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Home My WebLink AboutApplication and WC TOWN OF YARMOUTH BOARD OF HEALTH APPLICATION ENSE/PERMIT-2020 *Please complete form and attachFOR allLICnecessary documents by December 13,2019. Failure to do so will result in the return of your application packet. NOTE:ALL BUSINESSES WITH LIOUOR LICENSES MUST RETURN FORMS.BYNOVEMBER 13'x. ESTABLISHMENT NAME: 4mm(3AssA'y icI A3A) 5 01 TES TAX ID:,, LOCATION ADDRESS: 131 I ) :2i., SOUTH )I/i--14110 t1 TI-1 TEL.#: LVO e) 3 ciLl--9 OW MAILING ADDRESS:13111 -:1 , 5p. Ji Qrr1 OLS-j i'1 f -- 6‘.41- E-MAIL ‘.4E-MAIL ADDRESS: i Y1.f"u c,mhaoscc ),c.pccod.Lv yl OWNER NAME: > CORPORATION NAME(IF APPLICABLE): G at:f cthi k ' pGt'- cot, ' MANAGER'S NAME: Pc4-t/L- Pot)-c1,_.Gat: TEL.#: ( r08),39/2/-it OVO MAILING ADDRESS: —Scernc 11-s AinvVc. — 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. P iris rf PSG--.t._- 2. , z z Pool operators must list a minimum of two employees currently certified in standard First Aid and Community ((nT1 o („il Cardiopulmonary Resuscitation(CPR),having one certified employee on premises at all times. Please list the r- o (S employees below and attach copies of their certifications to this form.The Health Department will not use past Fill years'records. You must provide new copies and maintain a file at your place of business. 00 C1tv C 1. P iyv s PAE�L 2. P, staitt�..PA- EL__ H e��o (U 3. aft. .. ♦ LC:No. 4. c -201 lif+�.RISO Ai -u U 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. .CI- 1. /V/04 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. ” 1- 1. 1. /c)/A-- 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)(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 file at your establishment. 1. A)/A---- 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. 1. /U/fr- 2. e)01,4L-(8-05-Z61-$2.- 3. 8-05.61QZ3. 4. (i) 6OHSP-18--052.(3.--a.. RESTAURANT SEATING: TOTAL# 61)6� ��'[$—o q--62. eoAf-(0-o637-c L OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# I,CENSE REQUIRED FEE P I LJL. B&B $55 CABIN $55 MOTEL $110 rJO U . )9 INN $55 'CAMP $55 __[_SWIMMING POOL Si l0ea. LODGE $55 =TRAILER PARK $105 WHIRLPOOL SI IOea. c_ (0 FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# I1iIICENSE REQUIRED FEE RMIT 1 LICENSE REQUIRED FEE PERMIT S 0-100 SEATS $125 A_CONTINENTAL $35 NON-PROFIT $30 —>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...1t: $50 >25,000 ft $285 VENDING-FOOD $25 —<25,111 sq.i1. $150 FROZEN DESSERT$40 TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE = $ 3(:$5.00 *****Pi FARE'TURN()VIM ANT*rf)MPI.VTR()TRIM CHT*'AR FARM***** 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. 640 or 830 CMR 640,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()Wined at the Health Department,or from the Town's website at www.vannouth.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. tUNN l RG <.Vrrerre erVGKLLR VJ 1►LUJJ44I•/114JGLLJ WO Department of Industrial Accidents 1* Art 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: ;oaf D , .� .�/ .a . I • 1— Address: 1 3 ) �'_ City/State/Zip: I . i A1/i i _.. _ Phone#: (' M S)394-—4 Uva 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. 0 Restaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and 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. 0 Non-profit 3.❑ We are a corporation and its officers have exercised 9. 0 Entertainment their right of exemption per c. 152, §1(4),and we have 10.❑ Manufacturing no employees. [No workers' comp.insurance required]* 11.0 Health Care 4.❑ We are a non-profit organization,staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.0 Other kny 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 -ganization should check box#1. am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. isurance Company Name: AI Ar _ 4-4 # ALP' I f� isurer's Address: 'ity/State/Zip: olicy#or Self-ins. Lic.# T t,o C 3 77- Lf 22 I Expiration Date: 3 9/..2_0 .ttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ne 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 f up to$250.00 a day against the v. lator. Be advised that a copy of this statement may be forwarded to the Office of ivestigations_of the DIA for ins e coverage verification. do hereby certify,under t p nd penalties of perjury that the information provided above is true and correct. ignature: Date: ///7//,' hone#: 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 to vsitessz? Technology Instertmce Conqmint,Inc. A race Company WMIKERS CONVERSATION WC 99 00 01 3 I EMPLOYERS LIABILITY PISURANCE POLICY INFORMATION PAGE Noci 39071 1. Insured: Polity l*andieri TWOM4221 • Krulle corp" DOA;Ambassador fan it Suites 1314 Route 28 Individual tshiP Sixth Ymnouth,MA 02664 . Commotion Other w not shwa above: Federal Tax ID: See Extension of Information Page car" l: Renewal TWCM198055 AmTnM North America.Inc. rto GA Dunn Imam=Agency Inc. 64 Firtimen Road. P0,.Box 497 02739 " The policy period is from 32019 3A12020 I20a.1 .at the n mailing gess" A Workersion Insurance:Part One of. policy to the Wolters ComPCMAtiOn Law the states r ,Masimchtaetts B. Employers Liabilityl P24i Two Wild polity wort in each listed initem 3. . The limits of ourf lit ,.r,, Part Two me: BodilyState Injury 1 BodilyInjury by BodilyInjury by Disease $500t,trteach accident $500000 policy bore $500,000 met employee C. Other t Three of tbe policy whoa to the states,1f any,lewd lam: All states exceptND,Olt `A,'WY and Swans) ,'J,w, vr« hem 3A 0. This policy these ndo ments and sehedMes:See ettersion ofInformation 4, The presiMm for will be determined t is C:1 Rules, " ns,Rates and Rating Plans,All in On required below is to verification ,,,,, change by audit See Extension Winfromation Page TOTAL ESTIMATED D UA PREMIUM 1,763 f T TE ;> NT 53 TOTAL ESTIMATED COST mr 410 rum gay 1,816 Issue Date: Y V2019 Countersi try: '� .. ' �y., ... ,. entntt