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Home My WebLink AboutApplication and WC � ' LL o D �� TOWN OF YARMOUTH BOARD OF HEALTH ,_ ,,, APPLICATION FOR LICENSE/�L I �� p Ut(: O J ZO14 }�=# * Please complete form and attach all necess�ry; o�ents by Dec ber 5 2014. Failure to do so will result in the retut�Ei=Of ydnY�j5plication pa t EPT. ESTABLISHMENT NAME: T D• LOCATION ADDRESS: TEL.#: MAILING ADDRESS: E-MAIL ADDRESS: I Gl . C6YY1 OWNER NAME: CORPORATION NAME (IF APPLICABLE): I L MANAGER'S NAME: �/'-C, TEL.#: MAILING ADDRESS: i S'�s�� GtY11, Ml��y�C'�i r 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. l. 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cazdiopulmonary 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 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 will not use past years'records. You must provide new copies and maintain a file at your establishment. 1. KA�'IICPYI �AV-� _2. —. PERSON�N CHARU'E: _ -- - _ __ __ _ _ _ Each food establishxnent must have at least one Person In Chazge (PIC) on site during hours of operation. i. �1'h�r� I�Vt, z. ALLERGEN CERTIFICATIONS: 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 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. ' ,. ��-h�een Lav-e, 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-chokmg 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# LICENSE REQUIRED FEE PERMIT# C,ICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $110 INN $55 CAMP $55 _SWIMMINGPOO[.$110ea LODGE $55 _TRAILER PARK $l05 _WHIRLPOOL $110ea. FOOD SERVICE: [.ICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �0-100SEATS $125 _CONT[NENTAL $35 NON-PROFIT $30 >100 SEATS $200 COMMON VIC. $60 WHOLESALE $80 — — - —RESID.KITCHBN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQl3IRED FEE PERMIT# <50 sq ft. $50 • >25,000 sq.ft; $285 VENDING-'FOOD $25 �<ZS,OOO sq.ft. $15Q , � �. —FAOZEN DES�SERT $40 �TOBACCO $I10 NAME CHANGE: $15� � AMOUNT DUE _ $ 3gS•OO *"***PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***"* �C � ��O�� 3�� ,�Q�C�� _ � I ' AI)MINISTRATIC)N !Under Chapter 152, Section 25C,Subsection 6,the lbwn of Xannouth is now required to hold issuance or renewal of any license or permit to operate a bnsiness rf a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WdI2KER'S COMPENSATION INSURANCE AFFIDAVI'1" MUST BE COMPLETED AND SIGNED, QR CERT. OF INSURANCE ATTACHEI} OR _-- WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED � Town of Yannouth tarces and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES__�_ 1�T0 MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCIJPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be limitad ta the temporary ai�d shart term occupanoy,ordinarily and customarily associated with matel mnd hotel use. Transient occupants must have and be able to demonstrate that they maintain a principal place of residence elsewhere.Transient accnpancy shall generally refer to continuous occupancy of not more than th9r[y(30)days,and an aggregate af not more than ninety(90)days within any six(6)month period. Use of a guest unit as a residence or dwelling unit shall noi be considered transient. Occupancy that is subject to the eollaction of Room Occupancy Excise,as defined in M.G.L. a. 64G or 830 CMR 64G, as amended, shall generally be considered Transient. POt7LS POnL OPENING:A]I swimming,wading and whirlpools which have been closed for the season must be inspected by tkie Health Department prior to opening. Contact the Health Deparkment to schedule the inspection three(3) days prior to opening. PI.,EASE 7VdTE: People are NOT allowed to sit in the pooi area unfil the pool has been inspected and opened. POClL WATER TESTING: The water must be tested fbr pseudomanas,totat colifonn and standard plate caunt by a State certifiad lab, and submitted to the Health Departanent three (3) days prior to opening, and quarkerty thereafter. ]PQC3L Cf.