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Home My WebLink AboutApplication and WC ` S-r-q-Tor+RJe .S�EC.L_ ''� � TOWN OF YARMOUTH BOARD OF HEALTH �� APPLICATION FOR LICENSE/PERMIT -2015 ` ` '� ��d�D e.�c�'1csZo IR * Please complete form and attach all necessary�docw�i�nts b}��ecem °r 1 Qlb�a6 2014 Failure to do so will result in the retum of yow ap�il�c� on pa et.HEALTH DEPI . ESTABLISHMENT NAME: Wak�M 6�ter�,xs i►tt d/b(. �5}�i.�,/1w.54..\� TAX ID: M ' ' LOCATIONADDRESS: �146 '`.�t-��n.. A..a. 5•Y�r�o»l� , hA o1G6y TEL.#:(Sb�i) 398-.�337 MAILING ADDRESS: 5�.�..�. E-MAII.ADDRESS: i,.Da�c:«. 7�� alnvv . �gm OWNERNAME: (�'►u�+he.w W�k:.. -- CORPORATION NAME (IF APPLICABLE): ti�c.., �,xs TNL MANAGER'S NAME: {'Aat*w„� c�•t�,�. TEL.#: yvf yy�-3355 MAILINGADDRESS: 'iN6 Sht,�� fl..t. . 5. `��Mn_T. MA o�66y 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 certified in 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 f►le at your place of 6usiness. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments aze 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. Z. PERSON IN CHARGE: Each food establishxnent must have at least one Person In Charge (PIC) on site during hours of operation. L 2. _ _ 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 Deparhnent will not use past years' records. You must provide new copies and maintain a file at your establishment. l. 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 HeaUh Department wiil not use past years' records. You must provide new copies and maintain a �le 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 $55 SWIMMINGPOOL$ll0ea. � _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 � _>]00 5EATS $200 _COMMON VIC. $60 WHOLESALE $80 —RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 =<25,000 sq.ft. $150 .� _FROZEN DESSERT $40 �TOBACCO $ll0 .�1� NAME CHANGE: $I S AMOUNT DUE _ $ 2�O.o0 : � .:_ , , : *«**"pLEASE TURN OVER AND COMPLET&07'$ER SIDE 0B-FORM"•*** �� «6'�� ----- ��b�to ��1�(��t �' 4 ADMINISTRATION Under Chapter 152,Sectioti 25C,Subsection 6,the Town of Yarmouth is now requiced to hold issuance or renewal of any license or permit ta operate a business if a persan or company does npt haue a Certificate of Worker's Compensation Znsurance. THE AT'�'ACHED STATE W4I2KER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF iNSURt�NCE ATTACHED OR WOR.KER'S COMP. AFFIUAVTT SIGNED AND ATTACHED ✓ Town of Yarmouth taxes and liens tnust be paid prior to renewal ar issuance of your permits. FLEASE CHECK APPROPI2IA'CELY IF PAID: YES *r NO MOTF,LS AND OTHER LODGING F.STABLISHMENTS TRANSIENT OCCI7PANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be limited to the temporary and short term occupancy,ordinarily and oustcimarily associated with matel and hotel use. Transient occupants must havc and be able to demonstrate that they maintaan a principal place af residence elsewhere.Trstnsient occupancy shall generally refer ta continuous occupancy of not rnore than thirty{30)days,and an aggregate of not more than ninety(90)days within any six(6)month peripd. Use of a guest unit as a residence or dwelling unit shall not be considered transient. Occupancy that is subject to tlae collectian of Room Oceupancy �xcise, as defined in M.G.II. c. 64G ar$30 CMR 64G,as amended, shall generally be considered Transient. POOLS POOL OPENING:AIl swimming,wading and whirlpoals which have been clased for the seasan must be ins}3ected by the Health Department prior to opening. Contact the Health Department to schedule the inspection three (3) days prior Eo opeaing. PLEASE NOTF._: Peop2e are NOT' allowed to sit in the poal area until the paol has been inspected and opened. 1'04L WATER TESTING: The water must be tested for pseudomanas,total coliform and standard plate count by a State certified lab, and submitted to the Health Departrnent three (3} days prior Co opening, and quarGerly thereaftar. Pt}4L CLOSING: Every outdoor in graund swimming poal tnust be tirained ar covered within seven{7}days of closing. FOOD SERVICE SEASONAL FOOD SERVICE OPENING: All food service establishxnents must be inspected by the Health Department prior to opening. Please contact the Health Departrnenk to schedule the inspection three(3)days prior to opening. CATERiiVG POLICY: Anyone who caters within the Town of Yazmouth must notify the Yarmputh Health Department by filin� the required Temporary Food Service Application form 72 hours prior ta the catered event. These forms can be obtained at the Hea7th Department,or frorn the Town's website at www.varmouth.ma.us