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HomeMy WebLinkAboutApplication and WC r i,�t;"Y~,•I .:�.�� r'�� T O W h1 O F `� A R M O U T H ���.,r��, �' " . � Ilcutth � � . "',�- ,` !laG R[)l;'I'i:?S.SOL"!'4d 1 �ft41Q1''!'f{. \1;1SSAC 1Il CL"1"CS 4'_GG�1?-1�ti1 ' � s � ` �' 1'utaplwnc(>OS):�95-"±1.cst. I?-!I Hcahh .•+�,�„�,�" � I)irision `----- !';ti�t 5OS}?{�(T-=-47_ "1'c�: Yarmoutki Busines, I?stablisiyme�ris , :r:.� _� „ .�,i;<,' "�: �-: ���,�,��`�3� E�rom: 13ruce Ci. A�lurph�°. 1)ircwtor �"' �. Yarn�outh Hralth Dcparuncnt �}-�J ���' �i � 1�14 L)aue: ��avember 7. ?014 � HEf1LTH DEPT. Subjecc li�crrt�sc in License,'Yemxit !'oes i'le:ese 6e ar�rarc tlaat the 1'ans�t�tkth f3c�ard ef Iicultl3, under tt�e direciinn nF the Yanno�ul� E3oard 01' Sclectn�en. has raiscd a� nt�mher oI' licvns� tmd pennit tees issucd thratiuh Che Yarnroutl� i-teald� 13epsrrtment.c!'fectii�r lamian� ). 3E�15. :lUach4d is thc Yanatinutli 13usiness Lic�nselPcrn�ii .-���plicutian I'or 2015, You ��411 note that thu fees licted an: tbr fees efCective .iantjary }. '_'f�]5, '1'h�s�: 1'ecs Kill he ciuc if�tflu ca:npletc anc! submir thc uppiicatian alier.ianuary 1.'01�. lio��•c��cr. ii� �°c�u fi�li�• cc�mplete the upplicxtian. u�x! sul3mit ii tc� the 1"aannutlt tkcaitii I��parunent ��•ith alt requircd ccnilic�tions and ��•orker'+ campcnsation rnvcraz� inf'ormation (ccruficate of inst�ra�tcc (3R etHnpfc�€rd aE7idarit} pritrr tir !)ere�ttbcr 31. Zttl�4� 1=c�t� a�ili bc allcm�ed to pay the?01=4 rates tnr�he follo��•irrg licens�x: Carref�t201d Fce Puhtic S�vinur�ing Pools S SO.UO Pubtic \�'hirtperoi'�'a�or iiaths S 80.Ut1 ,_ '1'obucco Sal�s $ 9>.t10 �tc�tels S ��.tX} Rcstniaants(hipGSeats S SS.C)t? �- Rcstcnumnts i7��cr 1(70 S�ats S I GO.Op ` � Rctait Fc>c�d Seeviee �?5.40q st�. li� S Fid.fttl �, Kct�il Fond Service>25.QOC�sq. ft. b23?.OU � t3tiscr fccs o�ti'ed bui n�t listed aboti�e: 'Cotat fecs a�t�zd !'or yaur estal�tishEnent ���-�F.�_;'� ?v'�?G: To be entitled to p.iy tl�e current 201:1 raecs listed above, 4�our E�asiness apptic�ticrn, foac! arrcllor paol certifications, aiang vvith �rorker's compensatioti infn�•maYion must t�c recci�•etl, ar mo-�lled {�ostmarked) on or nP1or to UeeBntbCr 31, 201�4» f'1'hn.��c es�tihli.rhme�tls u�hich open i�r �he a��ri�rt� ivil! h�� <rtlair�cat ra j�rnci�k,li,c,i! und�or j�oci7 c•ertijic•urioirz txricir rn i�yeuirr;. lmt�rruer. 