HomeMy WebLinkAboutApplication and WC TOWN OF YARMOUTH BOARD OF HEALTH yikcu.)
'� i APPLICATION FOR LICENSE/PERMIT -2019 J U L 1 1 2019
* Please complete form and attach all necessary documents by Decem er , `MD E PT.
NOTE:ALL BUSINESSES WITH LIQUOR LICENSES MUST RETURN FORM ,d->' "°0J 47 4:i B ' i ` ,;
Failure to do so will result in the return of your application packet 4c1- " .,
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ESTABLISHMENT NAME: i134s5 P- 4Z‘)1 elf' YGcc* Club TAX ID: ( 'Lt=
LOCATIONADDRESS:22 "+-',Q.oT4{1v-sC-i1{A,wok WAY 'S Mac. TEL.#:Sot-3Q$•`r )
MAILING ADDRESS: .D.'-t�vo)c If-32 50.�}e. YekenictA. 1 1,..(14 02(cfccf.
E-MAIL ADDRESS:tr oe. bxssrw2r'ticLe_ dcb.orce..
OWNER NAME:
CORPORATION NAME (IF APPLICABLE):
MANAGER'S NAME:€‘2,i��1,D tU. e-C-ec.,-. =Pec54-- �nmo,�
► re 6Css TEL.#: -3bLi-4:642
MAILING ADDRESS: 2c' kbvv e Arcs Lt.) nriis 1.-Lig D 2(04-0
4OOL CERTIFICATIONS:
he pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated
—Pool s ` 4 • P at u s (Wilk ci lilt'. I to iris orm:
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 mustprovidenew copies and maintain a file at your establishment. /I II
1. Al CV1ktt e. D o 2. -'0 2. �ad e./l til(Q H-0 vv S O n
PERSON IN CHARGE:
Eachfoodestablishment must` hve at least one Person_In Charge (PIC) on site during hours of operation. _,
1. K�ii i �-- <t -- ,
2. (11/74-%k'W (- 60I
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. (LI/2il(J.e--PA ,11 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.
17(, )410471y1. r rn m l f) 2.
3. 4
RESTAURANT SEATING: TOTAL# ISS— 6044F-15:-A y57-0`1 i
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 TRAILER_ PARK $105 _WHIRLPOOL $110ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PIT
0-100 SEATS $125 _CONTINENTAL $35 I NON-PROFIT $30 PIT
0-100
>100 SEATS $200 _COMMON VIC. $60 WHOLESALE $80
RETAIL SERVICE: RESID.KITCHEN $80
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
<50 sq.ft. $50 >25,000 sgil. $285 VENDING-FOOD $25
_<25,000 sq.ft. $150 -FROZEN DESSERT $40 _TOBACCO $110
NAME CHANGE: $15 AMOUNT DUE = $ 30.00
*****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 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.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 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 COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ;'
DATE: 7 f r l /l 9 r ►�
SIGNATURE: ,'A ALA
PRINT NAME & TITLE: I E k-z r' 1 i
Rev.10/23/18
The Commonwealth of Massachusetts
l■ Yr Department of Industrial Accidents
Office of Investigations
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: i dSS i le( VOT C/ala
Address: ?� F ifi irl 4om toy
City/State/Zip: S )10 am 1431 Phone #: (e- -/72O
Areyo an employer? Check the appropriate box: Business Type(required):
1. I am a employer with yemployees(full and/ 5. ElRetail
or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment
2.n 1 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] 8 on-profit
3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment
their right of exemption per c. 152, §1(4), and we have 10.❑ 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.E Other
*My 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: redera 1 Sns(I(ona- COYnPc,
Insurer's Address: ,q (tJ/JG/f 1,k
City/State/Zip: YI eIA. hL(/WA CI OOP/
Policy#or Self-ins. Lic. # <90 7172 '9, ?- d' Expiration Date: &/25-�2 D
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 weltaservii 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 is true and correct.
/
Signature: _,�! / Date: & s 'O b 9
Phone#: 760-00
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
NOTICE �R =_ � NOTICE
TO - TO
EMPLOYEES ,,= T--_----= EMPLOYEES
The Commonwealth of Massachusetts
DEPARTMENT OF INDUSTRIAL ACCIDENTS
1 Congress Street, Suite 100, Boston, Massachusetts 02114-2017
617-727-4900 - http:llwww.mass.govldia
As required by Massachusetts General Law,Chapter 152,Sections 21,22 830,this will give you notice that I(we)
have provided for payment to our injured employees under the above-mentioned chapter by insuring with:
Federal Insurance Company
NAVE OF INSURANCE COMPANY
555 LONG WHARF DRIVE
NEW HAVEN, CT 06511-6107
_____
ADDRESS OF= WOE COMP NY
(20)7173-93-18 06/2.5/19 TO 06/25/20 _
POLICY NIII EFFECTIVE E D TES —
70 ESSEX ROAD
GSE GROUP INC(B1RGEE PROGRAM) WESTBROOK,CT 060)399-5945
NAME OF INSURANCE AGENT ADDRESS PHONE*
22 FROTHINGHAM WAY
BASS RIVER YACHT CLUB SOUTH YARMOUTH,TH, 02664
ELOPE E
EMPLOYER'S WORKER'S COMPENSATION OFFICER(IF ANY) DATE
MEDICAL TREATMENT
The above named insurer is m eases of personal njiries wrsang out of and zn the muse of empilorinentemployment ho
furnish adequate and reasonable hospital and medical services in accordance with the provisions of the VVorker"s
CorriperrKition fist. P.vow rf Fisk R u r3 Wiyar, meNt k,e g'raes ,o the;Fifes + wvg,lalee.The einValree mey selett
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 hose •
attention, employees are hereby notified that the insurer has arranged for such attention at the
NAME OF HOSPITAL ADDRESS
TO BE POSTED BY EMPLOYER
WC 7506H(Rev.8-10)*