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Home My WebLink AboutApplication and WC . G3GC��Hw � TOWN OF YARMOUTH BOARD OF HEALTH Utl: 'I S Z014 � � APPLICATION FOR LICENSE�� T��-,�0� � * Please complete form and attach all ne�ss� ., cum�enRs`by , ce� ��I Failure to do so will result in the refurn�F}��tr applicat}on pac et. ESTABLISHMENT NAME: !n,= 4 �, iJ TA D• - LOCATION ADDRESS: �1 S,1 �a.x-r E ?� S'o". YA a m �uT'td TEL.#:5 b�-3 9�'Q S3 2- MAILING ADDRESS: � � �o n ��I P� u-v�n� � s (�o r'C f� Oz t-'a � E-MAILADDRESS: Ivla�.lAg�%R„�� CY,,�cG,�� ytAJ • G �M OWNERNAME: Ma�-SIkA«. �+��vs`1 CORPORATION NAME,(IF APPLICABLE): 1 h�- � Q'Y GP �� p,� � ��( b MANAGER'S NAME: �`��R�-s k a l.� �". Fc�c r/1 TEL.#: D ' ��7i MAILING ADDRESS: Y O � o x S � '1 I� va n r i s {�o r AI�A p�.(o� 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 Sle at your place of business. 1. 2. 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. ��-� y`�n � b (cs 2. ��1�k� t-�7 ic.��l PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. 1. � e.�c�e. o� �jb6 f s btL�' t1 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 Department will not use past years' records. You must provide new copies and maintain a file at your establishment. 1. I�+ 8 r9 � aG/�# ��(�b�S�u,t1 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 wpies 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. �c� ��-�LA �od� 8�,u.�`1 2. 1y�4 wr n►J�_ 3. 4. RESTAURANT SEATING: TOTAL# 1`�i� OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B� $55 _CABIN $55 _MOTEL $110 $55 CAMP $55 SWIMMINGPOOL$IlOea _LODGE $55 _1RAILERPARK $105 _WHIRLPOOL $IlOea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# L>100 SEATS $200 �COMMON VIC $60 WHOLE3ALE $SO RETAIL SERVICE: � —RESID.KITCHEN $80 LICENSEq REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# QS,OOOs ft. $150 >z5,000sq.ft. $285 _VENDING-FOOD $25 — 4� _FROZEN DESSERT $40 _TOBACCO $110 NAMECHANGE: $15 AMOUNTDUE _ $ 2�o. pp *•***PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** /�-�-G� �ZZD`�O ��.--�r�� 1�1�� . 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 taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: / YES / NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the Iimitations ofNlotel or Hotel use,Transient occupancy shall be 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 collecfion 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 Heaith 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 area 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. FOOD 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 prior to the catered event. These forms can be obtained at the Health Department,or from the Town's website at www.varmouth.ma.us under Health Department, 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 prior approval from the Boazd of Health. OUTDOOR COOHING: Outdoor cooking,preparation,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 RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 15, 2014. ALL RENOVATIONS TO ANY FOOD ESTABLIS ME T, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AN AP D BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY I A SITE PLAN. DATE: j L-"� — ( � SIGNATURE: PRINT NAME& TITLE: r�'LA n��,�L� �p ,,�y �� (�— Rev. I 1/03/14 � The Commonwealth ofMassachuset[s Department oflndustrial Accidents Office oflnvestigations 1 Congress Street, Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Geueral Businesses A�plicant Information Please Print Legiblv Business/OrganizationName:��,q�� Address: �1 �� 6 t�� City/State/Zip:��,�� prL�M�,� Phone#:__ `s p �— ��( �— �i s 3� Are y u an employer?Check th�ppropriate box: Business Type(required): 1. I am a employer with t�_employees (ful]and/ 5. ❑ Retail o�art-time .