HomeMy WebLinkAboutApplication and WC wa .
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��� , TQWN OF YARMOIITH BOARD OF HEALTH �������D
APPLICATION FOR LIC`ENSElP� 5
�` * Please compiete form and attach a11 necess ����� �� n ���dZ0i4
Failure to do so will resutt in the retu�of � n�s y�ec ` be
}�'�Pplicahon p et.
HEALTN DEP
ESTABLISHMENTNANIE: F�llr�0t� T D�
�,oc�TlaN�r�D�ss: - � �;u-µ-�1� G t�`/I)U z�L.#: 3: ;
MAILING ADDRESS�:� ��"� 0 0I '
OWNER NAM�S—`�1.i+u1_�tt.l GC�O_��� ;
CORPORATION NAME{IF APP CABLE):
MANAGER'S NAME: TEL.#: U •
MAILING ADDRESS; S
POQL CERTIFICATIONS: �
The paal sapervisor must be certi� as a Poa1 Operatar,as required by State law. Please list the designated �
Pool Operatar(s)and attach a copy of the certification to this form. j
-- --__ _ __. __ — __ - .
i. _ 2. ��
Pool operat�rs must list a minimum of two employees currently certified in basia watar safety, sCandazd First Aid j
and Community Cardiopulrnonary Resuscitation {CPR), having pne oertified employee on premises at all times.
Please list the employees belaw and attach capies of their certifications to this farm.The Health Department will
nat use pust years' records. You must provide new capies atid maintain a file at your g}ace of business.
I. 2 '
3. 4
FOOD PROTECTION MANAG�RS -CERTIFICATIONS: ;
All faod service establishments are required to have at least ane fiili-time empioyee who is certified as a Food
Protection Manager, as defined in the State Sanitary Cade for Food Service Establishments, IOS CMR S9d.000.
Please attach copies of certification to this application. The Health Department will not use past years'records. �
Yau must pravide new copies and maintain a file at your establishment.
T. �l�il /� �.. i'i ���d.I�/ 2. � � �
PERSON IN CHARGE:
Each food establishment must have at laast ona Person In Charge{PIC)an site during haurs of aperation.
1. �1 YI� �1 � �1�1��'1 '
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ALLERGEN CERTIPICATIONS:
AII E'ood service establishments are required to have at laast one fuil-time empiayee wha has Allergen certification,
as defined in the State Sanitary Code for Food Service Establishments, I d5 CMR 590.009(G)(3)(a). Please attach
copies of certification to this applicatian. The Health Department will not uae past years' records. You must
pmvide new copies and maintain a �le at yaur estab(ishment.
1. ��/l2 f �,/�n�/ 2.� L �.,,C�C�c./�.`
HEIMLTCH CEKTIFICATI4NS:
Ali food service establishments with 25 seats or more musz have at least one employee trained in tha Heimlich
Maneuver on the premises at all times. Please list your empioyees tratned in anti-choking procedures below and
attach copies of employee certifications to this form. The Health Deparkment wiil not use past years' reeords.
You rnust provide new copies and maintain a file at your place of bnsiness.
L�.f l�l(., �/�s�1u-/! 2. ���1�? ��`?12f1(�
3. i) ' , 4.--� �LL'�
RESTAURANT SEATiNG: TOTAL#
� � � "--- 11TTl'/�T 'v
�_ v�-rsw��1'.sE @noT.�;ar.._—. __��.. _ _�
LODGING:
LICBNSE REQUI1tED FEE FERMIT# LICENSB REQUIRED FEE PERMII'# LICENSE REQUIRED fiEE PfiRMIT 7P
� B&B $SS CABIN $55 MOTEL $t SO
=INN $55 CAMP $Si uSWIMMINGP00L$li0ea
,LOD�E $55 �� vTRAILER PARK $lp5 �^ uWHIRI.,PQOL $110ea..
FOOD SBRVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQtfIRED FE� PERM T#
D-100 SEATS $125 �CON'CiNENTAL $35 ,�NON-PROFIT $30 l� -s a�8
>106 SEATS $200 _COMM(3N VIC. $60 WHOLESALE $80
—12ES[D.KITCHEN S80
RETAIL SERYICE:
LICGNSE RF.QUIRED FF.E PERMIT# I.ICENSE REQUIRF,D FBE PERMIT# LICENSE REQUIREL3 FEE PERMTT#
�50 sq.ft. $50 >25,000 sy.ft. $28S VSI3DINCi-FC16i? $2S
�<25,OOOsq.fl. $I50 �FR4LENUESSERT $40 �T4BACC0 $I10
NAME CFIANGE: $SS AMOUNT DUE _ $�� .CO
"*k°'pLEA$E TUftN OVEi2 AND CdMPLETE OTHER S►DE OF FORM"**"�*
4
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ADMINISTRATION ' .