under Health Department, Downloadable Forms. FRO'LEN DESSETt'TS: Frozen desserks must be tested by a State certified lab prior to opening and rnonthly thereafter,with sample results submitted to the Healkh Department. Failure to do so will resuIt in the suspension or revocation of your Frozen Dessert Permit nntil the above terms have been met. C}UTSID� CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior appcoval frorn the Board of Health. OUTDOOR COOHING: Outdoor cooking,preparation,ar display of any food product by a retail ar food service establishment is prohibited. NOTTCEt Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL Al'PLICATIflN(S)AND RI3QLIIRED FEE{S}BY DECEMBER 15,2014. ALL RENOVATIONS TO ANY FOdD ESTABLISHMENT, MOTEL OR POdL (i.e., PAINTING, NEW EQUIPMENT,ETC.},MUST BE REPORTEI}TO AND APPROVEl7 BY THE BOARD{7F HBALTH PRIQR TO COMMENCEMENT. RENOVATIQNS MAY RE s A 5ITE PLAN. DATE: li-�.6- �K SIGNATU�� -.._/�.- PRINT NAME& TITLE: (ri>tt�v., Cack;V•, '�Ks:rh.t w� Rav. itfR3114 r r � � The Commonwealth ofMassachusetts Department of Industrial Accidents Office oflnvestigations ' I Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Apnlicant Information Please Print Legiblv Business/Organization Name: („h.v.a,. �.,�vp�x+ ,TKG d/b/a St64.�� ,Aw. �� Address: 446 5i.t�� AYe. CiTy/State/Zip: S, �.,.mol\ ,AA 026bN Phone #:T� '�9Y-233� Are ou an employer?Check the appropriate bos: Busi ss Type(required): 1.� I am a employer with��employees(full and/ 5. [�Retail or part-time).* 6. ❑ RestauranUBaz/Eating Establishment 2.-0--f am a so-Ie propnefor or parEnership and have no 7, J[f O�ce 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 corporation and its officers have exercised 9. ❑ Entertainment their right of exemprion per c. 152, §1(4), and we have 10.❑ 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.❑ Other *Any applicant that checks box#1 must also fill out the secfion below shovring the'u workets'compensation policy infoimation. � •*If the cotporate officets have exempted themselves,but the colporation has other employees,a workers'wmpeasation policy is required and such an organizatlon should check box#L � I am an employer that is providing workers'compensarion insurance for my employees. Be[ow is the po[icy information. InsuranceCompanyName: �Cep.� @o��t Tn�• /1nsn�� Insurer'sAddress: `,L6 (�uowo^h 'S�. Clty/State/Zip: �crt+�o.. r (LT Q190L Policy#or Self-ins. Lic. # T0.uA- 9 A 9 5847-O- 14 Expiration Date: 6'I'/S Attach a copy of the workers' compensation policy declaration page(shawing the policy number and expiration date). Failwe to se_c_ure coverage as required under Section 25A of MGL c. 152 can lead to the imposiUon of criminal penalries 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 verificarion. I do hereby ceRify er er thepains andpenalties ofperjury that the information provided above is true and correM. Si na�ture� Date: 1�',26-1Y Phone#: �o�) 486-33SS 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 Oftice 6.Other Contact Person: Phone#: www.mass.gov/dia .� _ ��,._ �� ,f; . NOTICE � W NOTICE � � TO � TO � � � o A EMPLOYEES e= EMPLOYEES .� � y� O�M SVe The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston, Massachusetts 02111 617-727�900 — http://www.mass.gov/dia As required by Massachusetts General Law, Chapter 152,Sections 21,22&30, this will give}rou notice that I(we) have provided for payment to our in�ured employees u�der the above meutioned chapter by msuring with: TFE TRAVELERS INSIMANCE COMPANIES NAME OF INSURANCE COMPANY P.O. BOX 1450 MIDDLE8�20 MA 02344-1450 ADDRESS OF INSURANCE COMPANY ' (IAUB-9A95847-0-14) 06-01-14 TO 06-01 -15 � POLICY NUMBER EFFECTIVE DATES �� OCEAt�OINT INS AGENCY 26 BOSWORTtF ST e� �� BARRINGT�I RI Q2806 � NAME OF INSURANCE AGENT ADDRESS PHQNE# m� a= WAKIM ENTERPRISES INC 446 STA720N AltftiJE s SEE Et�ORSEI�NT WC 99 06 01 � SOUTH YARMbUTIi � MA 02664 � EMPLOYER ADDRESS �� .� � EMPLOYER'S WORKERS COMPENSATION OFFICER (IF.ANY) DATE � � � MEDICAL TREATMENT ^� The above named insurer is required in cases of personal injuries arising out of and in the course of '� emptoyment to Eurnish adequate and reasonable hospital and medical services in accordance with the �� provisio�s of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the '� injured empbyee. 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 �wrk eelated iajury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged forsuchattentiqn at tfie � .�, �o�4t�1'�a� �Y'�r�+3 � N.AI�E OF HOSPITAL�— ADDRES5 �,� W20P7G04 TO BE POSTED �Y El�+IPLOYER