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HomeMy WebLinkAboutApplication and WCa TOWN OF YARMOUTH BOARD OF HEALTH APPLICATION FOR LICENSE/PERMIT - 2019 * Please complete form and attach all necessary documents by December 15, 2018. NO ALL BUSINESSES WITHLIOU�OR LICENSESMUSTRETURNFO B N V BER 15-. Failure to do so will result inthereturn of your application packet. E-MAIL ADDRESS:QI OWNER NAME: CORPORATION NAME (IF MANAGER'S NAME. "/j MAILING ADDRESS:15ia 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. 1.�1L1 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. 1.1%A 2. 3. 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._Ai%A 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 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. W1r2 MMFWI HER%4LICH 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. . / 2. 3 3. / 4. RESTAURANT SEATING: TOTAL # RETAIL SERVICE: OFFICE USE ONLY LODGING: O $150 7 NAME CHANGE: LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT # B&B $55 CABIN $55 _CAMP —LODGE $55 _TRAILER PARK $%5 FOOD SERVICE: LICENSE REQUIRED FEE PERMIT # LICENSE RE ED FEE PERMIT # SEA>106 SEATS $200 _COMMON VA $60 RETAIL SERVICE: LICENOSEqq 8 QUIRED FEE PERMIT # =025,000 sq:B. O $150 7 NAME CHANGE: $15 LICENSE REQUIRED FEE PERMIT # >25,000 sq.8. $285 FROZEN DESSERT $40 LICENSE REQUIRED FEE PERMIT # MOTEL $110 _SWIMMING POOL $110ea. _WHIRLPOOL $110ea LICENSE REQUIRED FEE PERMIT # —NON-PROFIT $30 WHOLESALE $80 -RESID. KITCHEN $80 LICENSE REQUIRED FEE PERMIT # VENDING -FOOD $25 TOBACCO $110 AMOUNT DUE= $ ISO. 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 OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED. Town of Yarmouth taxes and liens must be paid prior 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 A SITE PLAN. DATE: It/J.6. SIGNATURE: PRINT NAME & TITLE: iWi l ( iAM At A+, PSS r U� � �r t/til WFA T Ja. Rev. IM3118 United Wisconsin InsuranceCompany Member Gf AF Gmup A. STOCK COLVAINY Insurer ID No (s): 24244 United Wisconsin Insurance Company 15200 West Small Rd New Berlin, WI 53151-0000 Workers Compensation and Employers Liability Insurance Policy Carrier Policy #: Policy Period WC515-00154-018 05/01/2018 to 05/01/2019 Information Page FEIN: 203189103 New Agreement Item 1: Named Insured and Address Agency HR Service Group LLC dba LCF Sunz Insurance Solutions, LLC Hunta Inc dba 1301 6th Avenue West Beef Jerky Outlet West Yarmouth Bradenton, FL 34205 3905 National Drive Suite 400 Burtonsville, MD 20866 Other Workplaces Not Shown Above: See Additional Locations Additional Named Insured: See Additional Named Insureds if Applicalbe Type of Business: Corporation Federal ID#: 203189103 Risk ID: NCCI / Bureau #: 24244 Unemployment ID #: File #: 515000000154018 Item 2. Policy Period The policy period is from 12:01 AM on 05/01/2018 to 12:01AM on 05/01/2019 based on the insured's mailing address time zone. Item 3. Coverage: A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed: 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 $ 1,000,000.00 each accident Bodily Injury by Disease $ 1,000,000.00 policy limit Bodily Injury by Disease $ 1,000,000.00 each employee C. Other States Insurance: All states except HI,ND,OH,WA,WY D. This policy includes these endorsements and schedules: See Endorsement Schedule Item 4: Premium The Premium for the policy will be determined by our Manual of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Classifications Code # Premium Basis Rate Per $100 of Estimated Annual Premium Total Estimated Remuneration Annual Remuneration Minimum Premium Form # WC000001A (Ed. 08/10) See Schedule of Classifications on Following Page(s) Prorated Premium Estimated Annual Premium Countersigned by:� Expense Constant © Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved. Page # 1 of 1