Under ChapY�r 152, Section 25C, SubsecUon 6,the Town of Yarmouth is now required to hold issuance or renewal
of any license ar permit to operate a business if a person or company does not have a Certificate of Worker's
Compensation Insurance. THE. •r�TTACH$D. STATE WORI�ER'S .COMPENSATION INSURANCE
AF�'ID�VyT 1VIIdST BE CQMPLL"I'ED 'AND STGNED;OR - ` i. '
c_ , •�C, . , " _ . ., _ �,', . -� , , „ ^i . "
•�•'�CERT. OF INSURATVCJE 1�`I'TR,CHEL7, .,� t'•.:.. ^
' 0�.�, ,,.{. � �e ` t . . ,: ., r r
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WORKER'S COMP. AFFIDAVIT SIGNEb AND ATTACHED
^ .
�Te�Rii�lf'I{aztnbhxtfi�taxes and liens must be paid prior to renewal or issufitide o�yoiuSp�mits. PLEASE CHECK
APPROPRIATELY IF PAID: • . ;-`..ti:�. `.�c . � , ,',"� :�-.
YES ' NO
MOTELS AND OTHER LODGING ESTABLISHMENTS
TRtSl`'SIEN1'OCCITFANCY: Fot purpoSes o�the lirriitarions of3vfotel or Hotel use,Transient occupa:�cy 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 ofnot more than thirfy(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 aze NOT allowed to sit in the pool azea 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 outdoar in ground swimming pool must be drained or covered within seven(7)days of
closing.
FOOD SERVICE
SEASONAI, FO�D 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 Deparhnent,or from the Town's website at www.yarmouth.ma.us under Health Deparhnent,
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 tei�ns have been met.
OUTSIDE CAFES: �
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Boazd of Health.
OUTDOOR COOHING:
Outdoor cooking,prepazation,or display of any food product by a retail ar food service establishment is prohibited.
NOTICE: Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILIT'I'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 RE UIRE A SITE PLAN.
DATE: �I Z SIGNATURE:
I ����-�-,�--C+I�--
PRINT NAME & TITLE: C 7 /CJ �
Rev. I I/03/]4 r /.. 1!"Y� , f1 ,I♦ � � //)/1�/ /I / �/1/1 .
N U 1 /l-1 �/ (J/l1 l�(JICAJ !C��c�
� � :7i,se Commonwea[th ofMassachusetts
Department oflndustrialAccidents
Office of Investigations
I Congress Street, Suite l00
Boston, MA 02II4-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Annlicaat Information Please Print Le2iblv
Business/Organization Name: /J� �//'
Address: � � , Z • � � �U��
City/State/Zip: lU• � �U � Phone#: , �
' Ar,�e y °an employer?CY� k the ap ropriate bos: Business Type(required):
1.U I am a employer with �� employees(full and/ 5. ❑ Retail
or part-rime).* 6. ❑ RestauranUBaz/Eating Establishment
_ _ -- --
2. �am a sole propn'etor or partnership andliave no - -- --
— -- --
7. ❑ 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 aze a corporarion and its o�cers have exercised 9. ❑ Entertainment
their right of exempfion per c. 152, §1(4), and we have 10.❑ Manufacturing
no empioyees. [No workers' comp. insurance required]* 11.❑ Health Care
4.❑ We aze a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp. insurance req.] 12.❑ Other
� *My applicant that checks box#I must also fill out the sectioa below showing their worke�s'compensalion policy information.
' **If the corporate officers have exempted themselves,but the cotporation 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 emp[oyees. Befow is the policy information.
InsuranceCompanyName:__ T� TfG���Q�Q1S rY1,$C1�(GYICQ CC)M�i111p�
Insurer's Address: ��� ' � �U�
' City/State/Zip: MIC1C�i.Q100(0� 1'Yl�q OZ',�{y- 14 5�
Policy# orSelf-ins. Lic. # �{��l.l(3 ' r"✓b��J�1' �� �� ExpiraYionDate: ��' �"Zd�r
Attach a copy of the workers' compensation policy declaration page(showing the policy nnmber and ezpiraHon date).
Failure to secure coverage as required under Sec6on 25A of MGL c. 152 can lead to the imposition of criminal penakies of a
fine up to $I,500.00 and/or one-year imprisonment;as wetT as civY penaltia�in the fotm tif a�TQF W�KIt ORDEI'c a�id�fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwazded to the Office of
Inves6gations of the DIA for insurance caberage verificarion.
I do hereby certify,under thepains andpenalties ofperjury that the information provided above is due and correct.