�* __ _ 6. [�'f�estauranUBaz/Earing 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 capacity. [No workers' comp. insurance required] g• ❑ Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exempfion per c. 152, §1(4),and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]* 4.❑ We aze a non-profit organization, staffed by volunteers, 11.❑ Health Care with no employees. [No workers' comp. insurance req.] 12.0 Other •Any applicant thaz checks box#I must also fill out the section below showuig the'v workers'compensafion policy information. •*If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compeusation policy is required and such an organization should checkbox#1. I am an employer that isproviding wotk1e',r�s'compensation insuran�or my employees. Below is the policy information. Insurance Company Name: �� r` IV� �,cT..tA�. .1 �.Ss Insurer's Address: 5 � � W� 11'-0 -�i)�n�,(,� City/State/Zip: �1�� '�`>> b � �66 3 Policy#or Self-ins.Lic. #v w�� I Ub�Io 6 (�P D J ' Expiration Date: D � � Attach a copy of the workers' compensation policy declarakon page(showing the poticy number a d es iration date). Failure io secure coverage u required under_Sec6on 25A of MGL a 152_�an lead to th�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 for' ance coverage verification. I do hereby certi un patns and penalties ojperjury that the information provided above is due and correM. Si ature: Date: I -^I Phone#: �()� ' 3�'j�� Cis� � 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 Nt� �X�r''_,F WORKERS COMPENSA710N AND EMPLOYERS LIABILITY INSURANCE POLICY t�'' itVFOftMAFIdN PAGE � A.LM. Mutual Insurance Company `""` k: 54 Third Avenue, Burlington, Massachusetts 47843-0970 '� $.,;� {800j 876-2765 NCCt No 26168 ��;�? POLICYNO. VWG100-6016011=2074A �K �PRIOR NO. VWC-70Q-601 601 1-2p13A 7EM `: 1. The�nsured: Pancake Man Ltd °�� :.a; pBA: Mailing address: P O Box 148 FEIN:"-*"2420 �� Hyannisport,MA 02647 �`" e ;;� 'ir Legal Entiry Type: Corporation , + . �ther workplaces not shown above: See Location 2. The policy p'eriod is from 08lO1/2014 to p8/Ot/2015 72:01 a.m.standard time at the insured's mailing address. 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Gompensation Law of the states liated here: MA B. Employers'Liability Insurance: Part Two of the policy applies to wark in each state listad in item 3.A. �?;�_ �, The limita of liability under Part Two are: Bodily Injury by Accident $ 500,000 each accident ��' Bodity Injury by dixease $ 500,000 policy IimiE :a Bodily Injury by Disease $ 500,000 each employee C. Other States Insurence: Coverage Replaced by Endorsement WC 20 03 O6 B D. This Policy includes these Endorsements and SchedWes: SEE SCHEDULE 4' a� 4. The premium for this policy will be determined by our Manuals ot Rulea,Classifications,Rates and Rating Plans. _ AII informa#ian required beiow is subject ta verificaiion and chartge by audit. � Ciassificatfons Prsmium Basis Rates Qode Estimated Per$1� Estimated No. Total Mnual Of Mnual Remuneration 8emuneraGon Premium '�'y � INTRA 39923 � `s INTER SE CLASS CODE SCHEDU E {,, Ninimum Premium $269 Total Estimated Annual Premium $3,317 "f GOV GOV Deposit Premiurn $3,41& F; STATE CLASS MA 9079 M.4 Assessmertt Chg. $2,840.00 x 3.4000% $97 (,/�' t� �/� ;��.7 i'his poticy,including aN endorsements,is hereby caarrtersigned by '"'—" � 4-J�"�-�T- 071i4/2014 Auth zetl Signawre I?ate — �� 3eroice Office: Olde Cape Cad ins Agency Inc i4 Third Avenue 296 Winter Street 3uriingto�MA 01803 Hyannis,MA 02601 NC 00 00 01 A(7-11) P^ n¢ludes copyrightetl material of tl�National Counoil on Compansation Insuranee, �� ised wiM ita permiwion. � � . . �