HomeMy WebLinkAboutApplication and WC f
� °` TOWN OF YATiMOUTH I#OARD OF HEALTH � �
� APPLICATION�OR LICENSE/PERMIT- 5 6�, N�V 2 6 2014
* Please cornplete form and attach all necessary doc nt�y�e�e EPl .
Pailure to do so will result in the retum of you$applicatton p
ESTABLISHMENT NAME: �: -
LOCA"I'ION AI7DRESS:,��.'( '}'�,�.$� (__��,4 f_�u(Ju TMA�2(,�?3 TEL#• �D��?7! !��F�$
MAILING ADDRESS: �
E-MAILAI}I}RESS: !t'1 �
OWNERNAME: A1 AIC � ! lll �JR. �
CORPORATION NAME (IF APFLICABLE): /� �
MANAGER'S NAME: �G 1�� T�L.#: Og� . Tr}�'
t�a�Lnv�.�Dtt�ss: � us G Y
POOL C�RTIFICATIQNS:
Tbe pool supervisor must be cerl ti�ed as a Pool Operator,as required by State law. Please list the designated
Poal Operator{s) and attach a copy of the certification to this form.
i. 2.
Pool operators must list a minimurn of two employees currently certified in basic water safety, standard First Aid
and Commwvty Cardiopuimonary Resuscitation {CPR), having one certified employee on premises at ail times.
Please list the employees below and attach copias of their certifications to this form. The Health Department will
not use past years' records. You must provide new copies and maintain a file af yaur place of business.
1. 2.
3. 4.
FOOD PROTECTION MANAGERS - CERTIFICAT10N5: /J��''
All food service establishznents aze required to have at least ane �izll-time emplayea who is certified as a Food
Protection Manager, as defined in the State Sanitary Cade for Faod Service Establishments, 105 CMR 590A00.
Please attach copies of certification to this application. The Health Department will not use past years'records.
You must pravide new eapies and maintain a�1e at yaur establishment.
l. 2_
_____-AERS6h�P.`I Ei-I�ItE�E:__- .___ _----___ ______�_._.___. _.__.__.
Each food establishrnent must have at least ane Person In Charga{PIC} an site daring hours af operatian.
1. 2.
ALLERGEN CERTIFICATIONS: �J�/k
AII food service establishments are required to have at least one full-time employee who has Atlergen certification,
as defined in the State Sariitary Code for Food Service Establishments, 105 CMR 594.009(G)(3){a). Please attach
copies of certification to this application. The Heal#h Department will not use past years' records. You must
provide new copies and maintain a file at your estabMishment.
1. 2.
HEIMLICH CERTIFICATIONS: ��X
ATI food service estahlishments with 25 seats or more must have at least one employee trained in the Heimlich
Maneuver on tha prernises at all tirnes. Please list your employees trained in anti-choking procedures below and
attach copies of employee certifications to this form. The Aealt6 Departmen#wilt not use past years'records.
You must provide new copies and maintain a file at your place of business.
1. �,
� 4.
TtESTALTRANT SEATING: TOTAL#
QFFICE USE ONLY
LODGINC:
LICEA'SE ItEQUIRED FEE PBRMT'I'# LICF,NSE REQUIREI7 FF,E PERMTT H LSCENSE REQUIR6D FEE PERMIT#
B&B $55 CABIN $SS MOTfiL $t70
INN $55 T� CAMF $S5 —SWIMMINGPOOL$IlOea
_LODGB $�5 _'1'RA3LERPAI2K $IQS ����i _WH[RLPOOL $]IQea. _
FOOD SEI2VICE:
LICENSE REQUIRED FEF. PERMIT# LICHNSE REQUIRED FEE PERMIT# LICENSE IZEQUIRIiD FEE PERMTT#
0-100SEATS $12S _CONTINENTAL $35 NON-PRO�'IT $30
^>I00 SGATS $200 COMM4N YIC. $60 —WFIOLESALE $&0
i` —RESID.KITCHF',N $80
FiETA[L 5ERV[CE:
LICENSE R.EQUIRED FE�, P 'RMIT# LtCENSE REQUIRfiU FE6 FERM[T# L1t7ENS.F REQU7RBD FEE PEItMtT#
1 <50 sq.ft. $50 �(;S-�I,$~ =^25,000 sq ft. $285 VENDING-FOOD $25
_<ZS,WOsq.ft. $I50 �_ _FR6ZL•NDESSERT $40 � �T4BACC0 $1I0
rrAm�cxnxc�: ��s AMQUNTDUE _ $ �o.Ob
*****PLEASE TURN OVER ANI7 COMPLETE pTAER SIDE OF FORM"***"
` J .