�SING: Every ovtdoc�r in gzound swimtning pool must be drained or covered within seven{7)ciays o1` - closing. FOOD SERVICE SEASONAL FOOD SERVICE OPENING: All food service establishments must be inspected by the Health Department prior to opening. Please cantact the Health Department to schedule the inspection three (3)days prior to opening. CATERING POLICY: Anyone who caters within the Town of Yarmnuth must notify khe Yarmouth Health Department by filing the required Temparary Food Service Applicatian form 72 hours prior to the catered event. These farms can be obtaained at the Haalth I7epartment,or from the Tawn's website at www.yarmouth.ma.us under Health Department, Downloadable Forms. FROZEN DESSERTS: Prozen desserts must be tested bp a State cerCified lab prior to opaning and monthly thercafter,with sample results subrnitted Yo the Health Deparcment. Failure to do so will result in the snspension or revocation of your Frozen I?essert Permit untii the above terms have been met. OUTSIDE CAFF:S: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Boazd of Health. --__ _ _.._ --_ -- --- __ _ __ . _ _ _ _ __ _ __ -- -- _ _._ OUTAOOR C04KING: - Chttdoor cooking,preparation,or display of any food product by a retail or food service establishment is prahibited. NOTICF:Permits run annually from January 1 to December 31 IS YOUR ItESPONSIBILITY TO RGTt.7RN '1'HE CO:VIPLETED REN�;WAL APPLICATION(S}ANI} QU sD FEE(S}BY DECEMBER 15, 2414, t1LL RENOVATTONS TO ANY FOOD �STABLIS , 'I'EL OR POOL (i.e., PAINTING, NEW EQUIPMENT, E1'C.}, MUST BE REPC7RTEI}TO AN P ROV 17 BY TITE BO�R.D OF HEALTH PRIC}R TO COMMEN BMENT. RENOVATIONS MAY I A 1"�PI,AN. I7ATE: SIGIVATLTRE: PRINT NAME& TITLE: R�_�zro�r�a Y. 171✓'CG'1W' C7�jQ„�,'�'i01�'1� � The Cammonwealth ofMassacliusetts Department of Industrial Accidents Office oflnvestigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Le2iblv Business/Organization Name: (tIObQI MOYI'��.LL�C?YOU��• Address��() SOl){'�l ��YYe'f'� SUI'fC�� City/State/Zip:,y�l-L�ydYYl Mh 6��-IS'3 Phone#: �SI -FS`i4-� Are y u an employer?Check the appropriate box: Bus�ine�Type(required): 1.�I am a employer with �O employees(full and/ 5. VL(Retail or part-Yime).* 6. ❑RestaurantBar/Eating 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 capaciry. [No workers' comp. insurance requ'ved] 8� ❑Non-profit 3.❑ We are a corporation and iu officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4),and we have �0.❑Manufacturing no employees. [No workers' comp. insurance required]* I 1.❑Health Care 4.❑ We are a non-profit organization,staffed by volunteers, with no employees. [No workers' comp.insurance req.] 12.�Other •Any applicant tha[checks box N]must also fill out the section below showing their workers'compensa[ion policy infortnation. '•If the wrpora[e officers have exempted[hemselves,but the corporation has other employees,a workers'compensa[ion policy is required and such an organi�ation should check box#1. I am an employer tkar u providing workers'compensation insurance for my employees. Be(ow is Oie po[icy information. Insurance Company Name: ��Y�ALI�`e� V Insurer'sAddress:��C 'R(✓ICP�PV �Y'(,L.k City/State/Zip:�S�Mp_�.��' Policy#or Self-ins.Lic.# wa� - l�i n- yl�ooc�ro- o�N Expiration Date: � Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration 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-year imprisonment,as well as civi]penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violatoc Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby ce i ,under t/ee p 'ns and plties ojperjury that the information pravirled above is true and correct. Si nature: Date: /8 t� Phone#: d � `3 3 Official use only. Do not write in H:is area,to be comp[eted by ciry or toivn officiaL City or Town: Permit/License# IssuingAuthority(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 . WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY �Liberty Mutual. INSURANCE INFORMATION PAGE 775BerkeleyStreet BosWn,t.v+ozt�s Issued by Liberty Insurance Corporation (a stock company) 21814 Palicy Number WA7-69D-460066-014 Issuing O�ce Lewiston, ME Renewai Of WA7-69D�360066-013 Issue Date 10/20/2074 Account Number 9-460066 Sub Account 0000 1. Insured and Mailing Address FEIN Global Partners, LP 800 South Street NJ TIN 141924242000 PO Box 9161 Risk ID 911385333 WALTHAM MA 02453 Status Limited Partnership Other workplaces not shown above:See Item 4. Premium -Extension of Information Page 2. Policy Period: The policy period is from 10/01/2014 to 10/01/2015 12:01 A.M. standard time at the Insured's mailing address. 