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Home My WebLink AboutApplication and WCi ,�� ' ' :��Iti�#"��`�� '� ,� C � E� ' � TOWN OF YARMOUTH BOARD��'H�`�b�'I��'. ' APPLICATION FOR LICENSE/PERMI ��i�l �'=Q��'�j "" * Please co 1 �� 3� �6� mp ete form and attach a11 necessary documents by December S .,�� Failure to do so will result in the return of your application pac e ESTABLISHMENT NAME: 1�S 0 F 0 `'� G. ID: �• ` � LOCATION ADDRESS: u. ?....� , A �t � L6�3 TEL.#: S��-?40 �.�3 _ �� d r E , tA1 � RM o ?��1 . M cr s`T MAILING ADDRESS: P CS (�nx �d3 . S � r1 iK,wt�u'c N,� I�lq Q Lb�� E-MAIL ADDRESS: � OWNER NAME: ��s �t� c � c� CORPORATION NAME I ( F APPLICABLE): S A S Q MANAGER'S NAME: T IJ E ►�E ��'�,S �r, S TEL.#: 0�'`�1�(7-0 � K� � � h�..� S 3 MAILING ADDRESS: 3 ��r� Z�S, G.�� A ti�►o��r W . M,A a Z-(,�1 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. ' I. � /� 2 _._ ' Pool o erators must list a minimum of two em lo ees currentl certified in standard First Aid and Communi P Cardiopulmonary Resuscita.tion (CPR), having one certified employee on premises at all times. Please list the em lo p yees below and attach copies of their certifications to this form. The Health Department will not use past ears' records. You must rovide new co ies and maintain a file at our lace of b in Y p p y p us ess. �II 1 2 3. 4. FOOD PROTECTION MANAGERS -CERTIFICATIONS: 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. l.___[�AT1SEti�►�E t�cT�.51MMoNs 2. PERSON IN CHARGE: . Each food establishment must have at least one Person In Charge (PIC)on site during hours of operation. }. ��F�!N�!N� -�F"C�'-�i°tt14�'!i N� �._ _ ALLERGEN CERTIFICATIONS: 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 for Food Service Esta.blishments, 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. ��T1�1Ett14.T� �1T �S\ Mrt �1 �S 2. HEIMLICH CERT�FICATIONS: A11 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-choking procedures below and � atta.ch 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. l. �t1� �flR�E �ANN A�--� 2. 3. 4. ; RESTAURANT SEATING: TOTAL# I 6� _ .—---__ - _. - 1�F10E USE ONLY I LODGING: ( LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LIGENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $110 INN $55 CAMP $55 SWIMMING POOL$110ea. '! _LODGE $55 _TRAILER PARK $105 _WHIRLPOOL $110ea. i FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 CONTINENTAL $35 NON-PROFIT $30 � �>100 SEATS $200 ��0 �COMMON VIC. $60 � C6 WHOLESALE $80 —RESID.KITCHEN $80 � RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED EEE PERMIT# <50 sq.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 <25,000 sq.8. : $150 _FROZEN DESSERT $40 TOBACCO $110 NAME CHANGE: $is AMOUNT DUE _ $ � � *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** o�+o O.00 i � ��4�- 1��3�.��► s _ ., t i 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 ATTACH�D STATE WORKER'S COMPENSATION INSURANCE � AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR � _ c , CERT. OF INSURANCE ATTACHED ! O� WORKER'S COMP. 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� NO � ' 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 f 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, shall generally be considered Transient. � POOLS POOL OPENING:All swimm�ing,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 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 tlie eaftere certified lab, and submitted to the Health Department three (3) days prior to opening, and quarterly t � � POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of � elosing. � �OOD SEi�VICE , _ : _ � SEASONAL FOOD SERVICE �PENING: � 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: i Anyone who caters within the Town of Yarmouth must' notify the Yarmouth Health Department by filing the required Temparary 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.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 CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. ' OUTDOOR COOKING: � i Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. ' �_ ___ .