 � �C�7'r9�2M �uTH. G/zG' OWNER NAME: __No N-P�/�-r i - N i`� CORPORATION NAME (IF APPLICABLE): �.ST Cc?rUlr2��F-!?CYi��- Ct(7NCCN C?f �/�.�ul CJL('�7f MANAGER'S NAME: f 2�� Pff 1 L 2 - ��4-c fC S C�-/��' TEL.#:,� - 3 6�l 7 7 MAILINCrADDRESS:��`� /ti(f�'CN S7'. , ��'�2lVtOu1/ -� �U/L-T O�(�� S POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operat.or,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. 1• �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 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. 1. 2, 3. 4, _ FOOD PROTECTION MANAGERS-CERTIFICATIONS: - --- ` All food service establishments are required to have at least ane full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitaiy 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. N�� 2; PERSON 1N CHARGE: Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. 1. 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 Sta.te 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 1Vlaneuver on the premises at all times. Please list your employees trained in anti-chaking 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# � _ ___ _--- -- --- --- --_ :=-- - - OFFYCL US� 0�11.�I' __ __ __ -- LUDGING: 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 _TRAILER PARK $105 _WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PE # ' _0-100 SEATS $125 _CONTINENTAL $35 �NON-PROFIT $30 �--�DI�D ' >100 SEATS $200 _COMMON VIC. $60 WHOLESALE $80 RETAIL SERVICE: —RESID.KITCHEN $80 ' LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 <25,000 sq.ft. $150 =FROZEN DESSERT $40 _TOBACCO $110 NAME CHANGE: $is AMOUNT DUE _ $ 30�OO . *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** ' �0��— l5' 'ZZ7o-t� t ; !, . � • _3' � ADMINISTRATION Under Chapter 152,Section 25C,Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal I 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 i � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED � Town of Yatmouth taaces and liens must be paid prior to renewal or issuance of our ermits. PLEASE CHECK � Y P APPROPRIATELY IF PAID: � YES ✓ NO i ; 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 ur�it as a residence or dwelling unit sha11 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:�11 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 aze 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 quarte�ly � thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of elosing. 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 eaters within the Town of Yarmouth musY notify the Yarmouth Health Department by filing the reqi,ured 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.varmouth.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. � NO'�'ICE: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 DECEl�IBER 15,2017. 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. RENOVATIONS MAY UIRE A SITE P AN. DATE: I I-2— I`] SIGNAT'URE: � � PRINT NAME& TITLE: ��2i P. �i 5, 1�� U.��1Z , 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 Legiblv Business/Organization Name: �'(P�'�-��6�Gf-�!�o�.AC., C��7il2Ctf- GF �� 0 UT�f Address: �'L_� M,4 rl� �7'� �� v(o u�f �D/L-� /w9 o Zro�7S" City/State/Zip:YA�ZI►1�uTN P02T Mf�- C�26 7S Phone #: �� -3(o Z- b�� Are you an employer?Check the appropriate box: Business Type(required): 1.�am a employer with�employees(full and/ 5. ❑ Retail or part-time).* 6. ❑ RestaurantlBar/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. ,-�,,T [No workers' comp.insurance required] g• IL�on-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.] 12.❑ Other *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 workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name:Cf-h(,�(/ZCff M Lf TL(F}L <�1lS��4�C E C�N(p�L'�/`�' � Insurer's Address: f d �� Z-�(Z- City/State/Zip:_��--GCJi9-�-f I G�`� Wl `5�3 20! � Z`�i � 2 Policy#or Self-ins. Lic. # �C�S?� �� d'?- DO.S Z 3 5 Expiration Date: r��-�f �� Attach a copy of the workers' compensation policy declaration page(showing the policy number and egpiration 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 c ' ,under the pains and pena[ties of perjury that the information provided above is true and correct. Si ature: � U�-� f�2 S Date: � —�r- � Phone#: ' �f `-- �.P Official use only. Do nnt write in this area,to be comp[eted by city or town official City or Town: PermitlLicense# Issuing Authority(circle one): 1. Board af 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---_ Church Mutual Insurance Company NCCI CARRIER CODE NO. 16853 WC 00 00 01A WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE 1. The Insured: FIRST CONGREGATIONAL CHURCH policy No. 0187606 07-005235 OF YARMOUTH Renewal of: 0187606 07-940073 Individual Partnership Mailing address:3 2 9 ROUTE 6A X YARMOUTH PORT, MA 0 2 6 7 5-1817 Corporation or , Federal Employers I.D.# See Schedule Inter/Intrastate Risk I.D. # Other I.D. # Other workplaces not shown above: See Schedule Contact Phone Number 2. The policy period is from 12/2 3/2 017 �2;01 a.m. to 12/2 3/2 018 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: M� 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 $ 5 0 0, 0�0 each accident Bodily Injury by Disease $ 5 0 0, 0 0 0 policy limit Bodily Injury by Disease $ 500, 000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: All states except states designated in Item 3 .A. of the Information Page and ND, OH, WA, WY. D. This policy includes these endorsements and schedules: See Schedule 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. Premium Basis Rate Per Code Total Estima#�d - $1OQ o#--- Estimated Classification No. Annual Remuneration Remuneration Annual Premium See Item 4 . Extension WC 00 00 OlA Total Estimated Annual Premium$ 2, 021 Expense Constant$ 3 3 8 Taxes and Surcharges $ 10 3 Minimum Premium $ 281 (MA) 9101 Deposit Premium $ 2, 124 See Item 4 . Extension WC 00 00 OlA for the Taxes and Surcharges for: MA Premium Adjustment Period: Annual Countersigned by: Servicing Office: Church Mutual Insurance Company Date: 10/2 0/2 017 Producer: �DERSON W. RYAN Church Mutual Copyright 1987 National Council on CompensaUon Insurance. � Original INSUIIANCE COMVANT