4r�ti n�usi ntrta ..II'ilt prc�ri�le rie thr.cprir>g prfcrr�o uprning"�m the npplieGrthat.J iu;>f�inal �;n^�ti •ro����or• v:uia�oi,7•i�a;oau�a c��f�F.�i.rfi -• ,:, • _ G?C�G�'i���`/[�C�7 = � :ir��i.re,���a�r rc�a i.tc�:ns�mr•.ta�irr.mi, C� �� � • I'IaG,ti:complc(c CE>nn and vtaclt;�71�K�cts+.ryn�ueuxncnts b}'Urcrrrrhrr 13 2(114. ��,` � g 2��� I^'niinrr m do so a�ilt resutt in ilrc rcmrn of��nur:ipplicminn�wic�ct. � l:�r��t��.ts�ti€r1r�:��t�t � aa HEALTH DEPT. ioe•�nrc�n �onu�sti��_�7 ,l�aY,�111�_.�g�_ ��t:s.x:yy—��2�.&[jJ �»u.��c,.tiuu�ir��tRo/,�� � 1 �,�,� i �i:u� nuuat tis: A�rd.+��akr�t�3 - _�Xi�K 4�.r�L_ � c�u�;t�x�itixt _�.Etr1-��t �sla -�r .0'a"1"Z _!�-tt t1 c�nL 6 , �-�-.——,+� _ � _ .._ � (D (dRPOItA UO\NAMts(Il^APPI.JCAIif.l'>:�S ,��1���'��/�u �,,.��--���' ��a�:.c,4,z S�n,.t� s�t �g �..,�;,�",� �m��---s'�'i.�.�rr, �, t�h��° �0 \iVt.l\6�1U1)Itt>tiS. - .: . . �0��, Pt3{)I.C-tsR'i'tF`IC:rI't7O;�5: � 'i'hcpunlcupcn�i�ormustbcrcrtified:�za!'aal(lprr.�tur,u�rr•yairnt6J�Statula�s. Nlc:ut:listtli4drsig�uncd Pcx+i Opresinr{s}atu!ati��ch a copr o{tlu certiGcns'ron Iu thix form. l, o Mnnl a��cruturs mast lis�¢�minimum of n�w emplag�ws tuaonUgecrtitie�l in Ux,,Sc uut�r s�ii�p�suu�d¢rd Fiist Asd aFxi£'onvaunity Cardtain�bsa�v�fy i2esuu;iintson tCPK).Ic�ving nae ceni@rd.vnpio�rc mi prcmixcs at:dl�imrs. I'ic:uc iisl Ihe emplo��cex txioe�nnJ aUach eopics of t6cire�rtilir.niau tu this li�mi.Tl�c Oetdth Ucpurtn�en��r311 nu[u+e p:�sl yc:�t:.'nMnrsis. Yuu roust pmriJc nen�cu�tias a�ss{»winhrin a fdc a�}•oar plsee nf bnniaess. � . � . I. � � ��. i�C3(7DI'i209'Iit:'1't6Ny1:i\rlGSiRR.C9iK'i7PICA7lUNS: c��(� r%N�� [ RC 14C'�S�E (,b� .�\II �iioJ serritt cstablitihmen�a am rt.�yai��d m Na¢e xt Wazt ime!id!•time employ��w9io i.c�rtilieJ:w a t�ond Prn[cction\i�itagcr.ax dcfitud in thr State S•s»iWry{Ip�i'ix Fowl ticn�icc tismblistmm�ts, i Ui(;�fR i90.0UU. Ykasc uuacii copics ufceniGcation tn�his nppli��alion.'I'6c Ile�tth Ilepartrocnt�rili nut usc g:u��'ran'rewrds. S"�m muKt pro1�idc n�we cupies a»d maeafain�6te at ynar��tahtuhment. I. � PIiRStl:�IA CILiKCiL"•: � �' ��� . � [xc#i tiwd e>tat�lishanea!nrast harc nt t�:Gq i7nc 1*�n.trn In Ctlr.�e(I'it'i nn nite during pnurx nl n�mr:uio�. 3. � \LLEIt(i7i\Clilt'CA'lC.nTIOh'S:�� �'� :lll fi�od xnicc esi:'hlish�nems arc reyuircd tn tw��e v Iw^�st onc lid4�ime empioyec�d�o has:\Ilcrgen cenificmion. . :�.Jctincd iu ihc Sr.