The URL can be used to link to this page

Home My WebLink AboutApplication and WCf ��:.-1r� � , ... _ .._ _ � TOWN OF YARMOUTH BOARD OF HEALT ' � APPLICATION FOR LICENSE/P�RM�'�-20 � NOV ji �? Z O Z� ' * Please complete form and attach a11 necessar�,�ocu�tent . er 3 Failure to do so will result in the return'�'your app�icahon pa �� -�Y �-- ---.��. ESTABLISHMENT NAME: � Ct Q�-w �e,l (.± uar� TAX ID: �� LOCATIONADDRESS: 1323 1�f2 28� � souf�+ Nai•moutl� ✓vIq OZ6G�I'EL.#: 50�39cAa�� MAILING ADDRESS: E-MAIL ADDRESS: OWNERNAME:__Kinni2 C iU CORPORATION NAME (IF APPLIC LE): MANAGER'S NAME: I�i n n i� L'��N TEL.#: Sd�' 39� 2/.2.� MAILING ADDRESS:�3'�3 aUfe �� i✓IIOUf ��4 Oz `F � I� 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. L 2. 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 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 one full-time employee who is certified as a Food Protection Manage�, 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. 2: PERSON IN 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# - - _ _____— — _ __---- ; OFFICE USE ONLY LQDGING: 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$1 l0ea _LODGE $55 _TRAILER PARK $105 _WHIRLPOOL $110ea. 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 _COMMON VIC. $60 WHOLESALE $80 —RESID.KITCHEN $80 RE'I'AIL SERVICE: LICENSE REQUIRED FEE ERMIT 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 ZTOBACCO $110 �Q NAME CHANGE: $is AMOUNT DUE _ $ ��o O,OO *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** �d�'F"(��a62��I �,��1--6or�-oy � 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 ATTACHED STATE WORKER'S COMPENSATION INSURANCE [ AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR � CERT. OF INSURANCE ATTACHED 4/ � OR i 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 temporasy and short term occupancy,ordinarily and customarily associated with motel and hotel use. j Transient occupants must have and be able to demonstrate that they maintain a principal place of residence I elsewhere.Transient occupancy sha11 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 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:All swimming,wading and�vhirlpools which have been closed for the season must be inspected by the Health Department prior to opening. Contact the Health Department to schedule the inspecNon 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 standardplate count by a State certified lab, and submitted to the Health Department three (3) days prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of i 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 Yarmauth mus� notify the Yarmouth Health Department by filing the required 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.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 Boazd of Health. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. i i � _ __ . __ . _ - � , i � NO�ICE:Permits run a.nnually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN ; THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 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 REQUIRE A SITE PLAN. / � D�iTE: l��3l�� SIGNAT'URE: �i�1�t�,P �'/? i�l� PRINT NAME& TITLE: /�i��.P C'�?'� , D�l/�/l.P�`' Rev. 10/12/17 � � • • � The Commonwealth ofMassachusetts Department of Industrial Accidents Office of Investigations ' ' ' 1 Congress Street, Suite I00 � Boston, MA 021I4-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Le�iblv Business/Organization Name: �OifP r W�� -i�j�°''s ' Address: �3�3 Ro�e 2� ' City/State/Zip: �OvrF� G�i'YtOvrf� lYI�I" D�6 phone #: �d�' 39� a l�-5 Are yqu an employer? Check the appropriate box: Business Type(required): 1.��I am a employer with � employees(full and/ 5. (�Retail or part-time).* 6. ❑ Restaurant7Bar/Eating Establishment ' - - —--- - ___-- ---- - _ ___-- -- — ----- -_-— — -- -- - ___ 2.�] I am a sole proprietor or partnership and ha�e no �, � Office and/or Sales(incl. 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. ❑ Enterta.inment their right of exemption per c. 152, §1(4), and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]* 1 l.