HomeMy WebLinkAboutApplication and WCi ,
� � �S a�3\ i"a`~. C> ,(t 1�-t � G31�G�CS�M��Au �S
` ' a TOWN OF YARMOUTH BOARD OF HEAL,TH .
k��� APPLICATIONFORLICENSE/P�� ��JF�S�� � DEC 1 l ZQ14
" * Please complete form and attach all neces�aty�lC��tnents-liy De m ��
Failure to do so will result in the return of your application T''
ESTABLISHMENT NAME• S-<�iv� �S TAX ID•
LOCATIONADDRESS• 2�0� p�c� Ma�r����c�cr TEL.#:50�39
MAILING ADDRESS: m�-
E-MAIL ADDRESS: t� na G�-r�c,v c��� C' M �s-� 2 /Y��
OWNERNAME: a Aco fY�
CORPORATION NAME (IF APPLICABLE):
MANAGER'S NAME: TEL.#:
MAILING ADDRESS:
POOL CERTIFICATIONS: N A
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. ,
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1. 2.
Pool operators must list a minimuxn 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 Hea►th Department will
not use past years' records. You must provide new copies and maintain a file at your place of business.
1. Z•
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. 2•
PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
- , i�a,r��,a #-�f-�-� £ �1�� _ 2.- 1 '��f� �
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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. 2•
HEIMLICH CERTIFICATIONS:
All food service establishrxtents 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.
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3. 4.
RESTAURANT SEATING: TOTAL#
FFIC�USE C�NLY" _ ___— -- -- ------
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$110ea.
LODGE $55 TRAILERPARK $105 _WHIRLPOOL $110ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE E�15 II�Z .
0-100SEATS $125 _CONT[NENTAL $35 �NON-PROFIT $30 �
� >100 SEATS $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
Q5,000 sq.ft. $150 —FROZEN DESSERT $40 _TOBACCO $ll0 ,.
NAME CHANGE: $15 `�` ' -�� � � � �. f AMOUNT DUE _ $ 3 0.o0
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*"*** �
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ADMINISTRA.TION ` `
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 persnn or company does not have a Certificate of Worker's
Compensarion Insurance. THE ATTACHED 3TATE WOI2KER'S COMPENSATION INSURANCE
AFFIAAVIT MiJST BE COMPLETED AND SIGNED, OR
CERT. C}l�IN5IIRANCE ATTACHED
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND A'fTACHED
Town of Yarmouth taxes and liens must be paid prior to renewal oc issuance of your pemuts. PLEASE CHI;CK
t�PPROPRIATELY IF PAID:
YES� NO _
MOTELS AND OTHER LODGING ESTABI.ISI�MENTS
`I'RAIVSTEIVI`OC'CIJPANCY: For ptirposes of the limitatiotis of Ivlotel ar Hofel nse,Ttansient occupancy shall oe
limited to the temporary and short term occupancy,ordinarily and customarily associated with matel and hotel use.
Transient occupants must have and be able ta demonstrate that they maintain a principal place of residence
elsewhere.Transient occupancy shall generally refer to cantinuous occupancy af not more than thirty{34)days,and
an aggregate of not mote than ninety(90)days within any six(6)month period. Use af a�;uest uni#as a residenoe or
dwelling uniY shall not be considercd trattsient. Oeeupancy that is subject to the eollec�ion of Room Occupaney
Excise, as defined in M.G.L. c. 64G ar 830 CMR 64G, as amended,shall generally be considered Transient.
PQQLS
POC1L flPENING:All swimming,wading and whirlpools which have been closed far the seasan rnust be inspected
by the Health Department prior to opening. Contact the Health Departrnetat to echedule the inspection three(3)
days prior to opening. PLEASE NdTE: People are NOT allawed to sit in the poot area untiI the pool has been
inspected and apened. '
POOL WAT�R TE5TING: The water must be tested far pseudomonas,total coliforcn and standard plate cerunt
by a State certified lab, and submitted to the Hcatth Department three (3) days prior to opening, and quarterly
thereafter.
P40L CL03ING:Every outdoor in ground swimming paai must be drained or cavered within seven{7}days of
closing.