��c Sanitan�CoJc Ii�r Fanl S�;n•icelixta6lishnunf.c.ltiS C\kR 594.04l9(GH3)(a). 1'kaxc stmck capiesoPeertification t<i Il�is ariptieatian. Tbe tleailt�Dep:�rlmcnl irill nut usc pasl�'cars'recurdn. 1'au musl pruvidr ac�e rapiez and u�aintain a Glc;il ynur es�u4ltchmeat. L_.._... ._��. itG.fA-ll..ICBt:GIY('IFIG1'i'I(7N5: � �II liwd servicc c+labliaNnums�citt�?S sea�s or mon:ncust hava at Icnct a�s sm�ln��vt train�K!in duu flcimliah \tane:u�'cr���s dm ptrnsist,�at aN times. I'ieax�lisl irour emptnyecs traiMxt in snti-ettuking ptuccdurcs ixic+w anJ �i�t:Mh cupics a1'amploycc ccrtifwtionn to�his fomt Thc Ficulth Dup:�rtmnnt��911 not usc p:a�ycsirc•rti�conls, S'wi tnu,t pru�'idr nca�copics aad tnaint:tin u Aic az y�ur�t@t��r nf buuncss. t. ? "'-.'.. ( •i' ' 3il��;S7':1i'it:l\'{'S1ifC!'I�:G: 'I'U'!'Al.i. t� (>FFtCF tfyti p7iLY i unlasc: IiCF�?t_h'I:pliRtiUHili 1'8�i�ilTH 11(7CRSP:Rfi4U1kCPH[F I'IR�11fv IJCIiRSIiRF.pUiNI:Ul9iP: i'iiit4l�.+ I4c11 S53 i]11UV T« \itllkL SIH3 3[s $$t -""""'�. .i:A\SP Sij "" SR`lU,til�(i!`OULSiltMa . ..... l�otNU' SSS '..�- `Ilidi6FNi'nNA Sliti ` . . t1'lI1NlPtN>L AI�Mn..�__.... FOOPSEiI\9C1:: -... .... . . .y� .. t#4XgltkEpi'IK�iUFffb I'FsitSNl4 4ICF\R7tiREt)liiitBDi},F. Pi7Lilif+ iRhlSiiktAt;lRIeUFj:t. PSiNbtli� �ilnrSFnfc TI73 __,,,�.. ,_C<7\TIRENf,U. S35 40\.1•ttlll°IT SiP __.,... AFi51(diti RIIU _ _._. _ �I)ll\IU11'IC. yAI �_ �.'�.-' Ltlk.lil:SAbf: $Sp .__. _.�. ...Rf.Sit),KT(titi�.�3R0 ._.__. !U.thiL N:NTR'C: �icr:�•s�Ik[u�•�ut:u refi rE�awrw ticcvxF.uerN:uarn ii:r. rekaa��= iicf�.� ar:oo�sPu eeP. ro-:ies�rr> — .sfxu�;y.n. i3p? `FR(�Y��i S'RF �I..VSk�6_t(kH)RS _"__ - .� �7�},'C� ,_ :$SEft9 StA ,i„_ _TU71ACC0 Si tit _' "_" .�,�rceu.+.�ce: sis _....�. AD�oU\Tnut? � S :i.;;. ...,•ri.rnxe'rm�nnv�:e.�rcu<'o.�frvt.cre:umeiixmr,nrrorsar••.• �tf� � ����� G�3�"7��� r z�19�1� _ ,... ' ,�t��n:�n•ru:ii�io� � ; � CitdcrClwrk(I32. weu25C.tiubS�titionG.�he'fmvnot'S'an»uut6isnmvrcquircdtoliuidissu:uieeorrenea:d � , ;�+�l:q�r;Iiccnscur pc�nii tn u�r.�te a business if:�pers�m ur eam�:im•.Mcs no�ha�Y:�Ccnifir.nc of Wnrkcr'. ' t'uw�xns;nion Inwr�nm. 7'llli A"1"1'ACIIED ti7'A'1'Iti �1`0!{li1?I2'ti C01iPE\ti:Ct'10\ t\SI'2�KCp: ,v�r•u�.���r;aius•t7�ti;ct»rr�,t:'nst�,��u stcnra>,o�: � :�. : �� � �, e��� .� ; t _ _ crr.r.oi>i�sina:�r:��i::�rr:�cuet� ,� nK ��c�Kti�at�s ca�tr.,�r•r•iu,�vrr+u��t_u:wu,�rr:�ri n:n llnrn of 1'am�oWh Ci�as mtJ licn.mu.0 t+c p;�id pripr to rcnc�val or is>unn�Y ul cour�xrmils. PI,EAS('s CtIGCIC AYPKUPRIA"1'141.Y'IF i'AIA: / YI�.S_.. .