The URL can be used to link to this page

Home My WebLink AboutApplication and WCTOWN OF YARMOUTH BOARD OF HEALTH APPLICATION FOR LICENSE/PERMIT - 2019 * Please complete form and attach all necessary documents by December 15 2018. NOTE: ALL BUSINESSES WITHL�I UOR LI ENSESMUST RETURNl� S�BYMVEMBER IS'". Failure to do so will result eour application packet. ESTABLISHMENT NAP LOCATION ADDRESS: MAILING ADDRESS:_ E-MAIL, ADDRESS: P__00T" OWNER NAME: �005 r lA"T&R, -,A-b&yA i CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: 1 c- TEL.#: -2 7 Y " 2l 2 , Su 37 MAILING ADDRESS: 20 h-AL LA&ra -1- L A— i f '2 _ _T' iV OA7 ,3a 02- i �,- POOL CERTIFICATIONS: M D CD The pool supervisor must be certified 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. 2, 1. 2. M 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 z 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 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 must provide new copies and maintain a file at your establishment. 2. PERSON IN CHARGE: a -: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. k-a t� Sz s 4 61 y�2/ 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 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. p (lj HEIMLICH CERTIFICATIONS: (A 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 file business. provide new copies and maintain a at your place of C1 3. 4. RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT # B&B $55 CABIN $55 $110 INN $55 —CAMP $55 _MOTEL SWIN54ING POOL $110ea. _LODGE $55 TRAILERPARK $105 _WHIRLPOOL $1loea. FOOD SERVICE: LICENSE REQUIRED FEE 0-100 SEATS PERMIT # LICENSE REQUIRED FEE PERMIT# LICENSE RE JIBED FEE $125 > _100 SEATS $200 _CONTINENTAL $35 _COMMON VIC. $60 1 NON-PRO�IT $30 �V WHOLESALE $80 —RESID. KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT # <50 sqq.ft. $50 =<25,000sq.& $150 >25,000 sy.ft. $285 TROZENDESSERT VENDING - FOOD $25 ' $40 TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE _ $ 3O ,Qo *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** 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 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 tern 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 transient. Occupancy that is subject to the collection of Room Occupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 640, as amended, shall generally be considered Transient. POOLS POOL OPENING: All swimming, wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. 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 area until the 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 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. 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 caters within the Town of Yarmouth must 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, Downloadabie 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 waitertwaitress service), must have prior approval from the Board of Health. OUTDOOR COOKING: Outdoor cooking, preparation, or display of any food product by a retail or food service establishment is prohibited. TOBACCO PRODUCT PERMIT CAP A tobacco permit holder who has failed to renew his or her permit within thirty (30) days of the previous year's permit expiration date is considered an expired license, and the tobacco license cap is reduced. NOTICE: Permits run annually from January I to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 15, 2018. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPRO D BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE S AN. DATE: ��' l q -1 b SIGNATURE: �,� PRINT NAME & TITLE: M S) d-'YN NAl eN l 571eA If t Rev.1=311a The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ' 1 Congress Street, Suite 100 Boston, MA 02114-2017. www.mas&gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Le¢ibly Business/Organization Name: Address: City/State/Zip: Are you an employer? Check the appropriate box: 1. ❑ I am a employer with employees (full and/ . or part-time)-* 2. ❑ I am a sole proprietor or partnership and have no employees working for me in any capacity. (No workers' comp. insurance required] 3. ❑ We are a corporation and its officers have exercised their right of exemption per c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required]* 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. -insurance req.] 0 Phone #: Business Type (required): 5. ❑ Retail 6. ❑ RestaurantlBar/Eating Establishment 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entdrtainment 10. ❑ Manufacturing I1.❑ Health Care 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. lam an employer that isproviding workers' compensation insurance for my employees: Below is thepolicy information. Insurance Company Insurer's Address: City/State/Zip: Policy # or Self -ins. Lie. # Expiration Date: 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 a 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 ORDER and a fine of up to $250.00 a day against the violator. Be adpised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance a verification. I do hereby certify, under the an of perjury that the information provided above is true and correct Phone #: b/ Offwkd 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/ft NOVA Casualty Company A STOCK INSURANCE COMPANY CAS JALiY COMPANY 726 Exchange Street, Suite 1020, Buffalo, NY 14210 1-866-633-6945 WORKERS COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE POLICY INFORMATION PAGE NCCI Company No. 14191 ITEM 1. NAMED INSURED ANn MAII 11dr. Annoccc. YARMOUTH MOOSE LODGE #2270 PO BOX 186 SOUTH YARMOUTH MA 02664-0186 LODGE2270@MOOSEUN ITS. ORG POLICY NO. LFR—WK-10001335-00 RENEWAL OF: LFR—WK-0012469-2 AGENT NAME AND ADDRESS- LOCKTON AFFINITY, LLC. P.O. BOX 410679 KANSAS CITY, MO 64141-M I AGENT NO. 10071 LEGAL ENTITY: NON PROFIT ORGANIZATION OTHER WORKPLACES NOT SHOWN ABOVE: SEE NAME AND LOCATION SCHEDULE ITEM 2. POLICY PERIOD: From: 12-15-2017 To: 12-15-2018 Effective 12:01 A.M. Standard Time at the Insured's mailing address. ITEM 3. COVERAGE: A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation 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 liability under Part Two are: Bodily Injury by Accident: $ 100,000 each accident Bodily Injury by Disease: $ 500,000 policy limit Bodily Injury by Disease: $ 100,000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: ALL STATES EXCEPT ND, OH, WA, WY AND STATES DESIGNATED IN ITEM 3A D. This Policy includes these Endorsements and Schedules: SEE SCHEDULE OF FORMS AND ENDORSEMENTS ITEM 4. PREMIUM: The premium for this Policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required on the Workers Compensation Classification Schedule is subject to verification and change by premium adjustment or audit. Minimum Premium: $ 212 (MA) Total Estimated Policy Premium: $ 894 Audit Period: ANNUAL Deposit Premium: $ 894 Issuing Office: WINDSOR, CT Issued Date: 10-09-17 WC 60 00 01 A 0615 "Includes copyrighted material of National Council on Compensation Insurance with it's permission" INSURED