HomeMy WebLinkAboutApplication and WC TOWN OF YARMOUTH BOARD OF HEALTH
4 APPLICATION FOR LICENSE/PERMIT-2819
*Please complete form and attach alldocuments mktmkt/km=
NOTL ALL BUSSES
Failure to resoltWITH ein the IC necessary application on packet Ir.
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ESTABLISHMENT NAME: VW) CA Pe LC1'1C. Get AX ID:
LOCATION ADDRESS: tct 5 Whae.s Nur - 501/42.71A-y tau. TEL.#: 503-3414-3511
MAILING ADDRESS:
E-MAIL ADDRESS: Sob viva c a.¢e,ctuek,,t, . c-av1
OWNER NAME: 'P•ob& Ma.le faX4t-i
CORPORATION NAME(IF APPLICABLE):
MANAGER'S NAME: TEL.#: 5-0g"-2-7g- -r4
-05
MAILING ADDRESS: L aticto IARCtiocr S .'•fO t Ati(-.
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. ��eAAVI�L. 2. �A.(•e ut36
1 y = c h)Pool operators must list a minimum of two employees currently certified in standard First Aid and Community > c"".
Cardiopulmonary Resuscitation(CPR),having one certifiedloyee on at all times. Please list the r c.
employees below and attach copies of their certifications to this form.The 1' Department will not use past 2 co in
years'records. You must provide new copies and maintain a file at your place of business.
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FOOD PROTECTION MANAGERS-CERTIFICATIONS: a71.
All food service establishments are required to have at least one full-time employee who is certified as a Food "t
Protection Manager,as defined in the State Sanitary Code for Food Service Establishments,105 CMR 590.000.
Please attachcopies of certification to this "`�
application. The Health Department will not use past years'ra�o�rds.
Yout
mast provide^sew copies and maintain a file at your establishment.
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PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation.
1. be.►} J A4iSk2.
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)(3Xa). 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 ilk at your establishment.
1. 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 limes. Please list your employees trained in anti-choking procedures below and If
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.
1.3. �CGQ altaSA L..
2. -t- ecC_.
RESTAURANT SEATING: TOTAL# 4.
B D tF-(' -C3S -65
OFFICE USE ONLY
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT S
B&B—INN $55$55 _CABIN $55 MOTEL $110
-=LODGE $55 CAMP $55 'SWIMMING POOL$110ea.
=1RAn.FRPARK $105 Twumu'oOL $110ea.If/g..824
FOOD SERVICE: '
LICENSE REQUIRED SEATS $
F E 1i'r LICENSE REQUIRED FEE PERMITS LICENSE FEE Pte#
1—>100 SEATS $200 . _CONTINENTAL 5 NON-PR
COMMON VIC. NO ....ippilia 0 —WHOLESALE MO
RETAIL SERVICE:
LICENSE REQUIRED FEE PERMITS LICENSE REQUIRED FEE PERMITS LICENSE REQUIRED FEE PERMIT S
<50, A. $50 >25 000 VENDING-FOOD$25
=525,i II sq.ft. $150 =�'ROMENDEESSERT$40 _TOBACCO $110
NAME CHANGE: $15 AMOUNT DUE = S VIS.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 to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID: /
YES V 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' by the
Health prior to opening. Contact the Health Department to schedule the inspection three(3) +s 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
-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
Depwhived 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
Temporary Food Service Application form 72 hours prior to the catered event These forms can be obtained at the Health
t
Department,or from the Town's website at www.yamou*h.ma.us under Health Department,Downloadable Forms.
FROZEN DESSERTS: •
Frozen desserts must be tested by a State certified lab prior to opening and monthly ttaereafter,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 CAFES:
Outside cafes(Le.,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 toDecember 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 CO N EMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
DATE: 11 I l ) SIGNATURE:
PRINT NAME&TITLE: R.06& t'A'�1 tjec,06 'R-estzteitk
Rev.1083/18
The Commonwealth of Massachusetts
�� Department of Industrial Accidents
_
'�k��'�r Office of
�rt 1 Congress S`t�eei;Suite 100
'= _ Boston,MA 02114-2017.
