HomeMy WebLinkAboutApplication and WC�
' TOWN'OF YARMOUTA BOARD OF HEALTH
� APPLICATION FOR LICENSE/PERMTT-2018
��� *Please com lete form and attach all necess documents b December IS 2017.
' Failure to do so wiIl result in the return of your application packet. �
ESTABLISHMENT NAME: � �
LOCATION ADDRESS: � T .#: '3 1 iy
MAILING ADDRESS: � �U`
E-MAIL ADDRESS: (�
OWNER NAME:
CORPORATION NAME(If�'A LICABLE).
MANAGER'S NAME: S TEL.#:
� MAILING ADDRESS: � � � �
POOL CERTIFICATIONS:
The pool supervisor must be cerhfied as a Pool Operator,as required by State law. Please list the designated
Pool Operator(s)and attach a copy of the certification to this form.
1. 2.
1
j Pool operators must list a minimum af two employees currently certified in standazd First Aid and Community 2 O �
Cardiopulmonary Resuscitation(CPR'�,having one certified employee on premises at all times. Please list the m n
' employees below and attach copies of their certifications to this form.The Health Department will not use past D --+ �
years'records. You must provide new copies and maintain a file at your place of business. � N �
+ GJ
I 1. 2. � rv �
� 3. 4' � o d
� FOOD PROTECTION MANAGERS-CERTIFICATIONS:
i All food service establishments are required to have at least one full-time employee who is certified as a Food
j Protection Manager,as defined in the�tate Sanitary Code for Food Service Establishments, 105 CMR 590.000. ---- --�
� Please attach copies of certification to this application. The Health Department witl not use past years'records. �_' . •,�
You must provide new copies and maintain a file at your establishment.
.�
� 1. 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,
1, as defined in the State Sanitary Code for Food Service Establishments,105 CMR 590.009(G)(3)(a). Piease 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 estabtishment.
� 1. 2.
�
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 certifications to this form. The Health Department will not use past years'records.
You must provide new copies and rrpaintain a file at your place of business.
L 2.
3. 4.
RESTAUAANT SEATING: TOTAL'#
� OFFTCE USE ONLY
' LODGING:
� LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
BBcB $55 CABIN $55 MOTEL $I10
I INN $55 CAMP $55 SWIMMING POOL$I IOea
1 LODGE $55 _TRAILERPARK $105 _WIIIKI.POOL $710ea
�
� FOOD SERVICE:
; LICENSE REQUIRED FEE PERMIT# ;LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
; 0-100 SEATS $125 _CONTINENTAL $35 NON-PROFIT $30
>IOQ SEATS $200 _COMMON VIC. $60 WHOLESALE $8�
1 — —RESID.KITCHEN S80
j RETAIL SERVICE:
a L10EVSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
� ' <50sq ft. $50 >25,000 sq.ft. $285 __ VENDING-FOOD S25
� �<25,OOOsq.ft. $I50 �(p —FROZENDESSERT $40 �TOBACCO $L10
� NAME CHANGE: $15 AMOUNT DUE _ � �SO-OO
,
*****PLEASE Til�[iN OVER AND COMPLETE OTHER SIDE OF FORM**"�•
����6�f-45(��{-0�(
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 COMPLET'ED AND SIGNED,OR
CERT.OF INSURANCE ATTACHED
OR
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 shall 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 unit as a residence or
dwelling unit shall not be considered tiransient. 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,waiding and whirlpools which have been closed for the season must be inspected
� by the Health Department prior to operiing. 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 azea unril the pool has been
i 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 quarterly
thereafter.
POOL CLOSING:Every outdoor in ground swimming pool must be drained or covered within seven(7)days of
closing.
i
i FOOD SERVICE
SEASONAL FOOD SERVICE OPENING:
All food service establistunents must be inspected by the Health Department prior to opening. Piease contact the
;
Health Deparhnent to schedule the inspection three(3)days prior to opening.
CATERING POLICY• �
' Anyone who caters within the Town of Yarmouth must notify the Yannouth 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 Departxnent,or from the Town's website at www.vannouth.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 Healfh Department. Failure to do so will result in the suspension or revocarion of your Frozen
Dessert Pezmit unril the above terms have been met.
OUTSIDE CAFES:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must haveprior approval from the Boazd of Health.
OUTDOOR COOHING:
Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited.
NOTICE:Pernuts run annually from January 1 to December 31. IT IS YOUR RESPONSTBTI.ITY TO RETURN
THE COMPLETED RENEWAL APP�.ICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15,2017.
ALL RENOVATTONS TO ANY FQOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR
TO COMME CE ENT. RENOVATIONS MAY REQUIRE A SIT •
DATE: 1 D SIGr+IAT'URE: V "����
�
PRINT NAME&TITLE: Q,
� Rev.10l12/17 � ,
,
Corporate O�cers and Directors of
Maxi Drug, Mc.
lncorporated in the State of Delaware on 11/28/1990
Federa//D#
Kenneth Black, President
Office Address: Rite Aid Corporation, 30 Hunter Lane, Camp Hill, PA 17011
Office Phone: 717-214-2550
Michael Podgurski, Vice President
i Office Address: Rite Aid Corporation, 30 Hunter Lane, Camp Hill, PA 17011
I Office Phone: 717-975-5888
!
