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Home My WebLink AboutApplication and WC ��rv� a TOWN OF YARMOUTH BOARD OF HEALTH � � � APPLICATION FOR LICENSE/PE�IVII'��,2015 �� r� ��0��D " * Please complete form and attach all necessa�y doe�°eneitts by Decei�i er 1 2 014 Failure to do so will result in the retur}�of yoktt'r application pac et. ESTABLISHMENT NAME: - TAX ID: - LOCATION ADDRESS: � TEL.#: ��- : 2' - 7�1� MAILING ADDRESS:. � ' C) E-MAIL ADDRESS: . ' , C OWNER NAME: " � ` CORPORATION NAME F APPLICABLE): MANAGER'S NAME: - :� I tYlti r� TEL.#: 7�-��cr�-7 e'!I MAILING ADDRESS:� �'��+� ��- rnnc5 �A U�i i I — POOL CERTIFICATIONS: The pool supervisor must be certi�ed 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, standazd 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 forxn.The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 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 wili not use past years'records. You must provide new copies and maintain a file at your establishment. 1. 2• PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1 _ 2 _ ALLERGEN CERTIFICATIONS: All food service establishments are required to have at least one fixll-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 file at your establishment. 1, 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 a11 times. Please list your employees trained in anti-choking 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. 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# L[CENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $110 INN $55 CAMP $55 SWIMMINGPOOL$ll0ea. LODGE $55 TRAILERPARK $105 _WHIRLPOOL $IlOea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQOIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 _CONTINENTAL $35 NON-PROFIT $30 '—>100 SEATS $200 COMMON VIC. $60 WHOLESALE $80 — —RESID.K[TCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERM[T# LICENSE REQUIRED FEE PERMIT# <50 sq ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 �<25,OOOsq.ft. $150 .��Ig _FROZENDESSERT $40 �TOBACCO $110 �/� xnmEcri.axcE: $is AMOUNTDUE _ $ 26D.00 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*•*** �'�'� ��L�� C�.�'Z3��m9 ►i j��l`� ADMINISTRATION Under ChapYer 152,Section 25C, Subsection 6,the Town of Yannouth is naw r�quired tn hold issuance or renewal of any Iioense ar permit ta operate a business if a person or company does not have a Certifioate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S CCiMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNEll, OR CER"(". OF INStTRANCE ATTACHED OR WORKER'S COMP. AFFII7AVIT SIGNED AND ATTACHED Tarvn of Yarmouth taxes and liens rnust be paid prior to renewal ar issuance of your pecmits. PLEASE CHECK APPROPRIA'I'ELY IF PAID: / YES ,/ NO MOTELS ANA OTHER LODGING F,STABLISHMENTS TRANSIENT OCCUPANCY: For purposes ofthe limitations of Motel or Hotel use,Transient occupancy shall be limited to the temporary and shcart term occupancy,ordinariIy and custarnarily associated with motel and hotel use. Transient oceupants must have and ba able to demonstrate that they maintain a principal glace of residenca elsewhere.Transient occupancy shall generally refer to continuous occupancy of not rnore than thiriy(30)days,and an aggregate of not more than ninety(90)days within any six(6)manth periad. Use of a guest unit as a residence or dwelling unit shall not be considered transient. Occupancy that is subject ta the coltection af Room Qceupancy �xcise, as defined in M.G.L. c. 64CJ or 830 CMR 64G, as amended, shall generally be cansidered Transient. POOLS P{}4L QPENING:All swimming,wading and whirlpools which have been closed for the seasan must be inspected by the Health 17epartrnent prior to opening. Contact the Health Departrnent to schedule the inspection three (3) days prior to opening. PLBASE NO"I'E: Peaple are Nt}T allowed to sit in the popl area until the paol has been inspected and opened. PQOL WATER TESTING: 7'he water must be tested for pseudamonas,tota(coliforrn and standard plate count by a State certified lab, and submitted to the Health Departrnent three (3) days prior to opening, and quarterly thereafter. PO{}L CL4SING:Every outdaor in ground sc��imming poal rnust be drained ar coverad within seven{7)days of closing. FO011 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 Yazmouth rnust notify the Yannouth Health Department by frling the required Tamporary Food Service Application form 72 hours prior to the caYered event. These forms can be obtained at the Health Department,ar from the Town's website at www.yatmouth.ma.us under Health Department, Downloadable F'orms. FROZEN DESSERTS: Frozen desserYs must be tested by a State certified lab prior to apening and rnonthly thereafter,with sample results submitted to the �Tealth Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit untii the abave terms have l�en met OUTSIDE CAF'ES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval frorn the Board of Health. OUTDOOR COOKING: Outdoor cooking,prepazatian,ar display of any food product by a retail or food serviee establishment is pro6ibited. NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETtTRN '1"HE COMPLETEA RENEWAL APPLICATION(S)AND REQUIRED FEE{S}BY DECF,MB�R I5,2414. t�LL RENOVATIONS TQ ANY FOOD ESTABLISHMENT, MO`TEL OR POOL (i.e., PAINTING, NEW �QUIPMENT,ETC.