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Home My WebLink AboutApplication and WC TOWN OF YARMOUTH BOARD OF HEALTH —° ' ED APPLICATION FOR LICENSE/PERMIT-2019 �y *Please complete form and attach all necessary documents by December 15,2018. l! , 2 Ei 2018 NOTE:ALL BUSINESSES WITH LIQUOR LICENSES MUST RETURN FORMS BY NOVEMBER Ir. Failure to do so will result m the return of your application packet. HEALTH DEPT. ESTABLISHMENT NAME: fiAf uERli'- F. 5740tL 61-4114,s(ffCCL TAX ID: LOCATION ADDRESS: 1/V0 ft16G;'c C11bcic1.L ftp TEL.#: S`d b' ` 777-79/� MAILING ADDRESS: tveST yn/sv7u7a! .04 0&"79 • E-MAIL ADDRESS: Pa;,iee-PA Cfff-rec/aital.K/2.44a.it f OWNER NAME: e A-Q aL t°C D Ri ue StpeieTE-A0 .fr CORPORATION NAME(IF PPLICAB E): DiwNnrt/.,2rrrec/n/ QL ,at1L ScriGtL DiIiiZicY MANAGER'S NAME: 'Q""ktCy TEL.#: ,re 351 76,;16 MAILING ADDRESS: .29A sntrte /hie S lu7N//Jiifaurti 4 P 0,1‘44 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. 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. 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 newcopiesand maintain a file at your establishment. 1. (1}�l'F//L 40.14F /Ale)F//ill) 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. C 1, 7f if i tr4-PFI/UP 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. C f 1. ii !' -�t1Y /Alb 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 listyour 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 co es and maintain a file at your place of business. 1. hE 2. 3. 4. RESTAURANT SEATING: TOTAL# 0644,F-45-48(n-0q 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 =TRAILERPARK $105 _WHIRLPOOL $110ea FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE P T# 0-100 SEATS $125 _CONTINENTAL $35 _NON-PROFIT $30 �! r<O7 >100 SEATS $200 _COMMON VIC. $60 WHOLESALE $80 —RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 •.ft. $50 >25,000 sq.& $285 VENDING-FOOD $25 —<25,111 sq.R $150 =FROZEN DESSERT$40 TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE = $ LtWAJ l/) 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 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.yannouth.ma.us 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 ITE PL DATE: f/��//b SIGNATURE: d % 6rt-tie' PRINT NAME&TITLE: QOLcy f - 0C4,0 ev(cE QjZ � Rev.1023/18 The Commonwealth of Massachusetts Department of Industrial Accidents fit Office of Investigations _18= 1 Congress Street,Suite 100 '11-11l= Boston,MA 02114-2017. - www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name:_Dennis-Yarmouth Regional School District Address:296 Station Avenue City/State/Zip:S. Yarmouth, MA 02664 Phone#: 508-398-7610 Are you an employer?Check the appropriate box: Business Type(required): 1. I am a employer with 3 employees(full and/ 5. ❑Retail or parttime).* 6. ❑Restaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnershipand have no 7. 0 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. 0 Entertainment theirright of exemption per c. 152, §1(4),and we have 10:❑Manufacturing • no employees. [No workers' comp.insurance required]** 11.❑Health are 4.❑ We are a non-profit organization,staffed by volunteers, with no employees. [No workers'comp..insurance req.] 12.N Other SQL tin-a/CX "Any-applicant that checks box 41 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: Mi-d-west Employers Casualty • Insurer's Address:,14755 N Outer 40 Rd It 300 City/State/Zip: Chesterfield, MO 63017 Policy#or Self-ins.Lic.# EWC006911 Expiration Date: 7/01/2019 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 MOL 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,u the pain d penalties of perjury that the information provided above is true and correct. Signature: Date: t// J/ a Phone#: S-65" 39Y - 76,4 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 Excess Workers°Compensation fin Midwest Binder Employerl CaSuaity =1.en4:0, instarolq Midwest EmPleYere-Castially Company Insurad; DenrliS YIrrooutti Regiort44 School Eitiefita. FrOtioy ilember7 Effective Cialha: 157e3112018 Quote Nigilliber: 02.162,0, ExPinitiort Datal 01741128,19, Nr aMBEZ: MaSeSaChlilletiS Service Clonigairy. Cook 4 pompany, Box TOW% Lial-sirfiekr,MA Cie2te)40458 -dee thamroio.F.• orsement§: (aae alkcha ) SPECrEaC: air.,,drir.,Limit STATUTORY .%5seido Retention: 5450,000 Eisipsters Liability 1,krilt: ,OMIACKi AC,4431IEGIATA,: A.mrvate Limit sapoosice Agwagrala Retordion(Rata as a Pen tagra of htnrrial Nark*: mow, rmum Aggregale Retention: $850,0,51 Agpregote LostiOn: 1:46000 ATIV.;SAS'E; Potiq Estimated Parc& $33.631A00 Porgy 5a1imied Olorkar•Moura: Poiky Estireed Pet'C*ta: Polley Nana!Premium: $295,W kale as a PerostItsga of Nom eg Premium: 1525% Total Ealimiatee Policy Pramilon(indbilitio tat charges): $214542 Pao)/Mirai Pramitm $40,118 Deposit PrAFnium: $44„542 Damask Flat Chang*); NIA rhal DizeasZtpuric TA41,6412 Tarrorivn Risk.insurarge A=Or 20112: i:inoludad Tial Depnit DUB Etigile) / DiStOS=8 Midwest gmeloyees Cray Dela naCit E341 stemso WitMidwest Endorsement ent Schedule EnmpCavers.Cm:trail Binder Insurer, ' ete :anRioyarr•Ceaual, Con p n Roliq EifectkceDats. 071131.2i11,8 Lured_ Leri Yxrrn u h Re0Onal o%Dist Pao"E*alian NW; G7.71!? i0 P+DIiq# E OMB91 t 1c_w Inc u!r__t ae fr_lowincl EnLi reser ts;_ Cru18.11 Amendment tO Schaduke m 11 3 CME1-197 Policyholder D,scbsure Notice or Trtr rgriirrx Insutarice Noe i! L r al Date Prime i+e81201.8