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Auulicant Information Please Print Legibly
Business/Organization Name: A 0 ' L f✓ , .e
'
Address: 1,13 `vNM $ Tce. tt� .( `
City/State/Zip: A YWkO V *ie#:dn5o N`c' -31,1
Are you an employer?Check the appropriate box: Business Type(required):
1.® I am a employer with 2t employees(full and/ 5. Q Retail
or parttime).* 6. 0 Restaurant/Bar/Eating Establishment
2.❑ I am a sole proprietor or partnership and have no 1 ❑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. Ei Entertainment
their right of exemption per c. 152,§1(4),and we have 10.0 Manufacturing
no employees.[No workers'comp.insurance required]"
4.❑ We are a non-profitorganization,staffed by volunteers, 1.0 Health Care _ `
with no employees.[No workers'comp..insurance req.] 12.® V'
Other `- 1(
purpose 2'�Earl
*Any applicant that checks box#1 must also fill out the section below showing tear waders'compensation policy information.
**If the corporate offices have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an
organization should check book#1.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information.
Insurance Company Name: R Ck11A0'o t C-ovlti b , Ivy c- '
Insurer's Address: � r" ` tam s1
g Ste • 12.
City/State/Zip: C.,k e-IJ -I , Okt 44 I t4
Policy#or Self-ins.Lie.# TW e- 3(55 8 70 Expiration Date: 20 J lq
Attach a copy of the workers'compensation policy declaration page(showing the policy number an 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 pains and penalties of perjury that the information provided above 1s true and correct
dr
Signmue: 1 Date: k't I/ill€
Phone#: 5O - 314 3 511
Official use only. Do not write in this area,to be completed by city or town of ciat
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.Cityffown Clerk 4.Licensing Board 5.Selectmen's Office
6.Other
Contact Person: Phone#:
www.mass.gry/dia
NP 101512265
NOTICEk, NOTICE
TO TO
EMPLOYEES . - EMPLOYEES
The Commonwealth of Massachusetts
DEPARTMENT OF INDUSTRIAL ACCIDENTS
600 Washington Street, Boston, Massachusetts 02111
617-727-4900 —http://www.mass.gov/dia
As required by Massachusetts Genera Law, Chapter 152, Sections 21, 22, 30, this will give you notice
that I (we) have provided for payment to our injured employees under the above-mentioned chapter by
insuring with:
Technology Insurance Company, Inc.
NAME OF INSURANCE COMPANY
800 Superior Avenue East, 21st Floor, Cleveland, OH 44114
ADDRESS OF INSURANCE COMPANY
TWC3734583 9/20/2018 to 9/20/2019
POLICY NUMBER EFFECTIVE DATES
Maguire Insurance Agency, Inc. One Bala Plaza, Bala Cynwyd, PA 19004 (800) 873-4552
NAME OF INSURANCE AGENT ADDRESS PHONE#
Mid-Cape Racquet & Health 193 White's Path, S. Yarmouth, MA 02664
EMPLOYER ADDRESS
EMPLOYER'S WORKERS' COMPENSATION OFFICER(IF ANY) DATE
MEDICAL TREATMENT
The above named insurer is required in cases of personal injuries arising out of and in the course of
employment to furnish adequate and reasonable hospital and medical services in accordance with the
provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the
injured employee. The employee may select his or her own physician. The reasonable cost of the
services provided by the treating physician will be paid by the insurer, if the treatment is necessary and
reasonably connected to the work related injury. In cases requiring hospital attention, employees are
0 hereby notified that the insurer has arranged for such attention at the
NAME OF HOSPITAL ADDRESS
TO BE POSTED BY EMPLOYER