}, NNST BE REP4RTED TO r1ND APPROVED BY THE BOARD OF HEALTH PRIQR TO COMMENCEMEN . NOVATTONS MAY REQUIRE A SITE PLAN. DATE: SIGNATURE: �i �j��t/ � g�rr�r Nazvt�� riTz�:��--��Y1�P-Q�--- ()t�.�t�o.l" Rev. (1103174 ' � The Commonwealth ofMassachusetts , Department oflndustrialAccidents Office of Investigations ' I Congress Street, Suite I00 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses A�alicant Information Please Print Legiblv Business/Organization Name:��ry�y�t, _ Address: I�,�, (�rC 2� ��J�� ("trm�.`�h � IuA (>o�(G�� City/State/Zip• ` � � CtY� "` � ��hone #: �Z$- ��[ -� Q/� Are you an employer? Check the appropriate box: Business Type(required): L�I am a employer with �i employees (full and/ 5. ❑ Retail --- -ar part-6me).* _ _ 6. ❑ RestaurantBaz/Eating Establislunent 2.❑ I am a sole proprietor or partnership and have no �, � 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 officers have exercised 9. ❑ Entertainment their right of exemprion per c. 152, §I(4), and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]# I 1.❑ Health Caze 4.❑ We aze a non-profit organization,staffed by volunteers, with no employees. [No workers' wmp. insurance req.] 12.� Other 'Any applicant thaz checks box#I must also 5ll out the section below showing their workers'compensation policy information. '•If the colporate office:s 6ave exempted themselves,but the corporaaon has other employees,a workets'compensation policy is required and such an organization should checkbox#1. � . I am an emplayer that is pro iding workers'compensation insurance for my er�ployees. Be[ow is the po[icy information. Insurance Company Nazne: Ll;��i C� �Yj"n I'�i n � Ylr7,l�LIY](� �177�p/S Insurer's Address: �; ^ � � P �{, City/State/Zip:�,��1�(,K.e, P � �_�� Policy#or Self-ins.Lic. # �� f 1_� Expiration Date: gl.�=�I�� Attach a copy of the workers' compensation policy declarallon page(showing the policy number and eapiration date). Failure tn secure coverage as required_undex 3ection 25Aof IvIGL c_1�2,_can learLtA the_imposition of criminal g�nalties of�__ _ fine up to $1,500.00 and/or one-yeaz imprisonment,as well as civil penalties in the forxn 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 pains and penalties of perjury thai the infarmarion provided above is true and correct. SiQnature: � Date: il �7J�1L� Phone#: 7 U� � �3tG- �.7UU OJfcial use only. Do not write in this area,to be comp(eted by city or town offacial City or Town: Permit/License# Issuing Authority(circle one): 1.Board of HealtL 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person• Phone#: www.mass.gov/dia � UTICA NATIONAL INSURANCE GROUP wC 0000o�a �„ , , , � � 184 Genesee SVeet . . ... , New Hartford, NY 13413 Issuing Gompany: Republic Frankli� Insurance Gampany MEMBER OF UTICA NATIONAI INSi,lRtWCE C�RQtlP W{�RKERS COMPENSATION AND EMPLQYERS LIABILITY INSURANCE POLiCY InfoPmatian Page Poiicy Number. 4792033 1. The Insured and Mailing Address: Prior Policy Numbee. Jay Mart Inc D8A JayMart 326 W PhAiN ST Producer: Oxford Insurance Agency P.O.Box 370 HYANNtS MA 02601 Ouford,MA 01540 Entity of Insured: Corporation Producer Number. 70917 _ _ ---_.._ . _ ___ _ _. . _ SIG#i"b4i1 _ _ Other workplaces not shown above: Insured's I.D.Number: NCCI Gompany Number: 10111 Risk I.D.Number. 2. The policy period is from 0 9/3 012 0 1 4 to 09/30/2015 12:01 AM SWndard Time at the insured's mailing address. 8. A. Warker3 Compensation Insurence:Part One of the policy appltes to the Workers Compensation Law of the states � iFsYed here:Massachn�tts � B. Employers Liabiliiy Insurance: PaR Two of the policy applies to work In each state listed in Ifem B.A. The limits of our flability under Part Two are: . � 8aiily Injury by Accident $ $50p,000 Each Acadent Bodily Injury by Disease $ $50d.� Policy limit Bodily lnjuty by Disease $ $`.�(?�000 Eadi Employee C. Qther States Insurance: PaR Three of tFre policy applies M the states,if any,listed here: All States except fhoso fisted in(tem 3.A.,ND,OH,WA,WY D. This policy includes these endorsements and schadules. d. The premium#or this poticy wllI be determined by our Manuals of Rulas,Classifications,Rates and Rating Plans. AII information required below is subject to verFfication and change by audlt. Premium Basis Rale Per 5100 ❑See Eztension of Informatian Page _——__- _ C�- -ivtatest krmuafi_ —� _ ___ �s�}�-pn°°a#- - __ ._-- — — tt�3�ifica�"ions — No. Premium Remuneretion emunerat on Minimum Premium: S 234 (�}q Expense Ca�sta�t 3 Employer's Liab Mlnimum Premium: 5 Totai EsSmated Annuai Premium $ 945 !f iruiicatad belrnv,interim adjustmeMs of premium shai(be made: Deposit Premium $ 945 issuing OPfice: New Hartfard, NY 13413 Date af issue:09-26-2014 cour�tersigned by _ &0.WC Ed.0&20p8 . Copy�igM�1988 National Council of Cwrrpensation l�surar�ce UNISILL NO. 100938566 � _,r.l"��'r�; --- -