Susan Lowell,Vice President
Office Address: Rite Aid Corporation, 200 Newberry Commons, Etters, PA 17319
Office Phone: 717-975-5744
Ghislaine Lespinasse-Bond,Vice-President
Office Address: Rite Aid Corporation, 30 Hunter Lane, Camp Hill, PA 17011
Office Phone: 717-975-5768
Daniel Miller,Vice President 8�Secretary
Office Address: Rite Aid Corporation, 30 Hunter Lane, Camp Hill, PA 17011
Office Phone: 717-214-2541
j Matthew Schroeder,Vice President&Treasurer
� Office Address: Rite Aid Corporation, 30 Hunter Lane, Camp Hill, PA 17011
Office Phone: 717-214-8867
I
j
I
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The Commonwealth of Massachusetts �-� _ ��
Department of Industrial Accidents
Office of Investigations
° 1 Congress Street,Suite 100
Boston,MA 02I14-2017
www mass.gov/dia
� Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
� /
; Business/Organization Name: �I �� A�d � � �1 q�
; Address: � ' 0 �(i� t n �C I 'Q..G�' �n �
i
� City/State/Zip:���(�-�� ��r� �5��5� Phone#: ��g`-- .3(�a- � �f �
Are you an employer?Check the appropriate box: Business T,ype(required):
1.(�' I am a employer with ���employees(full and/ 5. �,Retail
or part-time).* 6. ❑ RestaurantBar/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.
[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 10.0 Manufacturing
no employees. [No workers' comp.insurance required]* 11.0 Health Care
4.❑ We are a non-profit organization,staffed by volunteers,
� with no employees. [No workers' comp.insurance req.] 12.❑ Other
*A�y 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
I am an employer that is provid ng workers'compensation insurance for my employees. Below is the policy information.
' Insurance Company Name: (
Insurer's Address:
City/State/Zip:
Policy#or Self-ins.Lic.#�C� ���} �� 1-�U I�� � I Expiration Date: , +"�i' ��
Attach a copy of the workers' compensation policy declaration page(showing the policy number and 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$1,500.00 andlor one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certz��r the , an ' ry that the information provided above is tr and correc�
Si nature: Date: �
.� '
Phone#:
Official use only. Do not write in this area,to be completed by city or town officia�
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office
6.Other
Contact Person: Phone#:
www.mass.gov/dia
� ? `' DA?�(PA:':f�J;YYYY; .
;
�C���+ CERTIFICATE OF L[ABILITY iNSURAlt10E e,��:��7,
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' 7HIS CERTIF;CATE IS lSSUEC AS A N:ATTER OP INFORMA-10ti ONLY Aiv� CCNF�ftS ;�O RIGHTS UPOh THE CERTI=ICATE HO'�DrR. TY,1S
CERTIFICA7E DOES N07 AFFIRA4ATIVELY OR hEGATiVELY Af�1END, EXTEN� OR ALTER THE COVERAGE AFFORDEQ BY THE POUCIES
B�LOW. -HIS CERTIFICATE OF I��SURANCE D�ES NOT CQNSTITt;TE A CQNTRACT BEi;:'EEh 7}iE IccUING iNSURER(S), AUiHORI2ED
R�PRES�NTA7IVE OR PRODUCcR,AN^u TH�CERTIFICATE HOLDER.
ifr1PORTANT: If t;�a certif;C�te holdor Is an ADDITIONAL kNSUREi,, ihe pol.;cy(ies) must be ondorsc�, lf SiJI3ROGATIOU iS WAIVED.suhf�ct to �
' the ter�ns and�endit;ons of+he pofcy,coriai7 poli-'s.es may roqulre an endorsement. A statemer.t or�th's cortificato does not confer rlgn:s to the
� cert;ficafe hol�er In liou of such endorsementf,$).
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CERT�F�Cr'iTE YOLQ�R CANCEL!x;T10:`�'
fiile A�Ce�pc:a!ion
P:)Gox�ifi5 SHCULD ANY OF THE ABOVE DESCRIBED POLICiES BE CAhCELLED�ErOR£ �
f{o,;���.., �� y��a� 7HE EXrIRATION pATE 7HER�^vF, NOT':CE W��L 9E CEtiVERED Iy
ACCORRANCc YdITH T:;�F'O�ICY FRO`JISIOt�S.
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AUTHDRIZE:`7 REFRF.S[N7ATiYE
o(ta;rsh USti Snc.
'�ancy K;Ib:.`ell ��, ���,�{
0198E•201C ACORD CORPOFATION. All rights reser,ed.
ACORD 25(2C"4i01) Tf�Q A��RD namo and logo are registerod marKs of ACORC
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