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Home My WebLink AboutApplication & WC � . TOWN OF YARMOUTH BOARD OF HEALTH - ��S�LI�'IC� o �� APPLICATION FOR LICENSE/PE I�-2015 �, � 2��1 �� Utt� U ? 2u11 * Please complete form and attach all necessary cuments y Dece ber IS 2014. Failure to do so will result in the return of your applicahon pa ket�EALTH DEPT. ESTABLISHMENT NAME: � c�c TAX ID: � � LOCATIONADDRESS: l0(�b 1��2 S- `�G<W�cv`i'l1 TEL.#: Sb�-a3C.'—al°/d MaiLrrrG aDD�ss: s"� ci.�e� �t. 5-�� w -i N ��+al, n�✓� c'�Z3� E-MAILADDRESS: Yvtcbze�un�S� Jef� c.,�. ne OWNER NAME: M (Ih � �„n �t V✓1 �� CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: I�1t�Sfi11'\G PG��Pii IG�CI TEL.#: S�-3�l d' 3 � MAILINGADDRESS: S b��v�� 5-1- i..}') N -c��-}an VYII� ba3S� 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. L. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cazdiopulmonary 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. Z• 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. � Yl �� F'(`� i��:��(�l 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. �. l�`+�,��hvt��l�.t:� z. - - -� � ALLERGEN CERTIFICATIONS: All food service establishments aze 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 f51e at your establishment. 1. Z• 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-chokmg 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. +� r��t11�1� �1��Y `C� 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 FEG PERMIT# LICENSE REQUIRED FEE PERMIT# �0 100 SEATS $125 _CONTINCNTAL $35 NON-PROFIT $30 >100 SEATS $200 �COMMON VIC. $60 WHOLESALE $80 � —RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQIDRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq ft. $50 >25,000 sq ft. $285 VENDING-FOOD $25 Q5,000 sq.ft. $I50 �FROZEN DESSERT $40 _TOBACCO $110 NAME CHANGE: $IS AMOUNT DUE _ $ G Z J.Q�j *****PLEASE TURN OVER AND COMPLETE OTHER S[DE OF FORM***** �`� ��'�--� � ��z�b1 � ,��u� ��4 ADMINISTRA.TION Under ChapYer 152, Section 25C, Subsection 6,the T�wn af Yanncauth is now required tn hold issuance or renewal of any license or permit to operate a business if'a person or company does not haue a Certiftcate of Worker's Compensation Insurance. THE ATTACHED S'I'A'�'E WOF2KER'S COMPENSAT[ON INSUTZANCE AFFIDAVIT MUST BE COMPLETED AND SIGNEll, C1R Ck;RT. OF INS'URANCE A'I'TACH�I� � OR _ —. WORKER'S COMP. AFPII7AVI'I' SIGN�ED AND ATTACHED Town of Yannouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECR APPROPRIA'CELY IF PAID: , /' YES "' Nd MOTELS ANA OTHER LODGING F STABLISHMENTS TR.ANSIEN7"OCCUPANCY. Forpurposes of ihe iimitatiot�s oflvlotel or Hotel use,Transient occup�cy shall be limited to the temporary and shart term occupancy,ordinarily 1nd customarily associated with matel and hotel use. Transient oecupants must have and be able to demonstrate thaf they maintain a principal place af residenca elsewhere.Transient occupancy shall general:ly refer ta continuous occupancy ofnot rnore than thirty(30)days,and an aggregate af not more than ninety(90)days within any six(6)month period. Use af a�;uest unit as a residence or dweiling unit shall not be cansldered 4ransient. dccupancy tlaat is suhject to the collecfian of Room 4ccupancy Excise, as defined in M.G.L. c. 64Cr or 834 CMK 64G, as amended, sl�all generally be considered Transient. YOOLS 1'4QL QPENING:All swixnming,wading and whirlpaols cvhich have been closed fc�r The season must be inspected by thc Hetalth Deputment prior to opening. Contact the F3ealth Departrneni to schedul�the inspection three (3) days przar ta opening. PLBASE NOTB: Feople are NdT allowed to sif in the poa] area until the pool has been inspected and opened. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and sta�ldard plate count by a State certified lab, and submitted to the Health Depariment three (3) days priox Yo opening, and quart4rly Clzereafter. PQ(}L CLOSING: Every aatdoor iu ground swimmang poal must be drained or covered within seven{7}da}rs of closing. FOODSERVIGE - ---_- —.._ _.—__T_._� ---- SEA�+ONAL FOt1D SERVICE 4PENING: A71 food service establishments must be insp�cted by the IIealth Dapartment prior to opening. .Please contact the Health Deparirnent to sckedule the inspection three(3) dt�ys prior to opening. CATE�2ING PQLICY: Anyone who caters within the Town of'Yarmouth must notify the Yarmouth Health Department by filing the required Temporazy Pood Servsce Appiication form 72 hours prior ta the catered evenT. These forms can be obtained at the Health Department,or from tl�e Tawn's website at www.varsnouth.ma.us under Health Departnlent, Dawnlaadable Fornis. FROZEN DESSERTS: Frozen desserts must be tesYed by a StaYe cerfifieti 1ab prior to opening and rnonthly thereafter,with sample resulYs submitted to ihe Health Department. Failure to do sc� will result in the suspension or revocation of your Frozen Uessert PermiY until tbe above lerms have bcen met. CiUTSIDE CARES. (�utside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval frorn the Board of Health. CIUTDOOR COOHING: t)utdoor cooking,preparatian,c�r display of any food product by a retail or food service establishment is prohibited. NOTICE:Permits run annually frotn 7anuary 1 to December 31. I'I'IS YOiJR I2ESPONSIBILITY 7'O RETURN THE COMPLETED RENEWAL APPLICATZON{S)AND REQUIRFsD FEE(S}BY DECEM��;R 15,2014. ALL RENOVATIONS TO ANY I'OOD ESTABLISHMENT, MO`i'EL dR POOL (i.e., PAINTINti, NE�V EQUIPM�,NT, ETC.