HomeMy WebLinkAboutApplication and WC ^' TOWN OF YARMOUTH BOARD OF HEALTH
��� APPLICATION FOR LICENSE/PERMIT-2 i�.�'�,. ��� 2 9 2 �`
` * Please complete form and attach all necessary doc nts y Decem6er 5 2014. �
Failure to do so will result in the return ofyourappiicahon packet HEALTH DEPT.
ESTABLISHMENT NAME• ' PHr� S4�(L� l�l-C. TAX I "
LOCATION ADDRESS: c'3�I b (L� � , �•C�a��az�-, rr�� ��#: '�$ —t-1 �,��
MAILING ADDRESS: �.-��
E-MAIL ADDRESS: ��-�e�ors Ca�Pe QAm�,t\ . 'Lo,n
OWNER NAME: pe�l.ma�.�. P�� �
CORPORATION NAME (IF APPLICABLE):
MANAGER'S NAME: ��1 e�t� , TEL.#:
MAILING ADDRESS:
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 file at your place of business.
1. L�r�S 't���. 2.
3. 4.
FOOD PROTECTION MANAGERS - CERTIFICATIONS:
All food service establishxnents 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 CIIARGE:
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
l. 2,
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 Department will not use past years' records. You must
provide new copies and maintain a file at your establishment.
1. 2.
HEIMI�CH 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 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# LICENSE REQUIRED FEE PERMIT#
—� $55 C'��N $55 LMOTEL $1.0 O 2
LODGE C�P SWIMMING POOL$I IOea.-s���[�/
_ $55 _TRAILER PARK $$OS �WHIRLPOOL $l IOea. �
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_�I O�SEATS $200 �CONTINENTAL $35 ! - �( _NON-PROFIT $30
_COMMON VIC. $60 WHOLESALE $80
RETAIL SERVICE: _ —RESID.KITCHEN $SO
LICENSE REQIDRED FEE PERMIT# LICENSE RE UIRED FEE PERMIT# �
<50 sq ft. Q LICENSE REQUIRED FEE PERMIT�
<25,OOOs ft. $I50 �ZS,OOOsq.ft. $285 _VENDING-FOOD $25
— 4� _FROZEN DESSERT $40 _TOBACCO $110
NAME CHANGE: $15 AMOUNT DUE _ $ �SS�00
�+ D OKI 02 Fl h�2-
�F pp�p g��� i._ /31/i� *****PLEASE TURN OVER AND C � m �, � �`�p�� FORM***** � PA�
�N- l 2O15
�17o . 0d o�a�D ' ��'� �70. bd
ch:-#IzS�' � z�Z,�l�
ADMINISTRATION
Under Chapter 152,Section 25C,Subsection 6,the Tawn of Yarmauth is now required to hold issuance or renewal
nf any license or permit to operate a business if a person or company daes nnt have a Certificate of Worker's
Campensation Insurance. TFIE A1"FACFIED ST'ATE W012KER'S COMPENSATTON INSITRANCE
AFFTDAVIT 1VIUST BE COMPLETED AND SIGNED, OR
CERT. OF iNSURANCE ATTACHFD
OR
WORICER'S COMP. AFFIDAVIT SIGNBD AND ATTACHED
Town of Yarmouth taxes and liens must be paid prior to renewal nr issuance of your permits. PLEASE CHBCK
APPROP[2IA"['ELX IF PAID:
YES NO
MOTELS ANTI OTHER LODGING ESTABLISHMENFS
TRANSIENT OCCUPANCY: For purposes of the limitations ofMote l or Hotel use,Transient occupancy shaJl be
limited to the temporary and short term occupancy,ordinarily and customarily associated with motel and hotel use.
Transient occupants must have and be ahle to demonstrate that they maintain a principa] plaee of residence
elsewhere.Transient occupancy shall generally refer to continuous occupancy oPnot more than thirty(30)days,and
an aggregate o£not more than ninety(90)days within any six(6)month period. Tlse of a guest unit as a residence or
dwelling unit shall nat be cansidered transient. Occupancy that is subject to the callect3an of Roam Occupancy
Excise, as defined in M.G.L. c. 64G or 834 CMR 64G, as amended, shall generally be considered Transiant.
P40LS
POdL flPENING:Alt swiinm9ng,wading and whirlpoals which have been ciosed farthe season musk be inspected
by thc Health Department prior to opening. Contact the Health Departrnent to schedule the inspection three(3)
days prior to opening. PLEASE IV4TE: People are N4T allowed to sit in the pool area until the poal has heen
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.
P44L CLOSI1tTG:Every outdoor in ground swimming paoi rnust be drained or coverefl within seven{7)days af
closing.
FC►OTl SERVICE
SEASONAL FOOD SERVICE OPENING:
All food service establishmems must be inspected by the Health Department prior to opening. Please contact the
I Iealth Department to schedule the inspection three(3)days prior to opening.