FCIOD SET2VICE
SEASONAL FOOD SERVICE QPENING:
All food service estabiishments must be inspected by the Health Department priar to opening. Please contacf the
Health Department to schedule the inspectian three{3) days prior to apening.
CATERING PQLICY:
Anyane who caters within the Town of Yarmouth rnust notify the Yarmouth Health Department by filing the
required Temporary Foad Service Applicatian form 72 haurs prior to The catered event. These forms can be
obtained at the Health Deparhnent,or frorn the Tawn's website at www,yarmouth.ma.us under Health Department,
Downloadable Forms.
FROZEN DESSERTS:
rrozen desserfs must be tested by a State certified 1ab prior to opening and rnonthly thereafter,with sample results
submatted to the Health Department. Failure to do sa will result in the suspension or revooation of your Frozen
Dessert Permit untii the above terms have been met.
OUT3IDE CA�'ES:
Outside cafes(i.e.,outdoor seating with waitar/waitress service),must have prior approval from the Board of Health.
CIUTDOCIR COOHING:
Outdoor aooking,prepatation,or display ofany food product by a retail ar food serviee establishment is prohibited.
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�_ .��� ,::w_ _ -_..��____ --- - �
NOTICE: Permits run annually from January 1 to December 31. IT IS YOUR I2ESPONSIBILITY TO RET[TRN
THE COMPLETEI}ILGNEWAL APPLICATION(S}AND REQUIRED FEE(S}BY DF,CEMBF,R 15, 2014.
ALL RENOVATIONS TQ ANY FOOD ESTABLISHMENT, M01'EL OR POOL (i.e., PAINTING, NEW
EQUIPMrNT,ETC.), MI1ST BE RBPORTED TO ANI} Pk'ROVED BY THE BOARD QF HEALTH PRT(}R
TO COMMENCEMENT. RENOVATIONS MAY Q RE A SI � PLAN.�
DATE:� �--a`�� SICJNATURE: v
PRINT NAME&TITLE:_Csx-��o-�t�_ V �,.x'raS — ��-�� -�� �
Rev, ll?03ti4 � �"- '
,- ' , ` � The Commonwealth ofMassachusetts
Department of Industrial Accidents
Offzce of Investigations
I Congress Street, Suite I00
Boston, MA 02I14-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print LeEiblv
Business/Organization Nazne: S�F �v��S ���04`�\ C�-�u�
Address: �S ��c� 'Ma.�rS�-
City/State/Zip: S �-�s'rnc7-3�M`� 47�� Phone#: �(� 3�`{ `� �-aa
Are ou an employer? Check the appropriate box: Business Type(required):
1.� I am a employer with � employees (full and/ 5. ❑ Retail
or part-time).* 6. ❑ RestauranUBaz/Earing Establishment
---- —_
2. I am a sole ro netor or artnershi and have no
P P P p 7. ❑ Office and/or Sales(incl.real estate, auto, etc.)
employees working for me in any capacity.
[No workers' comp.insurance required� $• �Non-profit
3.❑ We aze a corporarion and its officers have exercised 9. ❑ Entertauunent
their right of exemprion per c. 152, §1(4), and we have �0.❑ Manufacturing
no employees. [No workers' comp. insurance required]*
4.� We aze a non-profit organization, staffed by volunteers, 11.❑ Health Caze �p
with no employees. [No workers' comp. insurance req.] 12.�Other C�wr�\
'Any applicant that checks box#I must also fill out the section below showiag the'v workers'compensalion policy infocmazion.
'*If the corporate officers have exempted themselves,but the corporation has otha employees,a workers'compensatioa policy is=equired and such an
organi�ation should check box#1.
I am an employer that is providing workers'compensation insu�ance for my employees. Below is the policy information.
InsuranceCompanyName: T� C��Jr� �rISU (d✓lG�nG�� �.Qf{� I�J 7��/lS �p..
