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Home My WebLink AboutApplication and WC, �� TOWN OF YARMOUTH BOARD OF HEALTH �� APPLI�ATION FOR LICENSE/PERMIT-2018 � �" *Please complete form and attach all necessary documents by December 1 S 20 . Failure to do so will result in the return of your applicahon packet. �/Q ESTABLISHMENT NAME: w � • - " � LOCATIONADDRESS: I � OW o7(0(o TEL.#: �U - �'�`�^ `7�� MAILING ADDRESS: E-MAIL ADDRBSS: .'f W C O M C Q � � '� O WNER NAME: �T�r� �i,S c.�7�_ CORPORATION NAME APPLIC' LE): MANAGER'S NAME: ,, C t7 T'EL.#: -a� 1 a -`: #! MAILING ADDRESS: � ��v1 p ` '`„`': '' � � 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. � ,,` A � .. 1. f v //'� � 2. ` � i b..�. a 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 a11 times. Please list the �"?>�� '� employees below and attach copies of Uheir 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. � j 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 t�is application. The Health Department will not use past years'records. You must provide new copies and maintain a�le at your establishment. �. ��(� ��di�nd � 2. ��►d �a I � PERSON IN CHARGE: Each food establishment must have at least one Person Irt Charge(PIC)on site during hours of operation. 1. _��Yl 1 � �f l ��,Wl I�S 2. ✓Ul 1'�1 C�1�- 7) S�.. ALLERGEN CERTIFICATIONS: �a S� � ��"��/ M e�i SS a '�G�f;nc��h 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 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�le at your establishment. �. Z.P,r'�� ► L�n o� ': 2.�CaS c� � S► S��e 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 certification�to this form. The Health Department will not use past years'records. You must provide new copies and maintain a�le at your ptace of business. �. r I�Pdlund : 2. /�l ��iSSG ��r►�� D� 3. C> 4. �� ' n ri►n s u�, RESTAURANT SEATING: TOTAL�# � � OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERM[T# 'LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $110 —INN $55 —CAMP $55 —SWIMMING POOL$110ea _LODGE S55 =TRAILERPARK $105 _WHIRLPOOL S110ea FOOD SERVICE: LICENSE REQUIRED FEE PERM[T# !LICENSE REQUIRED FEE PERMIT# LICENSE RE UIRED FEE PERMIT# 0-ip0 SEATS 5125 CONTINENTAL �35 NON-PRO�IT $30 �>100 SEATS 5200 �� COMMON VIC. S60 �I�� —WHOLESALE $80 '�� " " —RESID.KI7'CHEN S80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# ;LICENSE RGQUIRED FE� PERM7T# LICENSE REQUTRED FEE PERM[T# <50 sq.ft. S50 ' >25,000 sq.ft. 5285 VENDING-FOOD $25 =<25,000 sq.ft. $150 �FROZEN DESSERT S40 _TOBACCO $110 NAME CHANGE: $IS AMOUNT DUE _ $ �IpO.O� *****PLEASE TURN OVER AND COM@LETE OTHER SIDE OF FORM***** �o�- i�-6-3c�-oy , ADMINISTRATION Under Chapter 152,Section 25C,Subsection 6,the Town af Yarmouth is now required to hold issuance or renewal of any license or pernut 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 COMPLET�D AND SIGNED,OR CERT.OF INSURANCE ATTACHED OR t WORKER'S COlvIP.AFFIDAVIT SIGNED AND ATTACHED i ; Town of Yarmouth taxes and liens must be paid prior to rznewal or issuance of your permits. PLEASE CHECK I APPROPRIATELY IF PAID: n / YES V NO � MOTELS A111D O'�'HER LOOGING ESTABLISHMENTS , TRANSIENT OCCUPANCY: For purposes of the limitations of Motei or Hotel use,Transient occupancy shall be I 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 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,sha11 generally be considered Transient. POQLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to operiing. Contact the PIealth 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 quazterly 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 OPE1vING: 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 of Yannouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72�►ours prior to the catered event. These forms can be obta�ned 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 Heal4h 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 COOKTNG: 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 RETLJRN THE COMPLETED RENEWAL APP�.ICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15,2017. ALL RENOVATIONS TO AIVY FOi�D ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MiJST BE REPI�RTED TO D APPROVED BY THE BOARD OF HEALTH pRIOR TO COMME CEMENT. RENOVATIbNS MAY QU S P AN. DATE: I I SIGI�ATURE: ��t,/J � PRINT NAME&TITLE: � Yl 1 �O C;C ►"�'�Ct v�� Rev.10/I2/i7 � Florio, Mary Alice From: Danielle Siscoe <danielle.riverway@comcast.net> Sent: Friday, December 08, 2017 10:03 AM To: Florio, Mary Alice Subject: Re:2018 Health Department licensing Attachments: Worker's Comp Affidavit.pdf;Worker's Comp Info page.pdf Hi MaryAlice, That's funny...it was definitely attached to the application. Must have gotten lost in the shuffle! I have attached both the affidavit and the info page. Thanks! Danielle Siscoe On December 7, 2017 at 4:25 PM "Florio, Mary Alice" <MFlorio(a�yarmouth.ma.us>wrote: