HomeMy WebLinkAboutApplication and WC t
a TOWN OF YARMOUTH BOARD OF HEALTH
APPLICATION FOR LICENSE/PERMIT-2019
*Please NOTE:ALL BUSINESSESletefWITH LIQUOR LICENSESand attach all MUST RETURN FORMS BY NOVEMBER 15m. 1''1-j cuments by December 15,2018. "(-1: '.
Failure to do so will result in the return of your application packet.
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ESTABLISHMENT NAME: 01/4-r 4Cffc.l Sc,�/Y111.2 <2://791 1- TAX ID: ~
LOCATION ADDRESS: qqo //1/G/',.af C IEU. RV TEL.#:
MAILING ADDRESS: WeST y 7/,'14u771O.26-73
E-MAIL ADDRESS: Pd01ef I C d y-te yiodal,J4/a.ma.LLS
OWNER NAME: C IL u,f o; .4 y r si.K pc'X i .w 3nW7"
CORPORATION NAME(IF APPLICABLE): DP f 1/424.0407-1 RE6 twAl, SC o. ST 1CT
MANAGER'S NAME: ?00wawe-is TEL.#: z8- 396--76 16
MAILING ADDRESS: ..29b phInlcuTN. ,-hfj 4,2f'65/
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
yearsrecords. 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 new copies and maintain a file at your establishment.
1. 14/4141264 !/ 1 CE6Li l) 2.
PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation.
1. 4-4142C1- V! 5e6?rL.r o 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,a fnq maintain a file at your establishment.
1. kit/AWL LA SCE1U 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.
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1. ` 2 c1 S CL7}�6v 2.
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 _MOTEL $110
INN $55 CAMP— $55 SWIMMING POOL$110ea.
L ODGE $55 TRAILER PARK $105 _WHIRLPOOL $110ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE P #
0-100 SEATS $125 _CONTINENTAL $35 NON-PROFIT $30 rO�
>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 sq ft. $50 >25,000 sq ft. $285 VENDING-FOOD $25
-<25,000 sq.ft. $150 FROZEN DESSERT$40 TOBACCO $110
NAME CHANGE: $15 AMOUNT DUE = $ 1/1//3/1/5)
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.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 m the suspension or revocation of your Frozen Dessert Permit until the
above terms have been met.
OUTSIDE CAFÉS:
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 COMMENCE/ENT. RENOVATIONS MAY REQUIRE TE PL
DATE: 17 �/7 SIGNATURE: REQUIRE
dLitecA
PRINT NAME& !TILE:ILE: R W routK.1 ROD s VEC Q.
Rev.IOR3na
The Commonwealth of Massachusetts
Department of Industrial Accidents
■
=-'y 9� t Office of Investigations
—i = 1 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:.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 `' employees(full and/ 5. ❑Retail
or part-time).* 6. ❑Restaurant/Bar/Eating Establishment
2.❑ I am a sole proprietor or partnership and-have no 7. []Office and/or Sales(incl.real estate,auto, etc.)
employees working for me in any capacity.
[No workers'comp.insurance required] S. [I 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 10:0 Manufacturing •
no employees. [No workers'-comp.insurance required]** 11. Health Care
4.❑ We are a non-profit organization,staffed by volunteers,
with no employees. [No workers' comp..insurance req.] 12.N1 Other S,(flx't- )i J 77Lick
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: Midwest Employers Casualty
Insurer's Address: 14755 N Outer 40 Rd # 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 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,under the pain dpenalties of perjury that the information provided above is true and correct.
Signature: ( 60.Et Qiti`E.AA Date: ///9-6/( I
Phone#: 5-6&' b' - 76)6
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
d Binder
L A Employers COStPDVy
insurer. MIttilivat lemplielers Casualty Company
Insured: DarmAS IllmoiAttl Regional School District
Policy Number, EVirCitlaS911 Effectiwe Oats: C17101/2.018
Quote Number: 02.16214 ExPirgitfOrt Date:
Nan agasz Messactr_aetis
Serrta
Cony Coir ratenparly, Inc.
Pa Hat TO53
MarshfieV MA 02.0504038
N,att'oes the : (see.111..ohla,1:1
.SPEcC: SpeOafir.Limt,
STAIITTORY
'Sold 5c Reteritim: $450.004
Emp4fers Liability Writ 51,0a0,000
EAtrieLinn
sa,CCOOOD
Aggragaea RJim{Pb as a Peti-ie Ufrn2I Pia'niun* 2g3,074
fairrium Arte Raination: ,$950,0e1
Aggregota Lose Limitation: $450,0015,
RATING,BASE; Polloy Esinletkail Payroit $32,651 MO
Poky s-lit-Iteited Worker Mum:
Pokey E.slimateti Per CAoila:
NA
Pcilk Narral Pnernium:
$295,95.0
Rale as a Peri of Nortrig Premium: 1525%
Total Esiinkatea Polley Prernium(indudiN fiat Marge* $44.542
Paw taikerIUrit Prentagn:
Deposit Piernium:-
544542
Decesit It Charge(s):
iQi
httA
cinnositpuo!
$41-4,542
Tarroriwi Risk insurame Avg of 2002:
tincluded ko Total Deposit Due ab )
54144A 41-
0810aM18
MidAsst 8mployera Cutty
nate
2INCne34
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Iviiidwest Endorsement Schedule
Blindor
11.„ Einployeirs Casvally
Instffe.r; Mithrievi 5inplgyt.5trz.Casuglity Corwerry Policy Effisiothie Cute: 07M112018
1.4t urect Eit4inia Yenroulh ROMs'Sch001:Dittril Paw Eviralion Date; D7PJ141019
Policy a: EVo0tos9lt
s the flwjnq
C1103.1.1 .Amendittaryt to Schedule.Hemii
CMEI-i 97 Policyholder Clisolcsure Notice of Toirorisirt Institance
Pero tI Date Prim WVOSi.2018