}, MUST BE REPORTED Td AND APPROVED BY THE B(JAKI}QF HEALTH PRIOR TO CQMMENCEMENT. RENOVATTONS MAY REQUIRE A SITE PLAN. �AT�: I l J!�1��`� srGNA�ru�: 2�;Gi�z��-�. PRINT NAME & TI1"LE:.. �' ��G✓'l� �Q — O+��iLP I4`.-�5�-�'�" ftev. {7743114 � The Commonwealth of Massachusetts Department of Industrial Accidents - Office of Investigations I Congress Street, Suite I00 Boston, MA 02114-20U www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Apalicant Information Please Print Legiblv Business/Organization Name: ►V 1 C r� — �1-�2��_� �-L Address: � (��i�/t� �� S� W —I� City/State/Zip: f� �c,,S��I� G�3S� Phone#: � � —�3U ��L Ar,�e,yo�u an employer? Check the appropriate box: Business Type(required): 1.L9'I am a employer with � employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ RestauranUBaz/Eating Establishment 2.❑ I am a sole proprietor or parmership and have no 7, � Office and/or Sales (incl. real estate,auto, etc.) employees working for me in any capaciry. [No workers' comp.insurance required� 8• ❑ Non-profit 3.❑ We aze 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.] 12.0 Other *My applicant that checks box#1 must also fill out the section below shovring their workers'compensarion policy info=mation. '*If the cocporate officers have exempted tUemselves,but the corporafion has other employees,a workers'compensation policy is required a¢d such an organization should check box#L � I am an employer that isproviding work/ers'compeIn_sation insur¢nce for my emplayees. Be[ow is the policy information. Insurance Company Name: ��lS' ��S�'` �G� Insurer'sAddress: �U �� 1��t2f�� (J� �T(� '7�ZS City/State/Zip: � � v1/l � (VUl V � I� �0 U�� Policy# or Self-ins. Lic. # � I W C' � 7�� l �� Expiration Date: �/I I�S Attach a copy of the workers' compensation policy declarafion 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 imposi6on of criminal penalties of a fine up to $I,500.00 and/or one-yeaz imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwazded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify, under the pains and penalties ofperjury that the information provided above is true and carrect. Si ature: /bLli/yy//�i�_ Date: Il /�� Phone#: � �—a�v ��C'� Official use only. Do not write in this area,to be completed by city or town officiaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2. Building Department 3. City/Town Clerk 4.Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone#: www.mass.gov/dia �-__.� Massachus�tts __ McDonald's Operators Workers' Compensation Group, Inc. WORKERS' COMPENSATI4N AND �'�''' EMPLOYERS' LIABILITY CERTIFICATE DECLARATIQN5 ITEM 1. Name and P.ddress uf Memtrer: Certificate Number: MAWCI-17973{24) Mc$ee Ente�prises,LLC dtbla McDonald's Rastaurants 1'ype: Limited Liab Co 50 Oliver StreeY,Suite W-1B �Risk I.D.# Nort6 Easton MA 0235b FF.I# CYC#/Employer Code: Lucatiuns: All usUal workplaces of t6e member at or from which opera[ions covered by[his fund are conducted and located at lhe abGve address untess oiherwise stated 8erein:See Endorsement#I. , ITEM 3: Coutraet Period: P�om 1/IYZ014 tQ 1f1/2�15-12:01 a.m.Staodazd Time at address of inembez stated 1�ecein_ ITEM 3a:Coverage A of this certificate applies tp the wGrkers'compensatio�Iaw und any occupatfonAl disease law of MAssachusetts ITEM 36:Empbyers LiabiliEy tnsurance:Part Two of the policy applies to wock in cach state tisted in item 3. The limits oY liability under Part Two Are: Bodity[njury By Accident SOO,Q00 Each Accident Bodily Injury By Uisease SOO,p00 Polioy Limit Bodily[njury By Disease 350,p66 Eacfi Employee 1TEM 3c;piher SE�a[es Insuranoe_Part Three o#thc patiey App[ies to the Stxte,if any,listed here: Massachusetts ITEM 3d:See Endarsements: Pnd No.1,Lnd Np.E(I/�30),End No.[(2/82),End No.R(12/93) ITF.M 4. . PREMIUM BASIS RATES TOTAI.,S CLASSIF[CAT[024 pE OPERATtONS CODE �imATED'FOTAL. PER$100 . ESTIMATED REMUNERATION NEMCiNERATION PREMIUMS Clerical-N.O.C. ..... ...--- 8R10 2i3,481 0.12 $256 Superuisors 8742 279,18t 020 $564 Restaurant 9079 5,712,938 L4A $82,263 Subtotat: $A3,674 ExperienceMod L13 �43,879 NE'I'PRCM[UM $43,879 DIA Assessment 1,Q4Q Nat Premiam with DIA Assessment ,��$�4�4�,4��' DEPOStT PREM[UM............................................................_..�..... .,_.......,.........,........................................................See Encbsed Payment Schedule ForMquidesConsemingyour Adininisttator: DotuiaZar,b �� gy. J4_.��i.-��– Workere'CqmpensatronCoverage , Astimr�7.GsllsgherRis�Management.�',ervices,Inc �� 30150 Telegraph Road Ste 408 F'und Adminrstrator Da[r:12/2/2013 p/ease dlall-800.869•6402 g�ngham FamQvit 48025 ��.—