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Home My WebLink AboutApplication and WC' RECEIVED ; ! � � � TOWNiOF YARMOUTH BOARD OF HEALTH APPLICATION FOR LICENS�/PE�'�`.- , _ �o� oEc �4 zo�7 `"'� * Please corn lete form asid attach all necess �d �� p .arY _: ',�e�nts by� � er 1 DEPT. Failure to�do sa will result in the return of youri application pac . � ESTABLISHMENT NAME: ` TAX ID: - LOCATION ADDRESS: -� { S'-}Y�,"(--��nr, p4,c��, TEL#• S7jA-3-�lY-3g2.� MAILING ADDRESS: ��Q .S' � r S'�, S� ��_�- So� (��a.��•►1 �. c�L�S�f' E-MAIL ADDRESS: / } OWNER NAME: CORPORATION NAME(I�'APPLICABLE): -- j MANAGER'S NAME: (,�,� TEL.#: - -3 Z �'� MAILING ADDRESS: �( POOL CERTIFICATIONS: The pool supervisor must be certi�e�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, Pool operators must list a minimum a�two employees currently certified in standard First Aid and Community Cardiopulmonary Resuscitation (CPR�, havmg one certified employee on premises at all times. Please list the employees below and attach copies of their certifications to this form.The I�ealth Department will not use past years' records. You must provide niew copies and maintain a file at your place of business. l. 2, 3. 4. FOOD PROTECTION MANAGERS '- CERTIFICATIONS: All food sei�vice establishments are r�quired to have at least one full=time iemployee 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 mnst provide new copies and m;aintain a file at your establishment. l. 2. PERSON IN CHARGE: : Each food establishment must have at�east one Person In Charge (PIC)on site during hours of operation. l. V� 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 State Sanitary Code for Food Service Establishrnents, 105 CMR 590.009(G)(3)(a). Please attach copies of certification to this applicatidn. The Health Deparhnent will not use past years' records. You must provide new copies and maintain a fle at your establishment. ' , � l._ 2� ' V 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 a11 times� Please list your employees trained in anti-choking procedures below and atta.ch c�p�es of employee certification5 to this form. The Health Department will not use past years' records. You must provide new copies and m�intain a file at your place of business. 1. 2, 3. 4. RESTAUI2ANT SEATII�fi�: TOTAL"#� _ t3o��6S�1�73-6� l�ou--nP-16� G6�� OFFICE USE ONLY � LODGING: 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$110ea. _LODGE $55 TRAILER PARK $l05 , _WHIRLPOOL $110ea. FOOD SERVICE; LICENSE REQUIRED FEE PERMIT# ;LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# I 0-]00 SEATS $125 �Cg_faS _CONTINENTAL $35 NON-PROFIT $30 >100 S�ATS $200 COMMON VIC. $60 ' —WHOLESALE $80 RETAIL SERVICE: ' —RESTD.KITCHEN $80 LICENSE It�QUIRED FEE PERMIT# '-LICENSE REQtJIRED P'EE PERMIT# LICENSE REQUIRED FEE PBRMIT# <50 sq.ft. $50 >25,000 sq.ft. $285 ; VENDING-FOOD $25 �<25,OOOsq.ft. $150 =� =FROZENDESSERT $40 ; �TOBACCO $110 ��_�p�'� NAM E CHANGE: $15 AMOUNT DITE _ $ �S '�J.�O *****PL�ASE TURN UVER AND COMPLETE OTH�R SIDE OF FORM***** � ADMINISTRATION � Under Chapter 152,Section 25C,Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal j of any license or permit to operate;a business if a person or company does not have a Certificate of Worker's � Com pensation Insurance. THE A'1�TACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED ' ' OR WORKER'S �OMP. AFFIDAVIT SIGNED AND ATTACHED� � Town of Yaamouth taxes and liens must be aid rior to renewal or issuance of our ermits. PLEASE CHECK P P Y P APPROPRIATELY IF PAID: : YES� NO MOTELS�AP�TD OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For pitrposes 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 l�e 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 sha11 not be considered transient. Occupancy that is subject to the collection of Room Occupancy Excise, as defined in M.G.L. c. 64C�or;830 CMR 64G, as amended, shall generally be considered Transient. ' POULS I POOL OPENING:AIl swimming,��waiding and whirlpools wluch have been closed for the season rnust be inspected by the Health Department prior to operung. Contact the Health Department to schedule the inspection three(3) days prior to opening. PLEASE NOTE: People are NOT allawed to sit in the pool area until the pool has been inspected and opened. ' . POOL WATER TESTING: The water must be tested for pseudomonas,tota.l coliform and standard plate count by a State certified lab, and submittec� to the Health Deparhnent three (3) days prior to opening, and quarterly thereafter. � POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within severi(7)days of closing. ' ' FOOD SERVICE SEAS�NAL FOOD SERVICE O�'ENING: All food service establishments mus;t be inspected by the Health Department prior to opening. Please contact the Health Department to schedule the�ns�iection three (3) days prior to opening. � CATERING POLICY: ' Anyone who caters within t11e To�vn �f Yarmouth must notify the Yarmouth Health Department by filing the reqtured Temporary Food Service Application foim 72 hours prior to the catered event. These forms can be obtained at the Health Department,or from the Town's website at www.yaimouth.ma.us under Health Department, Downloadable Forins. FROZEN DESSERTS: . Frozen desserts must be tested by a Sta.�e certified lab prior to opening and monthly thereafter,with saxnple results submitted to the Healfh 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 witli waiter/waitress service),must have prior approval from the Board of Health. OUTDOOR COOHING: � Outdoor coolcing,preparation,or dis�play of any food product by a retail or food service establishment is prohibited. NOTICE:Permits run annually from J�.nuary 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 FO�OD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPiORTED TO AND APPROVED BY THE BOARU OF HEALTH PRIOR TO COMMENCEMENT. RENOVATTONS MAY REQUIRE A SITE PLAN. � ' G10 /� � � 0 ��.�"� DATE: I 2- �• 1�- SIGI�ATURE: PRINT NANIE&TITLE: �'h�2.f'�W ��-Q�,Q ,�, �p � Rev. 10/12/17 o . � . ; � �'lze Carnt�2otrweaf�Ii fl}`'.Nlassa�cliusetts ,3e�,��r:ie�t o,�`'�'';=d�=sa��r�d.��carde��ts �f�ee+vf Inv�s,�igufinr�s . � 1 eo�tgr�e�s,SYreet,,Suife 111t) Bos�Q�t,t�'A �1�'X I�1.��X 7 , wt�n�.�rrsss,�r��/r�in j Workers' Com�ensation Ins�uran.ce Aff'idavit: Gs�eral Susinesses Ap,pl�icant I�nfornnatiou �'Isase Print Le�ibiv �usi�ess/�r�anization Name: � t('�f��'�c� ��1 ��'� �� I I(y �ri ��`1,F�7 ��`/`� Adclress: ��:� � fl��-� "� �'� ,,.� r.��„�.� ��:`' ;_ � Ci�lState/Zip:�,��--%1 �7,4��Z( �'hons#: � �J� ` �'��°�_��'� A,re��ou an employer?Check the apgra�ariate lbox: Business Type(reqaired): i.� I am a employer with � empIoyees(fi�tI and/ 5. ❑Rstail or part-tivae).* 5. �Res�auran#/Bar/Eating Establishinent 2.� T am a sole proprietar or partnership and have no �, []Offics andlor Sa1es(incl,real estate,aufo,etc.) employ+e�s working�or me in any capacity. g, �Non-grofit [No workers'comp.insurance requixed] _ 3.� We are a corporatian and its officers have exercised 9. [�Entertainment their rieht of examption�sr c. 1 S2,§1{4),and we hava 10.�ls,�iar�ufacturing no employees.[1�To wcsrkers'coxnp.ia�surance required]* �� esirh Gare � 4.� We aXe a non-profit orgar�ization,staffed by volunteers, rvith no e�nptoyees.[No workers'�otnp.insurance req.j 12.