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Home My WebLink AboutApplication and WC �� - TOWN OF YARMOUTH BOARD OF HEALTH APPLICATION FOR LICENSEIPERNIIT-2018 *Please complete form and attach all necessary documents by December IS 2017. Failure to do so will result in the return of your applicaUon pac��et ESTABLISHMENf NAME: 6 � �4' ' � LOCAI�ON ADDRESS;5�17 A-/'191 U �i' 11�y�•921�bLrt�/�Di,9 TEL#- S�1d� 77I•�� MAILING ADDR$SS: � C�L6 -� E-MAI�,ADDRESS: � OWNER NAME: CORPORATION NAME(iF APPLTCABLE): MANAGER'S NAIvIE: ' � ' ' TEL.#: � � 8'E� MAILING ADDRESS: � ✓ ' � �'� POOL CERTIFTCATIONS: The pool supervisor must be certified as a P�1 Operalpr,as reqnirecl by State law. Please iist the designated Pool Opezator(s)and attach a copy of the certification to#}us form. 2. � 2. m 0 �a n Pool operators must list a minimum of two employees currenfly certified in standard First Aid and Community Dr � �� Cardiopulmonaty Resuscitation(CPR),having.one certified employee on premises at all times. Please list the y N � employees below and attach copies of t�eir cemfications to t}us form.The Health Department will not use past ,� � •a�-- ears'records. You must rovxde new co ies and maintaun a file at�onr place of bnsiness. , i-� ^� �� y P P _'_ v � !'Ys' 1. 2. � � � 3. ' 4. FOOD PROTECTION MANAGERS=CER'TIFICATIOI�tS: Ali food service establishments are required to have at least one full-time employee who is certified as a Food �t.: ;;, 4'' Protection Manager,as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. -� Please attach copies of certification to tbis application..The Health Department will not use past years'records. � You mnst prnvide new wpies and maintain a 51e at your establishment. ,� 1. �-�V�' V�`rfi�l �17� 2. _�>: PERSON IN CHARGE: ' ` "� Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. � 1. �� 1��i�� l�'�� 2 � � �.� ,ALLERGEN CERTIFICATIONS: ' All food service establishments are required to have at least one full-time employee who bas Allergen certification, as flefined in the State Sanitary Code far Food Service Eslablishments,105 CNIR 590.009(G)(3)(a). Please attach copies of certificaiion to this application. The Health Department will not use past years'records. You mast pmvide new copies and maintain a file at your establishment. 1. ��/ +' b� d�/�d �[ �f � 2. � HEIMI,ICH CER'I'IFICA'TIONS: All food service estabtishments wifh 25 seats or more must ha�e at least one employee trained in the Heimlich : Maneuver on the premises at all times: Please list your epmploy�s trained in anti-chokmg procedures below aaa ' attach copies of employee certifications to ttris form. The Health Department will not use past years'records. � You mnst provide new copies and meintain a Sle at your place of bnsiness. ; 1. �7�� +�'✓�°�/�� 2 �tI V aQ-IV �t7 1V Gk � 3. _ 4. � + RESTAURANT SEATING: TOTAL'# { ; OFFICE USE ONLY Loncnvc: LICENSE REQUIltED FEE PERMI"I'# L[CENSE REQUIREIY FEE PERMIT# LICEN3E REQilIRED FEE PERMIT# I' B&B S55 CABIId S55 MOSEL 5110 —INN $55 CAMP S55 SW[tiiIvIING POOL S110ea I —L.ODGE' S55 �i'RAILER PARK �105 _WHIltLPOOL SI l0ea FOOD SERVICE: LICENSE REQUIItED FEE p, LICENSE REQUIItED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �0.10�0 SEA�'S Si25 � �v COITI'II�EN'I'AL ' $35 p NON PROFIT S30 >100 SEATS S2(KI �COMMON VIC. ' $60 �4 �VHOLESALE $80 — —RESID.KITCI�N S80 RETAIL SERVICE: LICES�SE REQUIItED aFEE PERMIT# ;LICENSE REQUIREDI FSE PERMIT# LICENSE REQUIRED FEE PERMIT# sq >25,000sq ft. ' 5285 VENDING-FOOD SZS _<25,OOOsq.ft. 5150 =PROZENDESSERT S40 �COBACCO SI10 NAMECHANGE: E15 AMOUNTDUE _ $ IS'�J.00 •••*•PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM:::.: . �J v k�'F��d�lJ��r ` ' anNmvis�TTON Under Chapter 152,Section 25C,Subsection 6,the Town;of Yarmouth is now required to hold issuance ox renewal of any license or permit to operate a business if a persoln 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 INSURANGE ATTACHED OR� WORKER'S COly1P.AFFIDAVIT�IGNED AND ATTACHED Town of Yarmouth ta�ces and fiens must be paid prior to�[enewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES �_ N� MOTELS AND OTHER LOIkGING ESTABLISIIMENTS TRANSIENT OCCUPANCY: For purposes of the limit,ations of Motel or Hotel use,Transient occupancy shall be limited to the temporary and short term occupancy,ordinairily and customarily associat�with motel and hotel use. Transient occupants must have and lie able to demonsbrate that they maintain a principal place of residence elsewhere.Transieat occupancy shall generally refer to continuous occupancy of not more than tivrty(34)days,and an aggregate of not more than ninety(94)days within any six(6)month p�od. U�of aguest unit as aresidence or . dwelling unit sha11 not be considered ti'ansient. Occupancy that is subject to the collection of Room Occupancy Excise,as defined in M.G.L.c.64G or 830 CMR b4G,as amended,shall generally be considered Transient POOLS POOL OPENiNG:Al[swimming,wading and whu'lpoois which have been closed for the season must be inspected by the Health Depazhnent prior to opemng. Contact the�ealth Department to schednle tLe