{- tdn hi0'1'4:Lti A\P Q'1'111iR LODCI\G Gti'fAlil.I511i�1F.N'I'S '1'K:\\ti!G\'1'OCCUI'ANC)': Fprpurpnursnf�helimilalinnsul\duidorHo�cliu:.'Pnnsiem�wrupmxpsh�iltm Iimii.J lo Ihe tempanq�and sixm[crm uccu�uncr.urJinarilp and c�uhnn:�rily etsxrei:rtcd�rith mnlcl and huiol uxe. Transicnl �xcupanls mu�t L:n�v and lu ablc �n Jomuns�ntc ttmt dicy m:�imRin .i princip:J pian of rrsiJoncc cfvadicn.�fnmsicnt�ncupa�Kp sltd!gc�Yally�rNcr�ocuminun�u.xriyr.wcyof not murc thm�thim'f30)daas.mxl :m acgrcf:atv olliot mnrc Nr,u1 ninr�y(91q Jn��.�cithin:mv sis 1�1�������II��xvi�xl. I;s�ida g�kst unit:u:t raidcncc ur i'.���ollinc unil JcJi not ix ennsiAcrcd Iranzicnt. Uaup:mc��Ihal ix wihjcc�tn IBo ad3�Ylion ol'Iten�m Oecnpancp P'scis��.:u ddinrd ia\I.Ci.t..c.Gaf or 83(7 CMR Gd(i.as amenAcJ.siw111�¢ucr,dly fx•co0.<iJCnYI'fr.msi�ut. POOI.Y i'OOL OPE\INC:.111 s�cimming,���Jing and ufiid�als a�hic6 kn•c txrn ck�•d iorUic usson muu tn:ii�sprctcd hc thc I�calt6llepanm.nt priar lo oPci�inc. Cumnct�hc Iicalt6 Uc •mmcut to sch��ulc ibe inspectiou tLrcc(3) Ja}'s prinr to uprnin;;.I'l,.I;.\til:\O�I'li P�roplc urc?�Q'I'alloicc�io sil in lhc{�ul arca nn�il tik pool 6as�ron inspccticJ and u7xnrd. POOI.�YA'Pk:it'1'liti TI\G: 'ihc��:�icr musi Ix atiycil fur pscu�lumo�u�c.taal colili,nu nnd stanJanl pia�e caum b��a titatc ccrtili�Yl lah. anc!suhmi�0.`cl to thc IIc:Jtb Dcp:vtmcnt dvcc!3�Jays priur i�,o�nning.:mJ yu:utody ti�crr�Ocr. POOL Cl.t)til\(::licen�rnttdua�in gnnmd s�imming�xrol nnci tx drsineJ ur covercd�ciWin svicen ill Ju}s nf .. dusinEt. i�00U SICit\'ICF: St:AtiOX.V.FOOI!SIiR\'IC:1;OPF.UXS:: �VI iiiod servin csc�Mishnxuts ntazt Ix�inspeqcd by lbc I ic:dtl�Uq,anmcnt prior ro opcning. Plca.tt:.umact ihc i��:�i�n o�n.uu�����,�„S�n4a�a�un�nS�K����,��a�n��s}dars prinr io o�xning. C:1'i'F.RI\G PC)I.ICI': ,�u��»i.���In�ca�cn�cithin d�c'fi���n ui l':�minu�h mus�aotitj•thc 1'amwuth }Iralih I)epar�m�T� by lili�ig Ific rr,;uircd "I'em�xmin� Po�ul Scn�irc:\ppliu�ian lom� 7? hours prior ia ihc catu�d crcnt. 'lltcsc fixms can Ix uMaincdanl�ci�kai�hUcparumvu.nrimmtht'fnan'sw•cbsilc;ii�e.����.cannnm .ln;�q�,gtmd¢rllcdt6(>cp�nmcnt. Dot�nluadahlc fonns. FRO%4:�DEtiSlili'1:1: frorrn dessen,mu.i lu�c,ieJ Ip a tiw�e eeniticcl I,b prior iu upeninc anJ momhl}lhercn(ier.uith smnpie resnhs sui,mit�zJ io�hc I lcald�Do�smmcm. 