�Q�E� *Any applieani that checks box#1 mast also�ill out tha section below showing their w orkers'compensation polioy infom�ation. � �*If the corporate officers have exempted thamselves,but the corFaor�tion hAs other smpioyees,a rvorkers'compensat�nn policy is required und such un argaaization should aheck box#1. X ant an errtployer tliat is provi ing workers'compensatfon irrsuranee,for my em,�doyees Belnw is tlte pvticy i�tfortnatioat. Insuranca Company N�me: Insurer's Adrlress: �� City/State/Zip: 1� � � Polioy#� r Self-ins.Lic.#_��g(..�'�� .�-t� � f � Expiratiqn Datec If�"'�'I��5 � #�ach a cop�o�'#he workers'compensation poliay declaratian page(sBflsving the po�icy nunnber and expiratian dats). Failure t�secure coverage as required under Section 25A of MGL c. 152 car�lead to the imposition of cxim9nal penalties�f a , fine up to$1,50U.04 and/ox one-year imprisonment,as F�vel]as civil penalties iu#he faz�n of�ST�P W�RK ORDER and a fine of up xo$2SU.�0 a day against#he violator. Be advised that a copy of this s#atement may be forwarded to the(3ffice of Investigatinns of tiie DIA for insurance coverage verification. I do liereby ce ' ,under tlie pains and,penaliles of perjury tlzat ilie iaifvrmrrtto��provided above fs true arid correct. Si ature• Date: � ' � � � _ a Phone#: Official use only. Dn nvt�vrite in fhus aret�to he co�npleted bp city or town of,fici�t� C�ty or To�ti�n: PSl'111i�IL10EDSE� � �ss�uina Authori#y(circle one)s 1.Board of Healfh 2.Baildi�g Department 3.CityfFnvYn Clerk 4,Licensing Board 5.Setectmeri's Q�ce G.Other Contact Person: �� www.mass.gov/dia � � WORI�CERS COMPENSATfON AND EMPL.OYERS LIAB1LlTf 1 lNSURANCE ROLiCY I.1•berty Mulual• I fNSURAHICE ; lNFQRMATlON PAGE 776 Berkeley SMret BwWn,MJ1021i6 � � Issued by Liberty lnsuranoe Corporation (a stock companyj 2181� Policy Number WA7-68D-46006�017 Issuing Offic�e Lewiston, ME Renewal Of WA7�E'i9D-+46U06�-016 Issue Date 10/18/2017 Account Number 9�60066 Sub Ac�ourtt 0�00 1. Insured ar�d Mai�ing Adtlress FEIN GlobaE Partners, LP NJ TIN 14192424200a 804 South Street,Sulte 500 Risk!D 91'i3853S3 PO Bax 91B1 WALTHA�1 MA 42AS3 � Status Lim'ited Partnership Other workplaces not shown above:5ee Item 4. PremEum-Extensfon of infarmatifln Page 2. Pollcy Perfod: The policy period ts from 1aJ01l2Q77 to 'ifl10'E/2018 12:01 A.M. stsndarci time at the Insured's Imailing address. I 8. Coverage i A. Workers Cornpensation Insuranoe:Part One of the palicy epplies to the Workers Cflmpensation Law of tfie I stetes listed here: CT FL GA IN U4 NfE MD IVEA MT NH NJ NY NC OR PA Rl TX � VT VA 3. �mp4oy��Liabli'ity 6nsuranc�: E'art Tvvo of the poticy�pplie�to evork in each state 6isted in ttem 3.A. The limits of our IiabiEity under Part Two are: 0 Bodily Injury by Accident $ 9�U00,000 each accident Bodily Injury by Dlsease $ 1,OE��000 policy limst Bodily InJury by Dlsease $ 1,000,000 each employee C. Qther States Insuranc�:Part Three of the policy appltes to the states,if any,fisted het�e: Al!States exoept those Ilsted in ltem 3.A and the Stafes of: ND OH WA WY D. This poiicy includes these endorsements and schedWes: See ltem 3.Coverage D-F�ension of Information Page 4. Premfum: The premium for this policy will be determined by our Manuats of Rules,Classifit:ahans,Rates and Rating Plans. AII informaticm requtred below 6s subjed ta veriflcatEon and diange by audit Classifications Code Premium Basis Totat Rate per$100 Estimat�At�uwal Number Es�imsted Annuai Remunera�on of Remuneration Premlum See Extension ofi informatton Page' Minimum Premium Totaf Estlmate�i Annual Premium $ Premium will be bi1led nnnuat Deposit Rremium $ Deposit Tax/Surdtarge/Assessment $ Producer 0002 000499 Countersigned ay Atrthorized Rep. (FLj LOCKTON COMPANIES LLC(DALfAS SERIES) 2'i00 ROSS AVE STE 1400 QALLAS TX 7�2fl76706 WC 00 00 41 A �1987 Nationat Caunal on Campensation Insuranoe,lnc. WC �0 DO 01 B (CA) Ed.07IQ1I2011 AII RighFs Rsserved t'age 1 af 1