Hi Danielle, In processing your application for Riverway's food service and common victualler licenses, I noticed that there was no workers compensation affidavit OR certificate of insurance enclosed. I have attached another affidavit to this email. Would you please complete it and email/mail it back to me at your earliest convenience? If you prefer to have your insurance agency send a certificate of insurance instead showing the w.c. coverage,that would be fine as well. As soon as I receive proof of w.c. coverage, we will be able to finish processing your licenses. Thank you so much for your attention to this matter. MazyAlice Florio, Principal Office Asst. Yarmouth Health Department 1146 Route 28 South Yarmouth, MA 02664 508-398-2231, ext. 1241 i � � ��j�� _.�LL� The Cortzmonwealth of Massachusetts Departrfaent of Industrial Accaderets Off ce of Investigatians ', ' I Coregress Str�eet,Suite 140 ; Boston,MA Q211�,2017 www.mas�.govldia � j , Workers' Compensation Insurance Af�davit: General Businesses Applicant Ynformation Please Print L�gi.bly � Business/Oxganxzation Name: � 1�� C�.� .5 � Address: f.�� t�.� ': CitylState/Zip:J. �G�(�')'10 � 1"�r�� "��D�Phone#: fJ��.� I�"a �� Are ygu an employer?Cbeck the appropriate boa: Business Type(rec�uired): 1.��I am a empioyer witk► '�"v ,`�� employees{fult and! 5. ❑ Retait or part-time).* 6. �] RestaurantlBarBating 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] $• ❑ Non-profit 3.❑ We are a corporation and its of�icers have exercised 9. ❑ Entertainment their right of exernption per c. 152, §1(4),and we have i 0.Q 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.❑ Other *Any applicant thaz checks box#1 mast also fill out the sectioe beEaw showing their workers'compensativn policy informazion. "*If the co�orate officers have exempted[hemselves,but the corporation has ottter employees,a worke�s'compensation policy is required and sueh an ` organization should check box#1. I am an employer that isproviding workers'compensation insurance fvr rny ployees. Below is ihepolicy information. Insuranee Company Name: �iQ �� 1 1 ��'!��1�5 ��G (4 ro�.� I n�-- rnsu�ex�s��ss: �-�, 3ax �'S� � a� —q�-a� City/State/Zip: �� ,1 �,:�}��d� r 1 J� Policy#or Self-ins.Lic.� Q � �f o a 5 Q3�-a�a ' ` � Expiration Date: � 1 ��J Attach a copy o�tb�e workers'compensatioa poIicy declaration page(showing the policy number an expiration 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,SOOAO and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day aga�nst the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. �'do hereby certi der the pains and penadties of perjury that the information proVirled above is true and correc� Si ature: Date: � � i � ! Phone#• ��r c� t��c� � �a Of}icial use only. Do not write in this area,to be ca»spleted$y city ar town officiaL City or Town: Permit/License# Issuxng A,vthotity(circIe one): X.�oard of Health 2. Building Department 3.CityiTo�vn Clerk 4.Licensing Board 5.Selectnnen's OiTce 6.4ther Contact Person: Phone#: �mww.mass.gov/dia , INRQRMATION PA�E REI�IEtiTAL AGREFMENT Insurer: PRODUCER: Agent�� 2904 Mti Retail Merchants WC Group Inc. Mark Sylvia lnsurar�ce Agency, LLC PO Box 8�9222-9222 40� Main 5treet Braintree, MA 0218� Centerville, MA 02632 (Carrier Code: 3435�) Carrier Palicy ��; O1�!045432222117 Carrier Prior Policy ��: Q1404503222211b 1• The Insured: R3verway Lobs�er T3ouse, Tnc. Mailing Address: 1338 Raute 28 South Yarmauth, �iA 02664 �ein: Ot�±er wtsrkplaces x�at showr� above: Type of Busi,ness: Corporatian SEE SCHEDULE OF OPEI3ATIdNS Risk II}: 2. Tlze pol.icy period is �'rom 12;OI a.m. on _ 1/01j20i7 to 12.01 a.m. on 1/O1(2018 at the insurad's mail�ng address. 3. A. Workers Compansat�.on Insurance: Part One of the palicy applies ta the Workers Compensation Law of the states listed here: MA B. Employers L3ability Insurance: Par� 'I�aa of the policy applies to work in each state listed in I�em 3.A. The lamits of our iiabil.ity under Part Two are: Bodx�y Injury by Aceident $ __ 1.000,400 each acciden�t . Bodily Tnjuryr by Disease $ 1.000 000 golicy limit Bodily Injuxy by Disease $ 1 OOOR000 _._� each employee C. Ot�er St�tes �nsurance: D. This policy includes these endozsem�nts a�d sehedt�les: WC�00400C(pl/15) ��ICtl0041�(07/90) WC�qO%22B(01/7.5) GI�2003a1(0�/&4} WC2ad302(Q5/$b) WC200303$(p7f99) WC2003�6B(Q6/13} WC2Qp405(U6/01) WC2t?0601A(p7/08) 4. 'I'he pr�emium �or this policy will be de��rmined hy our 3�fan�aals of ltules, Classi�ications, Rates and Rating Plans.` A11 ir_formation re�uired bElow is subject to verification and change by av.dit. � Classi�icatiQns Code Premium Basis Rate Per Estimated No. To�Cal Es�timated $100 of Annual Annual Rem�neration Remuneration Breinium SEE SC�I.EDULE OF OPER4TTONS To2a1 Estim�tesi Annual Premium $ 12,589.00 M�n�.mum Premiu{n $ 292.00 Expe�se Constant $ .00 Deposit Frem�.um $ .00