Si�nature: 1 . � L ..-` �� Date• �1 /Z�o ���I
Phone#: 5� ' ''S 1'� - �—ZZ
Ojficial use anly. Do not write tn this area,to be completed by city or town offaciaL
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2. Building Department 3. City/Towu Clerk 4.Licensing Board 5. Selectmen's Office
6.Other
Contact Person: Phone#:
www.mass.gov/dia
• ��� �
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NOTICE � � NOTICE
TO �
� � TO
:,
0
EMPLOYEES P� EMPLOYEES
' ��
, �
0,9,H S�6
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 General Law, Chapter 152,Sections 21,22&3Q this will give you notice that
I(we) have provided for payment to our injured employees under the above mentioned chapter by
msuring with:
THE TRAVELERS INSURANCE COMPANIES
NAME OF INSURANCE COMPANY
P .O. BOX 1450
MIDDLEBORO, MA 02344-1450
ADDRESS OF INSURANCE COMPANY
(7PJUB-5643007-7-14) 06-30-14 TO 06-30-15
POLICY NUMBER EFFECTIVE DATES
= ROGERS & GRAY 434 ROUTE 134
� SOUTH DENNIS MA 02660
_ NAME OF INSURANCE AGENT ADDRESS PHONE#
��
or� CAPE COD CHILD DEVELOPMENT 83 PEARL ST
'= PROGRAM INC
o�
= HYANNIS
o�
= MA 02601
� EMPLOYER ADDRESS
�_
� EMPLOYER'S WORKERS COMPENSATION OFFICER (IF ANY) DATE
o=
,= MEDICAL TREATMENT
�- T'he 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 hereby notified
that the insurer has arranged for such attention at the
Cape Cod Hospital 508-771-1800
NAME OF HOSPITAL Z3 Park Street, Hyannis,MA 02601 ,�DRESS
ooZ,ae W20P1G02 TO BE POSTED BY EMPLOYER
��
ACORO� CERTIFICATE OF LIABILITY INSURANCE °"TE`MM,°°"�'",
`-/ o�/a�/2ois
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
� CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLIqES BELOW.
� THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER�S�,AUTHORIZED REPRESENTATIVE
� OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy�ies) must be endorsed. If SUBROGATION IS WAIVED, subjec[to the
terms antl conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the
� ceRificate holder in lieu of such endorsement s.
PRODUCER CONTACT
I ROGERS & GRAY NAME�.
PHONE FAX
434 ROUTE 134 ac,No.essc: ac,No:
E-MAIL
SOUTH DENNIS nooREss:
MA 02660
73 JRH INSURER(5)AFFORDING COVERAGE NAIC#
wsuReRn�SRAVELERS PROPERTV CASUALTY COMPANV OF AMERICA
INSURED
INSURER 8:
CAPE COD CHILD DEVELOPMENT in�suaeRc.
PROGRAM INC
83 PEAR� ST iNsuReRo:
HVANNIS MA 02601 mSUReRe:
� INSURER F �
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE
POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT
WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES
DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE
BEEN REDUCED BY PAID CLAIMS.
INSR ADDL SUBR POLIGV EFF PoLICV EXP
LTR TVPEOFINSURANCE INSR WVD POLICYNUMBER MM/DO/YVYY MMIDDIYVYY LIMITS
GENERAL LIABIIITY EACH OCCURRENCE $
� DFMAGE TO RENTED
COMMERCIALGENERFLLIABILITV PREMISES Eaocwrrence S
CLAIMS-MADE ❑OCCUR MEDEXP Hn one ereon 8
PERSONAL 8 ADV INJURY S
' GENERALAGGRE6ATE $
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG
POLICV PROJECT LOC $
UTOMOBILE LIABILITY COMBMED SINGLE LIMIT
Ea acpdeM $
ANV AUTO A AUTOSULE� BODILV INJURV Per rson 8
ALIOWNED NON-OWNED
AUTOS AUTOS BODILVINJURV PeracciCen[ $
PROPERTVDAMAGE
HIREDAUTOS Pereccitlent $
UMBRELLALIAB OCCUR EACHIX)CURRENCE $
EXCE55 LIAB CLAIMS-MADE AGGREGATE $ -
� �ED RETENTION S
� A WORNERSCOMPENSATION WCSTATU- OTH-
ANOEMP�OYERS'LIABILITV (7PiJU6-5643�7-7-15) 06-30-15 06-30-16 X TORVLIMITS ER
ANV PROPRIETOR/PARTNER/EXEWTNE
. OFFlCER/MEM9EREXCWDED9 VIN E.LEACHACQDENT S SOO,000
�MantlatorylnNM) N NlA E.LDISEASE-EAEMPLOVE $ 500,000
H yes,tlescribe unGer
, DESCRIPTION OF OPERFTIONS below E.L.DISEASE-POLICV LIMIT $ SOO,OOO
_._
. . . . _ _._.v.a..�
�
DESCRIPTION OF OPERATIONSILOCATIONSNEHICLES/AttacM1 ACORD 101,AEEitional Remarks SchetlWe,if more space is requfreE) ��, �`::_�..;;J ; �� '
RE: WEST YARMOUTH PRESCHOOL 367 ROUTE 28, WES7 VARMOUTH MA 02673 . � I
�
i_..__ . .__ .—��
CERTIFICATE NOLDER CANCELLATION
SHOULD ANV OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION OATE THEREFO,NOTICE WILL BE DELIVERED IN ACCOROANCE WITH THE
POIIGV PROVISIONS.
TOWN OF YARMOUTH �
AUTHORIZED REPRESENTATIVE � ��/�
1146 ROUTE 28 /�` V "T""-
SOUTH VARMOU7H MA 02664
�i986-2010 ACORD CORPORATION.All rights reserved.
ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD