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HomeMy WebLinkAboutApplication and WC - , �„�� TOWN OF YAItM4U1'H BOARI} 4F I3EAL1'H. G3L�C�I�04?l�DD oo. APPLICATION FOR LICENS�lP�' -34,1{,�5,�e D�.0 Q� ZQ�4 * Please complete forrn and attach all neces�s oeuments bp D em 019. Failure to do so will result in the ret�an pf}�our�ppIicatia T. " ESTABT ISHMENT NAME: � w. w� "7�l A ID• LOCATI4N ADDRESS: 'l l .� ` '�,+�- �t- TEL.#: OK �rl`� MAII.ING AT?DRESS: E-MAII,ADDRESS:_��_�� t�' ,� ,.,"n� S,C �M OWiVER NAME: CORPQRATIOIY NAME(IF APPLICABLE): MANAGER'SNAME:_"T�C,�Gra\,'Srj���,' TEL#• �S-"1`1�'-6S�\ MAILINGADDRESS: �a--.� c,3 A�,,,,.e POOL CERTTFICATIONS: T6e poa]supervisor must be certified as a Pool Ctperatar,as required by State law. Please list the designated Poo1 Operator(s) and attach�}a copy of the cartiiication to this form. 1. ��ec�n'a.q°-�, ,"�j� �-- ___-_____—_ —�_ �2. _ . Poal operatars must list a minimusn of two employees currenily certified zn basic water safety, standard First Aid and Community Cazdiopulmonary Resuscitatian (CPR), having one certified employee on premises at all times. Piease list the employees below and attach copies af their certifications to this farm.The Heatth Department will not use past years' records. Yoa must provide new copies and maiotain a file at your pls�ce of business. 1. �a�+-t>`b i�- C���-, 2. �?L-�c�w �� `�c 3. C�.� �.c ,�-,�...� 4.—�na�- ('a�w,-� -.-� FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishrnents ara required to have at least one full-titne employee who is certified as a Pood Protectian Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.d00. Please attach copies of certification to t�iis appiicatian. The Heaith Department wiit not use past years'records. You must provide new copies and maintain a file at your establishment. 1. 2, PERSON IN CHARCrE: Each food establishnxent rnust have at least one Person In Chazge (PTC) on site during hours of operation. �_.__.�___...___ _�.—�:- Y_.__— __ � __._ _ _ 2 . __ 1. _ _ - ----_ _ ___- _-- ALLERGEN CERTIFICATIC}NS: 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 Establ9shments, I OS CMR S90.Od9(G)(3)(a). Please attach capies of certification ta this applicatian. The Heaith Zlepartment wili not use past years' recards. You must provide new copies and maintain a �le at your establishment. 1. �. HEIMLICH CERTIFICATIONS. All food service establishxnenks wiih 25 seats or mare rnust have at least one employee trained in the Heimlich Maneuver an the premises at all times. Please list your employees trained in anti-cholcing procedures below and attach copies of employee certifications to this form. The Health Departmeut will nat use past years' records. You must provide new capies and maintain a file at your place of business. 1. 2. �• 4. RESTALIRANT SEATING: TOTAL# OFFICE USE ONLY L4DGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQt.JIRED F�E PERMIT# LiCENSE REQUIRF;D FF.E PE 1T# _B&B $SS CABIN $55 �MOTBL $I10 '-00 1hfil $55 CAMF $55 SWIMM7RiG PIX3L$110ea r =LODGE $55 =TRA[LERPARK $lOS — �WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQll1RED FEfi PERMIT# LIC6NSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-t06SEAT5 $125 _CONTINENTAL $35 IVON-PROF3T $34 >100 SBATS $200 COMMON V[C. $60 lWHOLESALE $80 � � —RE&[D.KI'I'CH6N $8Q RETAIL SERVICE: LICETJSE REQUIRED FEF, PrRMlT# LICBNSE REQUIRED FEE PERM#T# LICENSE REQUIRED FEE PERMIT# <SOsq.f�. $50 >2�,060sq.ft. $2$5 VENDING-FO{)B $25 __<25,000 sq.ft. $I50 _ _FROZF.N DF.SSERT $40 _TOBACCO $11.0 �� NAMECfiANGE: $15 AMOUNTDUE _ $ �v30-OC) *****PLEASE TLJ1tN OVER AND COMPLETE OTHER SIpE OF FOItM***** ��- (�C.� � 'Y�f S� ��t 3 ��-��`� 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 taaces and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES N� MOTELS AND OTHER LODGING ESTABLISHMENTS ---_ - - _ _ TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use;Transient oc�up�n���ha2Ybe-- _-- 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 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 outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOID 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 priar 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 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 terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have priar approval from the Boazd of Health. OUTDOOR COOKING: Outdoor cooking,prepazation,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 RETLJRN 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: SIGNATURE: PRINT NAME& TITLE: Rev. lUO3/14 � � � The Commonwealth ofMassachusetts Department oflndustrial Accidents Office of Investigations I Congress Street, Suite l00 Boston, MA 02I14-20U www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print LeEiblv Business/Organization Name: Q�-��, � W noo������n S Address: � l �fi'�-- �� City/State/Zip: S_��,-� a.n Phone #: 'SD� "���—`1��� Are ou an empbyer?Check the appropriate bos: Business Type(required): 1� I am a employer with � employees(full and/ 5. ❑ Retail or nart-timel.* ��., > 6. [� RestaurantBaz/Eatu�g Establishment _ _ _�.- -- - -- - 2.❑ I 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 capacrty. [No workers' comp.insurance required] $• ❑ Non-profit 3.❑ We aze a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §I(4), and we have �0.❑ Manufacturing no employees. [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 \�nt ��JC� *Any applicant ihat checks box#1 must also fill ou[the section below showuig t6e'v workers'compensation policy information. **If the cocporate officets have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#I. � . I am an employer that isproviding workers'compensation insurance for my employees. Be[ow is thepo[icy information. Insurance Company Name: Insurer's Address: City/State/Zip: Policy# or Self-ins. Lic. # Expiration Date: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expirafion date). _ _. Eailure to secure covsrage as required under_Section 25A_of MGL c._152 can lead to_the unposition of criminalpenalties of a fine up to $1,500.00 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 fonvazded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify,under the p s and penalties ofperjury that the information provided above is true and corre Si ature:�—�` Date: \ � ` Phone#: °Sb � �1� 0�1�� 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 O�ce 6.Other Contact Person: Phone#: www.mus.gov/dia WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE Associated Employers Insurance Company 54 Thtrd Avenue, Burlington, Massachusetts 01803-0970 (800) 876-2765 NCCI NO 40959 POLICY NO. j WCG500-5011467-2014A PRIOR NO. ;WCG500-5011467-2013A ITEM 1. The Insured: Pier 7 Condominium Trust DBA: Mailing address: 711 Route 28 FEIN:'="' South Yarmouth,MA 02664 Legal Entity Type: Trust or Estate Other workplaces not shown above: 2. The policy period is from 11/O6/2014 to 11/O6/2015 12:01 a.m.standard time at the insured's mailing address. 3. A. Workers Compenselion insurance: Part One of the pol'icy applies to the Workers Compensation�aw of the states listed here: MA 8. Employers'Liabifity Insurance: Part Two of the policy applies to work in each state listed in item 3.A. The limits of liability under Part Two are: Bodily Injury by Accident $ 500,000 each accident Bodily Injury by Disease $ 500,000 policy limit Bodily Injury by Disease $ 500,000 each employee C. Other States Insurance: Coverage Replaced by Endorsement WC 20 03 O6 B D. This Policy includes these Endorsements and Schedules: SEE SCHEDULE 4. The premium for this policy will be determined by our Manuals of Rules,Gassifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. ClassfficaGons Premium Basis Rates I�i Coda � Estimated Per$100 Eslimated No. i Total Annual Of Annual Remuneretion Hemuneration Premium I INTRA 28285 � INTEFi 9EEICLASSCADESCHEDU E � � � �' i �I � i I ; Minimum Premium $284 Total Estimated Annual Premium $4,018 GOV 'i GOV Deposit Premium $1,057 ' STATEjCLASS' i MA ! 9052 ' MA Assessment Chg. $3,562.00 x 5.8000% $207 This policy, including all endorsements, is hereby countersigned by ``-�� '-'"� L�-�.�x 09/09/2014 Authorizetl SignaNre Dete Service Office: Hart Insurance Agency Inc 54 Third Avenue PO Box 700 Burlington MA 01803 Buzzards Bay,MA 02532 WC 00 00 01 A(7-11) I�Iwles rnPyrl9hrotl mabriel W tlre Natbnel Counell on Compensation Insurance, used wflh itn permissbn.