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HomeMy WebLinkAboutApplication and WC r T 5 .. r. TOWN OF YARMOUTH BOARD O.F IIEA TH- qj . Y. 1 7 APPLICATION FOR LICENSE/P RIV :- 201 : : .�c - Nrjv "e :4 20- * Please complete form and attach all necessary :ocunibnts by �Ieeem :a 15 2014. Failure to do so will result in the return of your application packe . HEALTH DEPT. ESTABLISHMENT NAME: TAX ID: DAGGETT'S LIQUORS LOCATION ADDRESS: 1071 RTE. 28 TEL.#: 0 t r 34( Y- b S'f? MAILING ADDRESS: SO, YARMOUTH, MA 02664 E-MAIL ADDRESS: OWNER NAME: ji30a r- r i g p CORPORATION NAME IF APPLICABLE): r- t774c, MANAGER'S NAME: j, b rr 1 S TEL.#: MAILING ADDRESS: 16 MAIN •1o 1 ell arykittto 0 � � 02.3 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 certifiedin basic water safety, 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 new copies and maintain a file at your establishment. 1 . 2. • PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1 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 . 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 . 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. LODGE $55 TRAILER PARK $105 WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT # 0-100 SEATS $125 CONTINENTAL $35 NON-PROFIT $30 >100 SEATS $200 COMMON VIC. $60 WHOLESALE $ RESID. KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PE IT # LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT # ft <50 sq.ft. $50 l 80 >25,000 sq.ft. $285 VENDING - FOOD $25 <25,000 sq.ft. $150 FROZEN DESSERT $40 TOBACCO $110 *f(500(e, NAME CHANGE: $15 AMOUNT DUE = $ I ( OMO *****PLEASEFORM***** C--(d $ /415-10© TURN OVER AND COMPLETE OTHER SIDE OF C $. i99-{ ►1 2 � f ADMINISTRATION • Yarmouth is now required to hold issuance or renewal Chapter 152, Section 25C, Subsection 6, the Town of q , Underp ' person or company does not have a Certificate of Worker's of anylicense or. permit to operate a business if a p y ensation Insurance.nsurance. THE ATTACHED p STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGN ,,:l: VR 17300A.0 CERT. OF INSURANCE-ATT CHEIS OR P. AFFIDAVIT SIGNED AND ATTACHED WORKER'S COM 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 • occupancy, ordinarilyand customarily associated with motel and hotel use. limited to the temporary and short term p y, 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) da s within six (6) month period. Use of a guest unit as a residence or y any p 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 wadingand whirlpools which have been closed for the season must be inspected POOL OPENING: All swimming, p e the inspection three (3)to opening. Contact the Health Department to schedul p by the Health Department priorp days prior to opening. PLEASE NOTE: Peo le are NOT allowed to sit in the pool area until the pool has been inspected and opened. tested for pseudomonas, total coliform and standard plate count POOL WATER TESTING: The water must be 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 groundswimming 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 P 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 q p � pP under Health obtained at the Health Department, or from the Town's website at www.yarmouth.ma.usDepartment, Downloadable Forms. FROZEN DESSERTS: Frozen desserts must be tested by a State certified lab prior to opening and monthly thereafter, with sample results • the sus ension or revocation of your Frozen submitted to the Health Department. Failure to do so will result inp 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. 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, 2014. 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: B1211114 SIGNATURE: ,(\,,,h " To%etA 00614-% S fl ) t. PRINT NAME & TITLE. Rev. 11/03/14 The Commonwealth of Massachusetts Department of Industrial Accidents ' ' Office of Investigations s 1 Congress Street, Suite 100 * „1 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: a r r D , J' c , I _ Address: DAGGETT'S LIQUORS 1071 RTE. 28 • SO. YARMOUTH, MA 02664 #: City/State/Zip:1Phone � 3 r tY p g Are you an employer? Check the appropriate box: Business Type (required): 1 . a I am a employer with a employees (full and/ 5. Ealetail ___ or part-time).* _ 6. ❑ Restaurant/Bar/Eating Establishment 2. I am a sole proprietor or partnership and have no 7. p Office and/or Sales (incl. real estate, auto, etc.) employees working for me in any capacity. workers' com . insurance required] S• ❑ Non-profit [No p 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]** a1 11 .0 Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.❑ Other *Any 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: Mil J'di.A vtlIS 6/Do p Address: P • R - a s �, ' Insurer's C' b � J�7 ao? � r coGni rC�T e City/State/Zip: /A /- 01 L^ Policy # or Self-ins. Lic. # OI4 / e a 00 0 1 Expiration Date: 1 ( cl1 Attach a copy of the workers' compensation policy declaration page (showing the policy number an expiration date). Failure to-secure-coverage-as-requiredCT . 152 can 1 a o l e i osition o criminall 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 is true and correct. Signature: 4,1 Date: 4k f2,‘ Phone #: 3c‘ lip 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 ............. NOTICE TO � 1dt P21 *.1E � --- TO '"i CJItf w * EMPLOYEES �1�w11r EMPL YEES • '1414;t3k The Commonwealth of Massachusetts TMS T .OFINDUSTRIALACCIDENTS I3EF�� • 600 Washington Street, Boston, Massachusetts 02111 617-727.4900 - .http://www.mass. gov/dia As required by Massachusetts General Law, Chapter 152, Sections.21, 22 8z 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: MA Retail Merchants WC Group Inc . . 411 NAME OF INSURANCE COMPANY PO Box 859222-9222 Braintree, MA 01285 ADDRESS OF INSURANCE COMPANY 014001022000114 1/01/ 014 1/01/2015 POLICY NUMBER EFFECTIVE DATES Association Benefits Insurance 299 Ballardvale St , Suite 1 Wilmington, MA 01887 NAME OF INSURANCE AGENT ADDRESS PHONE # Daggett ' s Liquors 10.71 Route 28 South Yarmouth, MA 02664 EMPLOYER • ADDRESS _ EMPLOYER'S WORKERS' COMPENSATION OFFICER (IF ANY) DATE MED I CAL 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 ser- vices 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 hereby notified that the insurer has arranged for such attention at the NAME OF HOSPITAL ADDRESS TO BE POSTED BY EMPLOYER