ADMINISTRATI(7N
Under Chaptec 152,Section 25C, Subsection 6,the Town of Yannonth is now required to hold issuance or renewal
of any license or permit to aperate a business if a persan or campany does not have a Certificate of Worker's
Compensation Insurance. THE ATTACHEI) STATE WORKE;R'5 COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, t3R
CERT. OF INSURANCE ATTACHED
OR
WQR.KER'S COMP. AFFIDAVIT SIGNED AND A`TTACHED�
Town of Yarmouth taxes and Iiens rnust be paid p�ior to renewal or issuance of yotu parmits. PLEASE CHECK
APPROPRIATELY IF PATD:
XES NO
MOTELS AND QTHER L4DGING ESTABLISHIYIENTS
TRANSIENT OCCUPANCY: For purposes of'the lzmitations of Mote3 ar Hotel use,Transient occupancy shall be
limited to the temparary and shart term occupancy,ordinarily and custamarily assaciated with motei and hvtel use.
Transient occupants must have and be able to deinonstrate that they maintain a principal place of residence
elsewhere.Transient occupancy shall generaily refer to continuous occnpancy of not more than thiriy(30)days,and
an aggregate of nat more than ninety(90}days within any six(6}manth period. Use of a guest unit as a residence or
dwelling unit shall not be considered transient. Occupancy that is subject to tlae callection of Room Occupancy
�.xcise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shalI generally be considered Transient.
POOLS
POOL OPENING:All swimming,wading and whirlpools which l�ave been closed for tYie season must be inspected
by the Health Department prior to opening. Contact the Health DepartmenY ta schedule the inspection three(3}
days prior to opening. PLEASE NOTE: People are NOT allowed to sit in the poal azea until the pool has been
inspected and opened.
POOL WATER 7'ES'I`ING: The water must be tested f'or pseudomonas,total coiifornz and standard plate count
by a State certified iab, and snbmitted to the Heaith Depariinent three {3} days prior to opening, and quarterly
thereafter.
POQL CLOSING: Every outdoor in gtoun�l swzznming pool must be drained ur covered wiihin seven(7)days of
closing.
FO011 SERVICE
SEASONAL FOOD SERVICE G►PENING:
All food service establishments must be inspectefl by the 1-Iealth Departmetu prior to opening. Please contact the
Health Department to schedule the inspectian tharee (3) days prior to opening.
CAT�RING POLICY:
Anyone who caters within the Tawn of Yarmauth must notzfy the Yarmouth Health Dapartment by filing the
required Temporary Pood Service Appl'acation f'orm 72 hours prior ta the catered event. These forms can be
obtained at the Health Department,or from the Tawn's cvebsite at www.varmouth.ma.us under Heaith Department,
Downloac9able Forms.
FROZEN D�SS�RTS:
Frozen desserts must be tested by a State certified lab prior to apening and monthly thereafter,with samp(e results
submitted ta the Health Department. Failure to do sa wi11 result in the suspension or revocation af yaur Frozen
Dessert Permit until the abave terms have been met.
QUTSIDE CAF�`S:
Outside cafes(i.e.,outdoor seating with waiterlwaitress service},must have prior approval from Ehe Board of Health.
_ _ _ _ ___. __� _ . __ . _ . ----.. — _ __..._
C}UTDOrdR COf}KING: --- ___-- _—_
Outdoor caoking,preparation,t�r displav of any food prodact by a retail or food service establishment is prohibited.
NOTICE:Perrnits nut annually from January 1 to Dec;ember 3 7. IT IS YOiJR ItESPONSIBILITY TO RETURN
THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S) BX DECEMBBR 15, 2014.
