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Home My WebLink AboutApplication and WC TOWI�t UF YARMOUTI�BOARD OF HEALTH APPLICATION FOR LICENSEJPERMIT-2Q18 *Plesse complete form and attach alI necessary documents by Decenilier 1 S 2A17. Failure to+do so will result in the retum af your applicat�on'�i ESTABLISHMENT NAME: ' - LOCATT�N ADDRESS; G'�'��1RX?/.j'��% S,/�l,�R.�.�r� TEL,#: ��-��v'�/%�J MAILING ADDRESS: % �,�.�.s�l/ �',�� i'�/'1lr.fl,6�.�*i'� �6,'�S" E-1VIAIL ADDRESS:_��' G`'�.�•/�'� �WNER NAME• 1�Lf �•,�t3�1 CORP'ORATION NAME(IF APPLIC.4BLE): �� .— AdANAGER'S NAME: �% ' TEL.#: -� G— � MAILING ADDRESS: � �� PQOL CERTTIFICATIONS; The pool supervisar must be certified as a Pool Operator,as required by State law, Please list the designated Pc�ol Operator(s}and attach a cop af�e certifieation to Uvs form. "-"'�� '�"� l, ,��'� 2, ti/'� -- _� ._ ; , �Fool operators must list a minimum of two employ�s cucrently certified in standard First Aid and Comznunity � ' ��`- Cardiopulmanary Resuscitatian(CPR�,having one certified enp loyee on premises at all times. Please list the � ' ,-,;; j employees below and attach copies of�hheir certifications to ttus�orm.The Iiealth Department will not use past � �.,, � years'recards. Yon must prov de new copies and maiatain a file at yoar piace af business. r.,� : � l. �/� 2. /�/� �, :' � � 3. 4. , � l.._„ ' _�__� FOOD PROTECTION MANAGERS-CBRTIFTCA'ITONS, Ali food service establishments are required to have at least one full-time employee wha is certified as a Food ` ,'�,� �� Prot�tion Manager,as defined in the�tate Sanitary Code far Food Service Establishments, l OS CMR 590.Od0. -:- a Plesse attach copies of certification to�his applicatian. The Health Department will not use past ye$rs'records. You must provide new copies and maintaio a file at your establishment �; . �� 1. �%4C1 � �,�l.L'� 2. ,��`s i�i�/F�-/�—fri'.P�GSS �a PERSON IN CHARGE: r:,y �� Each food establishment must have at least one Person In Charge(PIC)on siUe during hours of operation. l. c ��i��i��i��'l'l��f/�� 2. ��'S�?.�l��!?� �� .�v� ALLERGEN CERTIFICATf�NS: All food service establishments are req�ired to ha�e at least ane full-time employee who has Allergen cerkification, as defined in the'State Sanitary Code far Food Service Establishments,105 CMR 590.009(G}(3}(a). Please attach copias of certification to ttus application. The Health Department will not ase past years'records. Yoa must prnvide new copies and maintain a file at yanr establishmen3. i. ��%�I/ �' �� z. �7�'�_��°��'t�'.r�`�'� HEIMLICH CERTIFICATIONS: AII food service estabtishments with 25 seats or more must have at least one employee trained in the Heinnlich Maneuver on#he premises at all times.: Please list yQw employees trained in anti-choking procedw�s below and at#ach copies of employee Gertifications to this form. Th�Health Department will nat ase past year�'r�ords. You must provide new copies�nd maiuotain a Sle at your piace of business. 1. •'�///'7`- 2. /1.�,�i� 3. 4. RESTAURANT SEATING: TOTAL# i.ancnxc: OFkTCE USE ONLY LICENSE REQUtRED FEE PERTviTT# LICENSE RE.QUIRED FEE PERMIT# LICENSE REQUIRED FE£ PEFtMIT# B&B S55 CAB1N S55 M07'EL 5110 INN $55 GAMP $35 _SWIMMING PC3QL 3l ltka. _LODGE $55 T'fRAIL&R PARK S105 _WHIRLpOOL $t t0ea. FOOD SERYICE: iICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FB& PERMIT# LiCENSE RF.QUtRED FEE PERMIT�l �>i QD SEATS $200 _CO�VIC S60 —WFIOl�SA1.E S$0 —RF.SID.KITCHEN$80 RETAIL SERVTCE• LiCENSE REQUtRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED F£E PERMIT# <SQsq ft. $50 >25,000sq ft. $285 