___ _ _ f ; NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETLJRN ; THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S}BY DECEMBER 15,2017. ''� C ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW i EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR ' TO COMMENCEMENT. RENOVATIONS QU ITE'PLAN. � DATE: �� L 1 ZO �� SIGNATURE: PRINT NAME&TITLE: K0� �(� C(J IC.l�7�f 1� �J s`��„J��,�,�#��c��, x�. ioiiaii� i TOWN OF YARMOUTH �o�raaf �` Health = 1146 ROUTE 28, SOUTH YARMOUTH, MASSACHUSETTS 02664-24451 - �,,,,o Telephone(508) 398-2231, ext. 1241 Div s,ion � Fax(508) 760-3472 December 6, 2017 Sons of Erin Cape Cod Attn: Rodger Christiansen; Treasurer P.O. Box 403 South Yarmouth, MA 02664 Re: 2018 Application for Licensing Dear Mr. Christiansen, Thank you for submitting the 2018 renewal application for Sons of Erin licenses issued through the Health Department. The application and the fee submitted were only for the food service license. Please note that the $ons of Erin also has a common victualler license that must be renewed. We can correct the application to include the common victualler license, however, we will still need the fee payment in order to complete processing of the license. Please remit $60.00, check payable to the Town of Yarmouth, to the Health Department at your earliest convenience. As soon as our office receives your payment, we will be able to issue the permits to you. If you have any questions on the above, please feel free to contact the Health Department at (508)398-2231, ext. 241. Thank you for your an�icipated cooperation. � Sincer�ly; Mary Alice Florio Principal Department Assistant cc: file � �� .�"' d�3✓� �-- � � ,..:�� ,♦„k.a RE��'IVED DEC 1 �3 ?.�)7 H��TH DEPT. � � � The Commonwealth of Massachusetts Department of Industrial Accidents ' Of�ce of Investigations ' ' 1 Congress Street, Suite 100 Boston, MA 02114-20I7 � www.mass.gov/dia , Workers' Compensation Insuranee Affidavit: General Businesses= � '` ' Applicant Information Please Print Le�ibly Business/Organization Name: S Q�J� Q f �R 1 N C�1P� Ca A . �r. Address: (d 3 3 �0 v,,T� Z,� City/State/Zip: , �t. 'f � �Z6 Phone #: ,�Q� —�9� -'� 35� 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. ❑ RestaurantlBar/Eating Establishment 2.❑ I�m a ssle�ropri�or�:p��::ershi�anu' 1^.ave�ro - - - - - ___ __ _ '�. �O�ce aridlor Sales�ncl. 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.❑ 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#1. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: �,C� AM�I�I,C A�.1 �xJS�tAGA�CSS � Insurer's Address: City/State/Zip: Policy#or Self-ins.Lic. # (o S�ZU('�, — V�.U'�P�L Expiration Date: t� Attach a copy of the workers' compensation policy declaration page(showing the policy number and piration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a _fit�ap to ni,5$@�8f�ard/or - � ; �, cveil-�s�' ' , '., : .. . , �-�'�'fQP�J£3�.�G'1�J��a��.:, _____ of up to $250.00 a day against the violator. Be advised that a copy of this sta.tement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereb ertify, under paitZS an e ties of perjury that the information provided a ove is true and correct. Si ature: Date: � � �� 7 Phone#: 0 � 1�I� " I 1 Official 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 ! � VDAC THIS IS A QUOTE , NOT A POLICY � H U B B� WORKERS COMPENSATION AND EMPLOYERS LIABILITY POUCY { QUOTE PROFILE — VERSION 01 POLICY NUMBER: (6562UB-4705P92-8-17) RENEWAL OF (6562U6-4705P92-8-16) INSURED'S NAME AND ADDRESS WORKERS COMPENSATION SONS OF ERIN CAPE COD INC INSURANCE PLAN PO BOX 403 A/R (WCIP) # MA ', SOUTH YARMOUTH MA 02664 I POLICY PERIOD FROM: 08-02-17 TO 08-02-18 TOTAL ESTIMATED ANNUAL STANDARD PREMIUM $ 625 PREMIUM DISCOUNT NONE 0900-20 EXPENSE CONSTANT 250 TERRORISM 20 TOTA� ESTIMATED PREMIUM 895 TAXES AND SURCHARGES 35 DEPOSIT AMOUNT DUE 930 Employer's Liability BI Limit: $ 100000 Each Accident 500000 Policy Limit 100000 Each Employee INSURER: ACE AMERICAN INSURANCE COMPANY Adjustmer�ts of Premiums shall be made ANNUALLY ***********,r*,r****,r************ Deposit Amount Due: $ 930 **,r**�**********,r**,r,r,r,r***,r*** POLICY NUMBER: �6S62UB-4705P92-8-17) DATE OF ISSUE:06-07-17 WC ST ASSIGN: MA OFFICE: RI� CHUBB 24M PRODUCER: BRYDEN & SULLIVAN INS 756KG