3. Coverage A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: CT FL GA ME MA MT NH NJ NY OR PA RI TX VT VA B. Empfoyers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident $ 1,000,000 each accident Bodily Injury by Disease $ 1,000,000 policy limit Bodily Injury by Disease $ 1,000,000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: All States except those listed in Item 3.A and the States of: ND OH WA WY D. This policy includes these endorsements and schedules: See Item 3. Coverage D- Extension of Information Page 4. Premium: The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Classiflcations Code Premium Basis Total Rate per$100 Estimated Annual Number Estimated Annual Remuneration of Remuneration Premium See 6ctension of Information Page Minimum Premium $1,835 (PA) Total Estimated Annual Premium $ 688,867 Premium will be billed Annual Deposit Premium $ 688,867 DepositTax/Surcharge/Assessment $ 31,084 Producer 0002 000499 Countersigned by Authorized Rep. (FL) LOCKTON COMPANIES LLC (DALLAS SERIES) 2100 ROSS AVE STE 1400 DALLAS TX 75201 Producer MASTERS 8828 V Irving, TX WC 00 00 01 A OO 1987 National Council on Compensation Insurance, Inc. WC 00 00 01 B (CA/NJ) Ed.07/01/2011 All Rights Reserved Pa e 1 of 1 9 Stem 4. Premium - Extension of Information eage C1Aa01EiCatlon of Operatioaa Premium Baala Rate Entrics lo [hie Stem, except ae epeetYfcelly provided �Pa ro�11 - Vnleea pavxnll- elsewhere in Chie Bolicy, do nat modify any oi tha othar othexwiae indicated p�, �100 pxwl.eione oE this policy. Claes a) Plat Chaige Hetima[ad Code b) Per CapSta Premium a) Paaeengex Beat d) PremLum e) ather COTIC.S.RllOCI: Maesachuaetta Ayera 27 Harvard Rd 01932 Aehlands 272 Pond St 01721 Leomineter: 280 New Lancaster &d 01543 6andwich: 3 Coaet Guard &d 02563 New 8edford: 30 Pine St 02740 Hubbardatoa: 35 Maia 6t 01452 Beverly: 44 Dodge St 01915 Wellesley: 453 Washiagtoa St 02482 Revere: 49-222 Lee Burbank Hwy D2151 8astons 491 Poundry St 02334 Chelaea: 5-21 Ssoadway 02150 Yarmouth: 511 9tation Ave 02664 Mashpee: 518 8almouth Rd 02649 � Swampecott: 525 Paradi�a Rd 01707 Fitc2�burg: 56�9 &lectric Ava 01420 Mathuen: 5A Ayers Village Rd 01844 Groton: 6 eoatoss Rd 01450 Aahburnham: 6 Gardner Rd 01430 Marlborough: 656 Soatoa Poet Road 01752 4 Framiagham: 696 Chochituate Rd 01701 Policy No.WA7-69D-460066-013 Page No. 7 GPO 2923� WC 00 00 O1 A Ed. O1/O1/2001 WC 00 00 O1 B (NJ) Item 4. Premium - Extension of Information Page C1asalYicatian of Opexationa Pzemium Haele Rate Entriea Sn this it¢m, except ae sp¢cifieally provided Patzall - �aleae pavxoli_ elsewhexe in th[e policy, do not moCify any of the o[her otherwlse indicated prwisiona o4 thie policy. Claes a1 Flat Chaiga pex $ioa Batimaeed � Code li) Per Capita Premium c) ¢aesenger eeat d� Pzemium e) Other Continued: MassachuBetta Wrentham� 1001 8outh St 02093 . Orleanst 109 Route 6A 02653 Chelsea; lY BroaBway 02150 Saugusl� 1123 Broadway 01906 Aaynham: 1266 Broadway 02767 Ashby: 1274 Main St 01431 Luneaberg�e 131 Maeaaohusetts Ave 01462 Revere: 140 Lee Surbaxtk Hvey 02454 Spriagfiel8: 160 Rocus St 01104 Gardner: 17 Pearson elvd 01440 Athol: 1728 Main St 01331 ' Centarville: 1734 8almouth RdJ&oute 28 02632 Westford: 185 Littleton &d 01886 8andwich: 2 Coast Guard Rd 02563 Athol: 2143 Maia SC 01331 Concord: 22 Concord Tuxnpike 01742 Wiachendoa: 234 Spriag St 01475 Toovnsend: 238 Main St 01469 Hraintrae: 250 Grasiite St 02�184 Sraintree: 265 Granite St 02184 � Policy No. WA7-69D-460066-013 Page No. 6 GPO 2923 WC� 00 00 O1 A Ed. O1/O1/2001 WC 00 00 01 B (NS)