1':iilurc io du sqx�ill rcsuli in thc suapensiixi or rcvocalion ol}'our I�nrzcn Ucsscn Pcm�i�imtil ihc:iUi�a�e iennx liuvc hea�mei. � � . . . OC'fSlUli GIFI•'.ti: O:etside c:drs{i.c..owdoan¢:uinz xi�t��raitedi�cdtrexa a�n�irc}.ntust hm�c prior aM�rorai I'rmn�he iln:vd ot'li�yl�h. Ul�'I�llUOR COOI�f\G: UuW�xircouking.prcpumtion.ar displ:rv of anr linKl pmdnct M a mcti!ur IiKiJ x:rvicc es�ihlishrocut is proLibitcJ. \O'1lCE:Penniu run annualtp fimm Januaq�I ta Dctnnbcr 3L PI'IS l'OGR R4:tiPt)\Sl UILl71'TO ItE'P(;Ii\ PIIfE CO\ii'LG'ftill Rii\h:U'AI.APPLIC,\'!lt)X(Si:1\U It6Vi'IRIiU i�liP.(Si ItY UGCIiMlifilt I5.'_tlla. AL7. RI'\OV:\I7(�NS -f(7 :1\l' POOU fiSl':\ISI.ISfI\Ili1"I�. \iC111iL UIL PUOL li.c. 1'AI\1'I\ti, \1:U' tiQi;IP\IIS\T,6:fC.).�Il�ti'I'RF.KItPf)Rllsll'I'DA'iDAYPROVIS!)Itl"fiI�RONtUUI�Hft:V.Tli 1'(tlOR i���c'<�U�i�:�cF.�ifi\I�. Iii;\OV:�fIpT.S�4L�1'Kh:Cn!IRI�.A�Il'id VI..\�. U:U7�.: � Si(i\:1'PURfi: 1'Rl\7'\Ak1E N'll]'I.lt: :, n ,,u � "!'ft� C�xurtrot�weitlttr of rktnssartrusetts � �� Depnrtute»1 aflrtrlrre•lrialAcriticrrts• �,rftCl'G,r]tA�CSf7,g(lJ7ql7S 1 eougrc�ss SYrrer,Srritr IOtI �� 6ustar,111A 0�114-3U17 rvn��v.�nnx,s.b�orJtli�r Wprkecs' Compensntion Insi�r.�nce Affid.iviY: General Businesses .� �licant Tnfarmation Ple.ise !'rint LeQiUh� �3usiness;Organizationi�amc: �'it!'(2},��`1t1,�e�t'r�y�5"��'��=__. ncidfess:___�GlJ c C`'K' _j�r----_.___ .r. Citti�iStsue!"I,ip:,�1,j ' � Phone�:: �p�'"����c� Ar�c 1 an rmn3aticr?Ci�eck the as�propriatc Ewa: Bus��n Tti•�rc{rec�uiretl}: L L.� ! .i�u a omptoyer�vith�_employeos(full aiid/ �. L! �<e�ail ar}�nrt-tim�).* G. �R�staurantJBarlEating Establishment 3.Ci 1 cam s solc prtiprictar or pannersbip as�d tiavc no 7. �p�ce andlzv Sales(inrl.rca!eztate,�ata,etc.} cn��itoycws H�arkins 1'or me in an�•capacity. [10+��arkcrs' camp.Sost�rance rtK{uiredj S. ❑\on•profit 3.❑ 1Ve:v�u corpara[ian and its of�icers have cscrciswd 9. ❑ Entenainmont thcirr'sgGsofa�er�ij�csanperc. 3i3,xi{4},anditehai�c �p,0 �4�anufacmrin� no emplvyces.(Vo worker'wmp,insurancc�equircdj"' �� ��a���th Car� •I.❑ tt'c ari:a non-profit or�onication,statied by�voluntccr>, ��ith uu cmplovezs. [t�o��orken' rump. insurancc nq.� 13.�Other___,.� 'Aar applicant that Ch�is box�1 must:sl,iw{iil uut thc seetiun bcla�csM��+ing Uicir xurl'sri compr.nv�ion policy inionnatinn. . ""[!Qs�c�upnrale uflicers havc c�ciopuYt thcnwcch�cc,hut�hc tor�aratian hax o.lrer cmployccs,a.ivsF:ca'u>iapc�u.ition pnfiay i>nyuiu;!uici ss:ch an Jt�::SIt1Y2l�IW�!i}IO\I�d l'�lCi�.