J
Insurer's Address: l � E �� 3`1� �
c��yisr��iz,p: P�`1 N y I o o,l�
Policy#or Self-ins. Lic. # W� 7 6 �����D�OI`{ 3(o D� Expiration Date: �9�3 0� � j
Attach a copy of the workers' compensation policy declaration page(showing the policy nnmber and eapiraHon date).
Failure to secure coverage as required under Secuon 25A of MGL c. 152 can lead to the imposition of criminal penalties of a _
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�ine up to$I,SOOA�and/or one=yeaz imprisonment,as welI as civi�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 : under t e p ' s and pena[ties o perjury that the information provided above is true and correct.
SiQnature• /�-t/`- V Date: � ��`�
Phone#• �� J \� ��
Official use only. Do not write in this area,to be completed by city or town offaciaG
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 Office
6. Other
Contact Person: Phone#:
www.mass.gov/dia
� � �
' ACORU �ERTIFICATE OF LIABILITY INSURANCE �A'�`��"
l i November 7Q
THIS CERTFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BEiWEEN THE ISSUING INSURER(S),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the pdicy(les)must be endorsed.lf SUBROGATION IS WAIVED,subject to
the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to
the certifieate holder in lieu of such endorsement(s).
ROWCER e: Trece Parent
The Church Insurance/�gency Corp oxe Fnx
79 East 34'"Street ac,tro,ezt: S00 293-3525 ac,wo: 800 557-7395
New York,NY 10076 +�w�
DRESS:
ODUGER
. USTOMER ID&
INSURER S RFFOROING COVERAGE NAIC f
NSURED
nEftn: Libe MutuallusCo
Diocese ofMassachusetts sun�Re:
738 Tremont 3t NSURER C:
Boston Ma 02717 N9URERD:
NSURERF:
COVERAGES CERTiFlC/kiE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUEO TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED.NOTWITHSTANDING ANY RE�UIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT W ITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REpDUCED BY PppA�ID CLAIMS.
RTaYLPEOFINSURANGE IN POLIGVNUMBER MMIDDVEF MMIDOv LIMRS
E�LNEILfTY CH OCCURRENCE �S
OMMERCIAL GENERAL �MSES EeOCWrtGnce
CWMS-MADE OCCUR EDEXP M oiro rson
RSONAlBADV IWURV
ENERALAGGREGATE
EML AGGREGATE LIMIT APPLIES PER: RODUCTS-COMP/OP AGG
LICV PRO-CT LOC
��(ry MBINED SINGLE LIMR
6
Ee accident)
Y AUTO DILY IW URY(Per persOn)
OWNED AUTOS � DILV IWURV(Peracdtlen�)
CHEDULEDAUTOS ROPFRTYDAMAGE
IRFDA1f�05
N-OWNED HIf�OS
MBRELlAUA6 OCCUR CHOCCURRENCE
�E��'B CWMS-MADE GGREGATE
EDUCTIBLE . _ . _. _ . _ ... ._ .. _ ._. _.�.�_ _.
ETEMION S
RKERSCONPENSATION WCSTATU- OTH-
/� DEMP�OYERS'UABILRY ��N � X WC7625900090143607 8���$��4 9/30/2015 TORVLIMITS E '
g#��IETOR/PARTNER/EXE .L.EACHACCIDENT 'I OOOOOO
!`F9�TIFI..WFG FY(:11Il1FM
etoryinN7) .L.DISEASE-EAEMPLOVEE 5�,000,000
..ce n��nb��.ne.
ESCRIPrIONOFOPERATIONSbelaw .L.DISEASE-POLICYLIMR $'I�OOO�OOO
ESCRIPTION OF OPERATIONS/LOCATION51 VEHICLES(Adaeh AGORU f01,Adtlitlonal Remarks Sehedule,Hmore spaw b requiratl)
CERTIFICATE HOLDER CANCELLATION
St Davids Chu�th SHOULD ANYOF THE ABOVE DESCRIBED POLJCIES BE CANCELLED BEFORE
20$Old M�ain St TNE EXPIRATION DATE THEREOF,NOTICE YVILL BE DELIVERED IN
SoUth Ya�mOuth,MA 02664 ACCORDANCE WITH THE POLICY PROVISIONS.
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