mspection three(3) days prior to opening.PI.EASE N01'E:People are NOrI'allowed to s�t in the pool area until the pool has bezn inspected and opened. POOL WATER TESTING: The water must be tested fior 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 CLOSTNG:Every outdoor in ground swimming�ool must be drained or covered within seven(7}days of I'� closing. � FOOD SERVICE � SEASONAL FOOD SERVICE OPENING: All food service establishments must be inspected by the Heaith Deparhnent 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 Yarmouth must notify the Yarmouth Health Departrnent by filing the ; zequired Temporary Foad S�rvice Application form 72 hours prior to the catered even� These forms can be i obtamed at the Health Department,or&om the Town's website at www.yarmouth.ma.us under Health Departnient, � Downloadable Forms. � FROZEN DESSERTS: Frozen desserts must be tested by a State certified lab pridr to opening and monthly thereafter,with sample resuits submitted to the I�ealth Department. Fatlure to do so will result in the suspension or revocation of your Fmzen Dessert Permit until the above terms have been met � OUTSIDE CAF�S: Outside cafes(i.e.,outdoor seating with waiter/waitress service)>must have prior appmval firom the Board of Health. OUTDOOR COOI�TG: Outdoor cooking,preparation,or display of any food prodµct by a retail or food service establishment is prahibited. NOTICE:Permits run annually from Januazy 1 to December 31. 1T IS YOUR RESPONSIBILITY TO RETURN Tf�COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15,2017. ALL RENOVATIONS TO ANY FQOD ESTABI,ISIi�MENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO ANDi APPROVED BY'THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQIUIRE A STI`E PLAN. DATE: �D�I� ' � 7 SIGNATURE: �-/l�/�. !/��./�� PRINT NAME&TITLE: S��ll.�`�+r�,y�J �"I D�{ �GO.I�� x�.iaian� 1 z; il s` � . � The Commonwealth ofMassachusetts ='�� "�� Department of Industrial Accidents Office of Investigations � 1 Congress Street,Suite 100 Boston,MA 02114-2017 www mass gov/dia ', Workers' Compensation Insurance Affidavit: General Businesses Anplicant Information Please Print Legibly Business/Organization Name: �¢�► � �9 22-/9" Address: � 4' � yV1 � 1 , �Y'� City/Sta.te/Zip: � . �2b73 Phone #: SD� .�3��'T -y' �c�`� Are you an employer?Check the appropriate bog: Business Type(required): l.U t am a employer with�_employees(full and/ 5. ❑ Retail or part-time).* 6. L�fa�urant/Bar/Eating Establishment 2.0 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] 8• ❑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•0 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 corporarion 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 Com an Name: �V 1 G 1 y' P Y � � 1 �� Insurer's Address: Z ``Z� �"'¢j"'��k�/V� �ye �V� ��° ; City/State/Zip: � 2.L19 � D �' �Z '� 'i Policy#or Self-ins.Lic.# 6�ZU�j— �?�2iU�" g"y�o Expiration Date:��"� + Attach a copy of the workers'compensation policy declaration page(showing the policy number and egpiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead ta the imposition of criminal penalties of a j fine up to$1,500.00 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 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 ofperjury that the information provtded above is true and correc� Si ture: Date: Phone#: Official use only. Do not write in this area,to be completed by city or town offtciai 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 r ��* � VDAC � ZURICH WORKERS COMPENSATION AND EMPLOYERS LIABI�ITY POLICY TYPE AR INFORMATION PAGE WC 00 00 01 ( A) POLICY NUMBER: (6ZZUB-0762N00-8-17) RENEWAL OF (6ZZUB-0762N00-8-16) INSURER: AMERICAN Zt�ICH INSURANCE COMPANY NCCI CO CODE: 17965 1. INSURED: PRODUCER: , VARETIMOS, STEVE DBA CHAGNON INS AGENCY INC TAKIS PIZZA P 0 BOX 355 547 MAIIV STREET ROUTE 28 WEST YARMOUTH MA 02673 WEST YARMQUTH MA 02673 Insured is AN I NDI VI DUAL Qther wark places and identffication numbers are shown in the schedule(s) attached. 2. The policy period is from 05-22-17 to 05-22-i 8 12:�� A.M. at the insured's mailing address. 3. A. WORKERS COMPENSATION INSURAMCE: Part One of the policy appiies to the Workers Compensation Law of the state(s) listed here: MA s � � � B. EMPIOYERS LIABiLiTY INSURANCE: Part Two of the policy applies to work in each state listed in . _ item 3.A. The limits of our liabiliry under Part Two are: , = Bodily Injury by Accident: $ 10000o Each Accident ' � BodAy injury by Disease: $ 50000o p��y Limit ; s Bodily Injury by Disea�: S 100000 Each Employee ' = C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here: i � � =' COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06B � i � � ; � � � � ; � D. This policy indudes these endorsements and schedules: ' � SEE LISTIN6 OF EI�ORSENIENTS - EXTENSION OF INFO PAGE i � ' = 4. The premium for this pdicy wili be determined by our Manuais of Rules, Class'rfications, Rates and Rating ; _ Plans. Ali required-information is subject to verification and change by audit to be made A�A��Y. � � � DATE OF ISSUE: 04-17-17 WC ST A55IGN: MA OFFICE: ZURICH-ORLAN 809 ^��