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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 BUSIIVESSESWITHLI UORLICENSESMUSTRETURNFORMSBYNOVEMBERIS'". Failure to do so will res t m e return o your application packet. ESTABLISHMENT NAME: E- I d e t b r a LOCATION ADDRESS: S A YF S MAILING ADDRESS: E-MAIL ADDRESS: uiSIL 5, OWNER NAME: CORPORATION NAME QF APPLICABLE): MANAGER'S NAME: v MAILING ADDRESSA Ir (1 t i SLI POOL CERTIFICATIONS: 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. 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. 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 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. 1. IV a.i.y ``I�I �/SC.kc- 1 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation I. C1 kA M1)LD C,_ -,I 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. liCGL. j �1�11j C I 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 maintain a file at your place of business. 3. 4, RESTAURANT SEATING: TOTAL # � ()— RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT # <50 fL $50 =<25;sgA $150 NAME CHANGE: $15 LICENSE REQUIRED FEE PERMIT # >25,000 sq.fL $285 FROZEN DESSERT $40 LICENSEREQUIRED $EE PERMIT# _MOTSWIMMING POOL $110=7 _WHIRLPOOL $110e7 LICENSE REQUIRED FEE NON-PROFIT $30 —WHOLESALE $80 —WHOLESALE KITCHEN $80 LICENSE REQUIRED FEE PERMIT # VENDING -FOOD $25 TOBACCO $110 AMOUNT DUE = $ _S0,00 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT # B&B $55 $55 --LODGEINN 55 _CABIN $55 —TRAILER—CAMP PARK $1$05 FOOD SERVICE: LICENSE REQQUIRED FEE PERMIT # LICENSE REQU FEE PERMIT # 0-100SEAIS $125 RED _CONTINENTAL $35 >100 SEATS $200 _COMMON VIC. $60 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT # <50 fL $50 =<25;sgA $150 NAME CHANGE: $15 LICENSE REQUIRED FEE PERMIT # >25,000 sq.fL $285 FROZEN DESSERT $40 LICENSEREQUIRED $EE PERMIT# _MOTSWIMMING POOL $110=7 _WHIRLPOOL $110e7 LICENSE REQUIRED FEE NON-PROFIT $30 —WHOLESALE $80 —WHOLESALE KITCHEN $80 LICENSE REQUIRED FEE PERMIT # VENDING -FOOD $25 TOBACCO $110 AMOUNT DUE = $ _S0,00 *****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 V OR / WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED ✓ Town of Yarmouth taxes and liens must be paid pri 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 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 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.maus 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 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 1 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 APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE SITE AN. DATE: � lj T p SIGNATURE: PRINT NAME & TITLE: Lows F --pas AIA. a jau QDDArs^a a.5 c it Rev. 10/23/18 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations kvi I Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Elder Services of Cape Cod and the Islands Address:68 Route 134 City/State/Zip: South Dennis, MA 02660 Are you an employer? Check the appropriate bog: 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.] Phone #:508-394-4630 Business Type (required): 5. ❑ Retail 6. ❑ Restaurant/Bar/Eating Establishment 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) 8. ❑✓ Non-profit 9. ❑ Entertainment 10. ❑ Manufacturing 11.0 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. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: �ame: (ILL•- FCI rr)N►,0'_ Insurer's Address: k A L �Lv_ ,NJ oy ,,jj, Aj r. &2 MC 4411 � r� City/State/Zip: �� r, qL�l., C �Vv,, pn _ M 6 ,-b Policy # or Self -ins. Lie. # () �) Q D I" 13 0 �tExpiration Date: l �-7 / / 2/ / l 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 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,wqx ?r thep ns and penalties ofperjury that the information provided above is true and correct. ,/ -- Date: it/ 7/10 Phone #: C Soy } L� 006 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 VDAC Tx WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY TYPE AR INFORMATION PAGE WC 00 00 01 ( A) POLICY NUMBER: (GS60UB-BH20309-3-18) RENEWAL OF (6S60UB-8H2O309-3-17) INSURER: HARTFORD UNDERWRITERS INSURANCE COMPANY 1. NCCI CO CODE: 10456 INSURED: PRODUCER: ELDER SERVICES OF CAPE COD AND HUB INTERNATIONAL NEW THE ISLANDS INC 265 ORLEANS RD 68 ROUTE 134 NORTH CHATHAM MA 02650 S DENNIS MA 02660 Insured is A CORPORATION Other work places and Identification numbers are shown In the schedule(s) attached. 2. The policy period Is from 07-07-1 a to 07-07-19 12:01 A.M. at the Insured's malling address. 3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers Compensation Law of the state(s) 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 our liability under Part Two are: Bodily Injury by Accident: $ 1000000 Each Accident Bodily Injury by Disease. $ 1000000 Policy Limit o_ Bodily Injury by Disease: $ 1000000 Each Employee C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here: COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06B oma. D. This policy Includes these endorsements and schedules: o SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All required information Is subject to verification and change by audit to be made ANNUALLY. DATE OF ISSUE: 06-08-18 WC ST ASSIGN: MA OFFICE: ORLANDO DA HTFD 05G PRODUCER: HUB INTERNATIONAL NEW 24P4N 0111362