ALL RENOVATIONS Tp ANY FOOD ESTABLISHMENT, 1YIOTEL OR PdOL (i.e., PAINTING, NF,W
BQUTPMENT,ETC.), MUST BE REPORTED TO AND APPROVEI7 BY THE BOAR.D Op I�EALTH PRTOR
TO COMMERICEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
DATE: I_t�T,',C�JI� SIGNATURE: �''2ll�t/K,L`.4 . .(�,,(�-U(,(/V
PRINT NAMB& TITLE: N�}/UGy �, . (,�1 L�UK Q L�N�(�
--�
Re¢ il/03/14
. � ��
The Commonwealth ofMassachusetts
Department oflndustria[Accidents
Office oflnvestigatdons
' I Congress Street, Suite I00
Boston,MA 02114-20U
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legiblv
Business/Organization Name: ,/'� '�Q UC� OF �'� �� C�
Address: 'j/�'� �/�!Y(& �-�
City/State/Zip: � �MDU�� �� 0�73Phone#: ,56g'`17l-��{$$
Ar,�e `°u an employer?Check the appropriate box: Business Type(required):
1.L1 I am a employer with�i_employees(full and/ 5. ❑ Retail
or part-rime).* 6. ❑ RestaurantlBaz/Eating Establishment
2.❑ I am a sole proprietor or parmership and have no �, � Office and/or Sales (incl.real estate, auto,etc.)
employees working for me in any capacity.
[No workers' comp. insurance required] g• ❑Non-profit
3.❑ We aze a corporation and its officers have exercised 9. ❑ Entertainment
their right of exemption per c. 152, §l(4), and we have �0.0 Manufacturing
no employees. [No workers' comp. insurance required]* 11.❑ Health Caze
4.❑ We aze 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 showing their workecs'compensation policy information.
•*If the colporete officers have exempted themselves,but ihe corporation has other employees,a workers'compensation policy is requ'ved and such an
organizxlion should check box#L �
I am an emp[oyer that is providing workers'compensation insur¢nce for my empfnyees. Be[ow is the policy information.
InsuranceCompanyName: �1Av�L�QJ �1����� ��MQ�(1�H
Insurer's Address: a��� �� �/�l� y� ��' �D�
City/State/Zip: ���.A�� "1 L' ✓���Y'
• . .
_ _ _ FaliCy#bTSelf=, .ir�iio:-#- ---£xpiratmir� :--.---_—
Attach a copy of the workers' compensation policy declaration page(showing the policy number and eapiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties 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 forwazded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify,under th�pains and penalties of perjury that the information provided above is bue and correct.
Si ature: Date: �a�{ �
Phone#• �Q ' ��1 • �Y D b
Official use only. Do not write in this area,to be comp[eted by city or tawn official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2. Building Department 3. CitylTown Clerk 4.Licensing Board 5. Selectmen's O�ce
6. Other
Contact Person: Phone#:
www.mass.gov/dia
TRAVELERS WORKERS COMPENSATION
AND
EMPLOYERS LIABILITY POLICY
TYPE AR INFORMATION PAGE WC 00 00 01 ( A)
. POUCY NUMBER: (6HUB-5637385-3-14)
. RENEWAL OF (6HUB-5637385-3-13)
INSURER: THE TRAVELERS INDEMNITY COMPANY OF AMERICA
� NCCI CO CODE: 13439
INSURED: PRODUCER:
WILBUR, NANCY � OCEANSIDE INS GROUP .
DBA A TOUCH OF CAPE COD 52 WEST MAIN ST
327 ROUTE 28 HVANNIS MA 02601
WEST YARMOUTH MA 02673
Insured is AN INDIVIDUAL
Other work piaces and identification numbers are shown in the schedule(s) attached.
2. The policy perfod is from 07-2a-1 a to 0�-28-15 12:01 A.M. at the insured's mailing address.
3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers
Compensation Law of the state(s) Iisted here:
MA
c B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state Iisted fn
— item 3.A. The limits of our Iiabllity under Part Two are:
��
,= Bodily InJury by Accident: $ 100000 Each Accident
,� Bodily InJury by Disease: S 50000o policy Limit
� -- — - -�fldlly 4n}ucy by-Blseas�S —___�-99o�0-�ach-Er�ployee _ __ -- --
�= C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here:
� COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06A
m�
= D. This policy includes these endorsements and schedules:
�
o� SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE
o�
= 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating
= Plans. All required information is subject to verification and change by audit to be made ANNUALLY.
DATE OFISSUE: 07-17-14 WC ST ASSIGN: MA
OFFICE: ORLANDO INDUS AFF 161 .
PRODUCER: -OCEANSIDE INS GROUP 28GDS
oar�3e