YENAING-FOOD S25 �QS,{?00 sq.ft. S150 �a? '�ROZEN DESS&RT$40 �'£OBACCO $110 ��/a YAME CHANGE: S15 AMOUNT DUE _ $ �,GO.Op **'•*PLEASE TURN OYER AND COM�'LETE OTtIER StDE OF FORM'*'*• j301�F-4�-c��3�-6y g��k-b��3-o y ADMINISTRATION Under Chapter i 52,Section 25C,Subsectian 6,the Town of Yarmauth is now required to hold issuance or renewal of any license or pernut to operate a business if a person or company does n�ot have a Certificate of Worker's Compensation Insurance. THE AITACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE CUMPLEI'ED AND SIGNED,OR CERT.O�F INSt7R.ANCE ATTACHED (/ �R WORKER'S COMF'.AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth t�es and liens must be paid prior to renewal or issuance of your pertnits. PLEASE CHECK AFPROPRTATELY IF PAID: YES_� NO MOTELS A1�iD OTHER LODGING ESTABLISAMENTS TRANSIENT OCCUPANCY: For p�soses ofthe Iimitations of Motel or Hotel use,Transient occup�ncy shall be t;mi�r�r�e c��or�y ana sno�r c�=occu�n�y,ordinarily and customarily associated with matel and hotel use. Transient accupants must have and li� able ta demonstrate that they maintain a prineipal place of residence etsewhere.Transient occupancy sha11 generally refer to cantinuous occupancy of not mare than thirty(30)days,and an aggregate of not more#han ninety(90)days within any six(6)month period. Use of a guest wnit as a residence or . dweIling unit shall not be cansidered t�ansient. Occupancy that is subject to the call�tion of Room Occupancv Excise,as defineci in M.G.L.c.64G or'830 GMR 64G,as aznended,shatl generally be cansidered Transient. POOLS POOL�PENING:All swimming,waiding and whirlpools which have been closed fox the season must be inspected by the Health Degartment prior ta o . Contact the,Heatth Departnient to schedute the ins�on three(3) days prior to opening.PLEASE I�O'�E�People are NOT ailowe�to sit in the pool area until e 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 Tab,and submitted to tbe Health Department three(3)days prior to openiag,and quarterly thereafter. POOI.,CLUSING:Every outdoor in ground swimming pool must be drained ar covered withizi seven('7)days of closing. FOOD SERVICE SEASONAL FOUD SERVICE OPII�iING: All food service establishments must be inspected by the Health Department prior to opeaing. Please contact the Health Department to sehedule the inspection three(3)days prior to opening. CATERING PQLICY: Anyone who cazers within the Town qf Yarmouth must notify the Yazmouth Health Department by filing the required Temporary Food Service A plication forra 72 hours priar to the catered event. These forms can be obtatned at the Health Department,ar�m the Town's website at www.ya�mouth.ma.us under Heatth I�epartment, Downloadable Forms. FROZEN DESSERTS: Frozen desserts must be testal by a State certified lab prior to opening and monthty thereafter,with sample results submitted to the Healfh I}egartment. Failure to do so will result in the suspension or rev�ation of your Fmzen Dessert Permit until the above terms have been met� 4UTSIDE CAF�S: Outside cafes(i.e.,outdoor seating with waiter/waitress�n+ice},must have prior approval from the Board of Health 4UTDOOR COOI�TGc Outdoor cookin�,preparation,ar display of any food product by a retail or food service establishment is prohibited. NOTICE:Permits run annt�elly from Jam�ary i to December 31.TF IS YOUR RESPONSIBIIdTY TO RETURN TI�C�MPLETED RENEWAL APPLICA'TIOAT(S)AND REQUIRED FEE(S}BY DECEMBER 15,2017. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, N�W EQUII'MENT,ETC.),MUST BE REAORTED TO P►ND APPROVED BY THE BOAR.D OF HEALTH PRtOR TO COMMENCEMENT. RENOVA'T'IONS MAY REQ SITE PLAN. DAT'E: �l'�l/-r7//�SIGNATURE: PRINT NAME 8c TITLE: ,�� 7`� j�� x�.ia��►2 . INFORMATION PAGE RENEWAL AGREEMENT Insurer: PR�DUCER: Agent�� 932 MA itetail Merchants WC Group Inc. Dowling & O`Neil Insurance Agency PO Box 859222-9222 PO Box 1990 Braintree, MA aa1s� Hyannis, MA 02601 {Carrier Code: 34355) Carrier Policy ¢�: 014005030998117 Carrier Prior Palicy ��: Q14005030998116 1. The Insured: Smithfield Market of Yarmouthport, LLC Peterson's Market Mailing Address: c/o Barnstable Market 3220 Main St. , PO Box 323 Barnstable, MA 02b30 Fein: � Other workplaces nat shown above: Type of Business: Limited Liability Co SEE SCHEDULE OF OPERATIONS Risk ID: 2. The policy period is from 12:01 a.m. on 1101/ZQ17 to 12:01 a.m. on 1101/2418 at the insured's mailing addre�s. 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Gompensation Law of the states listed here: MA 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 'I�ao are: Bod�ly Ir�jury by Accident $ 500,000 each accident Bodily Injury by Disease $ 500 000 policy limit Bod�.ly Injury by Disease $_ ,�OOQ each employee C. Other States Insurance: D. Thxs pol�ey includes these endorsements and schedules: WCOOQOOOC(�l/15) WC000308{04/84) WCOOQ406(08/84) WC000414(07/94) WCOOQ422B(O1115) WC200301(0�/84) WC200302(05/86) WC200303B(07/99) WC200306B(Ob/13) WCZ00405('06I01) WC200601A(07/08} 4. The premium for th1s policy will be determined by our Manuals of Rules, Classi�ications, Rates and Rating Plans. Al1 inf4rmation requirad below is sulaject to ver�ficat�.on and change by audit. Cla��ifications Code Premium Basis Rate Per Estimated Na. Total Estimated $lOQ of Annual Annual Remuneration Remuneration P.remium SEE SCHEDUL� OF OPERATIONS Total Estimated Annual Premium $ 14,171.00 Minimum Premium $ � 533.00 Exgense Con.stant $ .00 Deposit Premium $ .00 �� NC�TICE NOTICE x = TO � tl Ta EMPLO�EES �� v�� EMPL�YEE� °q s�e The �ommanwealth of l��assachusetts . DEPARTMENT OF INDUSTRIAL ACCIDENTS I Congress Street, St�ite 100, Boston, Massachusetts 02114-2417 617-727-490Q - http:I/wwv�l.state.ma.us/dia As required by Massachusetts General Law, Chapter 152, Sections 21, 22&30,this wi11 give you notice that I (we)have provided for payment t�o�.0 injured employe�s under the above-mentioned chapter by insuring with: MA Retail Merchants WC Group Inc. NAME OF INSURANCE COiVIPANY P(� Box 859222-9222 Braintree,MA 02185 ADDRESS OF I'��SURANCE COMPANY 014005030998117 - 1/QU2017 - 1/Q1/2018 POLICY NUMBER EFFECTIVE DATES Dowli�g &O'Neil Insurance Age PCl Box 1990 Hyai��is,MA 02601 SOS-775<16= i�IAME OF INSUR�NCE AGENT ADDRESS F'HONE�` Peterso�`s Maxket c/c�Barnstable�VIarket Barnstable, MA 02630 EMPLQYER ` � ADDRESS EMPLQYER'S'WORI�ERS' COMPENSATION O�FICER (IF ANY) DATE MEDIGAL fiR�ATMENT The above na�ned insurer is required in cases of personal injuries arising out of aild ir�the course of empl�yment to fuznish adequate and reasonable hospital and medical seivices in accoidance with the provi�ions of the WQrlcers' Compensation Act. A copy of the£�irst Report of Injury niust be given to the injured emplqyee. The employee may select hi.s or her Qwn physician. The reasonable cost t�f the ser- vices provide�l by th�treating physician will be paid by ihe iilsurer, if the treatment is necessa3y and � reasonably connected to the worlc related injury. In case�requ�ring liospital attention, employees are hereb�y noti��d that the insurer has arranged for such attention at tha NAIV�E OF H+OSPIT�AI, ADDRES� ' TO �E POSTEI� B� EMPL�'YER