{16X lT�. 1 zrm an enlpfurer t&at is pr�nlrlTa{nro�kerx�'cnu�r�rn,s�at�infl iasarunre fnr nt}'tiuPfnyecx ticto�r is tGe potir}'Infrurrtu�tnn. InsuranceCanptu�y\uino: �1w��-y� !__� l��,1�tJ/� L _ lncur4r's:l�idrt�s:_��/T7J /"��7'�'+� K Je ____. C'in�;St:uc/7i�: (� G��_�• �f1� 1 /_ ,�,,. f'ulicy�ur$ciC-ins.l,lc.:�_ � � �D v ;i �!��/' Espiratian Date:^�� — :ltiach a cup��oC tl�e ssorkers`co �aensutinn policy�cclurntion page(shoe�ing t6e policy numUer and espimtion date). I�aitura to scetitre covcragc as roquiriKl under Seetiott 2Stl pCk1Gt.c. I>2 can Sead to ihe imp�sition oCcriminai pr:nalties af u ti�ze up tE�fit,i00,0(�andlor a�o-�ear imprisonmene,ns��•clf as civil pr:naltics in thc ibnn afn S'I'OP 1VORK ORUEit.md a tin� ��f up�a 5350.00 a day against the��iotat�c Be�dvis�d th,�G:�eopy of this siatument ma}�Gc tonvar.Iccl ta the OFYice ut lnvestigation;n1'Qie U1:1 for iiuurance coverage veriGcatio��. I r/o leere/�y ccrtJf��,ruu �lee pains u!peimlties of perjnn*!lrnr t/�e tnforruatian pruvideJ abure i.�lrrec und currect. `i1HIYlttlfC` �""l____--- � ,_�,Y {7341': �7(111"i:: UjJirin!fesr ou[,s�. Da rFut wrfre in tliic are�y ia he rniupleted by citj�ar toavie ojfteletl. Cih'or'C��va: PermiULicense� Ixsuin��Auth�rih�(circic onej: � t. 13nnrct ntllr.rttl� 2.13uilctin;;llcp:irtment 3.CitjdTu�rn Clcrk i. I.iccnsin�a 13uurcf a 3�lec4mun's OI'ficc G. OU�cr Cont:ict t'erson: Phone#: xwrv.m�sx.�vfdin ^ ,: "�n� CERTIFlCATE t3F LIABILITY INSURANCE Page � of � oaiZei o=+' TNIS CERTIFICATE IS ISSUED AS A MATTER OF INfOR�tATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVEtY OR NEGATIVEIY AMEND,E%TEN�OR AITER THE COVERAGE AFFORDED BY THE POL�CIES BELOW. THIS CERTIFICATE OF IN3VRANCE DOES NOT CONSTITUTE A CONTRACT BETW6EN THE�SSUING INSURER�S),AUTHOR2ED ftEPRESE N7ATIVE OR PRODUCER.AN�THE CERTIFICATH HOIDER. - IMPORTANT: I(tlw cortificate holder is an ADOITIONAL INSURED,IM1e policy(iespnusl Ua ondorsod. it SUBROGATION IS WAIVED,subjact b tiw eerms a�d aontlitlons oftbo pd�ty,eonain policios nmy requiro an en�or,emenL A statemont on thle eerQfleatn doas nat conter ripbts to Ihe certilic�to holder in linu of such endonemeN(s). VRO�UCEN � I"' __.____ �. � itlSliu oL ttaw Yo:k. 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