❑ 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:�l,��} �QQ f C(,�I �QYC�QY►tg l�llC �YDU p -�-✓1 C . Insurer's Address:_ _�O �'h( gSq�2Z - 92�2 Z d�Y�tl►�-{Y,(Q , �'� ��J�5 City/State/Zip: Policy#or Self-ins.Lic. #_�_��D(��D�D 5 3)1 I � Expiration Date: �/� ��0�C� 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 ORDEK 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 information provided above is true and correct. ' Si�nature: /` �� `- ��M1� Date: �� 3�/ , Phone#: �� 3�� 2/�5 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 �� NOTICE - _ NOTICE F TO _ � tl TO EMPLC�YEES q �� EMPL4YEES � The Commonwealth of l��Iassachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 1 Congress Street, Suite 100, Boston, Massachusetts 02114-2017 617-727-4900 - hrip://www.state.ma.us/dia As required by Massachusetts General Law, Chapter 152, Sectians 21,22&30,this will give you notice that I(we)have provided for payment to our injured employees under the above-rnentioned chapter by insuring with: MA Retail Merchants WC Group Inc. NAME OF INSURANCE COMPANY PO Bo�859222-9222 Braintree,MA 02185 ADDRESS OF IN3UR.ANCE COMPANY 014005D30531 X 17 1/Ol/2017 - 1/O1/2Q18 POLIC�.'NUMBER ` EF'FBCTIVE DATES Wm F�orhek Insurance Agency, 311 Plymoutt�Street Halif�,lVjA 02338 '181-293,-63? NAME fJF INS�JRANCE AGENT �ADD�ZESS � �HONE# Waterc�rheel Li�uors 13t3 Route 28 5outh Yar�outh,MA 02664 EMPLQYER � � ADDRESS ! EMPLQYER'S WORi�ERS' COMPEN�ATION O�FICE�(IF ANY) t DAT� MEDICAL TR�;ATMENT The above named insurer is required in cases of p�rsonai injuries arising out of and in the course of emplqyment to furnish adequate and reasonable hospital and medical services in accordance with the provi�ions of the Workers' Compensation Act. A copy of the First Report of Injury must be �iven to the injured empioyee. The employee may select hi.s or her own physician. The reasonable cost of the se�- vices�rovide� by the treating physician will be paid by the insurer, if the treatment is necessary and ' reaso�ably connected to the work related injury. In cases requiring hospital attention,emplo.yees are hereb�notified that the insurer has arranged for such attention at the ` NAM'E OF H�SPITAL ADDRESS � # TO BE POSTED BY EMPLOYER 1 INFQRMATIQN PAGE RENEWAL AGREEMENT Insurer: 'i, MA Retail Merchants WC Group Inc. PRODUCER: Agent�� 641 PO Box 859222-9222 Wm F Borhek Insurance Agency, Inc + 311 Plymouth Street Braintree, MA 02185 Halifax, MA 02338 (Carrier Code: 343�5) Carrier Policy ��; 014005030531117 Carrier Prior Policy �: 014005030531116 1• The Insured: Waterwheel 28, Inc. Waterwheel Liquars Mailing Address: 1323 Route 28 ! South Yarmouth, MA 02664 i � Fein: I Other workplaces not shown above: NO OTHER WORKPI,�;CES FOR THIS POLICY �'3'Pe of Business: Corporation Risk ID: % 2. The policy period is from 12:01 a.m. on 1/O1/2017 to 12;01 a.m. on 1/O1/2018 I 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: ( MA i � B. Employers Liability Insurance: Par�t 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 $ 100.Q00 each accident Bodily Injury by Disease $ 500,000 policy limit Bodily Injury by Disease $_ 100 000 each employee C. Ot�er St�,tes Insurance: D• Th�.s policy includes these endo�semQnts and s�hedules: WCOOQOOOC(Q1/15) WC000414(07/90) WCOQ0422B(O1/15) WC200301(04/84) WCZ00302(05/86) WC200303B(Q7/99) WC200306B(06/13) WC200405(�6/O1) G�C200601A(07/0$) 4. The premium for this policy wil�. be detqrmined by our Manuals of Rules, Classi�ications, Rates and Rating P�ans. All'`infArmation required below is sul�ject to ver�.ficat�.on and change by a�.dit. � Classificatipns Code Pxemium Basis Rate P�r Estimated No. To�al Es�ima�ed $100 of 'Annual Annual Remuneration Remunera�tion Aremium ,SEE SG�iEDULF� OF OPERATIONS Total Es�imatee�l.. Annual Premium $ 1,132.00 Mxnimum �'remiu�n $ 216.00 Expense Canstant $ .OQ Deposit Premium $ .00 , 1 i ! SCHEDULE OF OPER.ATIONS FOR: PAGE: 1 ***** PREMIUM INFORMATION FOR MA ***** Waterwheel Liquors Carrier Poli�y #: 014005030531117 Waterwheel 28, Inc. Fein: 1323 Route 28 ; South Yarmouth, MA 02664 � DIV #: 00000 E/L Number: 0000000001 � � � Code Cla�sification Payroll Rate Premium i i 8017 Store: Retail Noc 126, 609 .00 1. 07 1, 355 .00 � � 1 � l�anual Premium 1, 355 .00 ; �ate Deviation 15.00� 203 .44 N�erit Rating 1, 094 .OQ � S,tanda�d Pre�nium 1, 094 .00 I�jormal .Premium 1� 094 .00 Expense Constant � � �omesti;c Terrorism C .030 38 .00 ; �nnual `Premium 1, 132 .00 � AIA As�essme�t (00930) 2 .0700� / 2 .0700$ ° 27 .00 � Total - 1� 159 .0¢ ; i i Merit l�ating j .9500 1/01/2017 I ( � ; � WC 00 00 01 B