CATF.RING POLICY:
Anyone who oaters within the Town of Yarmouth must notify the Yarxnouth Health Department by filing the
required Temporary Foad Service Application form 72 haurs prior to the catered event. These forms can be
obtained at the Health Department,or frorn the Tawn's websita at www.yarmouth.ma.us under Health Deparhnent,
Dowtiloadable Forms.
FitOZEN DESSERTS:
Frozen desserts must be tested by a State certified lab prior to opening and rnonthly thereafter,with sample results
submitted to the Health Department. Failuze to do sa will resulf in the suspension or revocation of your Frozen
I7essert Permit untii the above terms have been met.
QUTSIDE CAFES:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have pzior approval from the Board of Health.
OUTDOOR COOHING:
Outdoor 000king,prepazation,�r dispIay of any food product by a retail ar food service estabIishment is prohibited.
NOTICE;Permits run annually from January 1 ta December 3 I. IT IS YOUR RESPOPiSIBILITY Tt3ItETUIZN
1'HE COMPLETED RENEWAL APPLTCA'ITQN{S)AIviD REQITIREI}FEE(S}BX DECEMBEi2 I5, 2414,
ALL RENOVATTONS TO ANY FOOD ESTt�BLISHMENT, MOTEL OR P�OL (i.e., PAINTING, NEW
EQL�iPMENT,fiTC.},MUST BE REPQRTI:D TO AND APPROVEI7 BY THE BOARD C}F HEALTH PRIQR
TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
L7ATE: SIGNATURE:
PRINT NAME& TITLE:
RCv_It/43tS4
' � � The Commonwealth ofMassachusetts
Department oflndustrial Accidents
Office of Investigations
' I Congress Street, Suite I00
Boston, MA 02114-2017
www.mass.gov/dia
Workers' Compensafion Insurance Affidavit: General Businesses
A�plicant Information Please Print Legiblv
Business/Organization Name:��n�*.c��e���c-� ��
Address: �-�(o �1� �T"�- tX�.0 c�clOvti�n vYlPr b8.��`l '3
City/State/Zip: Phone #: �� `j,`j5 aC�,��
Are you an employer?Check the appropriate box: Business Type(required):
1.�I am a employer with�employees(full and/ 5. ❑ Retail
or part-rime).* 6. ❑ RestauranUBaz/Eating Establishment
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 corporation and its officers have exercised 9. ❑ Entertainment
their right of exemption per c. 152, §1(4), and we have 10.❑ Manufacturing
no employees. [No workers' comp. insurance required]*
4.❑ We are a non-profit organization, staffed by volunteers, 11.❑,�/Health Caze
with no employees. [No workers' comp. insurance req.] 12.0 Other �
•Any applicant that checks box#1 must also fill out the section below showing their workecs'compensa[ion policy infoimation.
*•If the corpomte officets have exempted themselves,but the cotporation has other employees,a workecs'compensation policy is requ'ved and such an
organization should check box#1.
I am an employer that is providing workers'compensation insurance for my empinyees. Below is the policy information.
Insurance Company Name: �Co.�t e�V���
Insurer's Address: �'(�� e��P C Sqv.ole-
City/StaYe/Zip: ��-�� b� � $�J
Policy#or Self-ins. Lic. #_�.t= �—t �'� (p�-�'� ^� — ��- Expiration Date: o�
Attach a copy of the workers' compensation policy declaration page(showing the poticy number nd e piration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of cruninal 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
Invesrigations of the DIA for insurance coverage verification.
I do hereby certify,under the pains and penalties of perjury thal the information provided above is true and correct.
S�ature: � � �� •� Date:
Phone#: /
Officia!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 Oftice
6.Other
Contact Person: Phone#:
www.mass.gov/dia
,f tr p .iMIM�
TRA M EL.G iif�� WORI{ERS COMPENSAT�ON
vtis _�our,r s4�aee AND
uxo'TFnA", `'.��� a�.'`'� EMPLOYERS LfABILITY POLICY
TVPE V INFORMATION PAGE WC 00 QO 01 { A)
PO�ICYNUMBFft: iZEUH-3Ai6&47-2-14}
RENEWAL qF (YEUB-1A7684?-1-13)
iNSIfftER= R"HE TRF+�4ELERE INpE[4t77:TY COMPANY tiF C(3NNECTICU'C
NCCI C4 C4DE� 22631
1
iNSURED: PROt7UCER:
SPxPhS= SH1�1�: i,r: GR�VSTE PRQ�ESS�ONAL ZN:�
')HA 't9F. THi.fIVUF.RHZRP MOTEL Fi600 KOLL CTR PKWY 9TE 100
?�G kkZtJ STRaF:�t PLEASANTOhT CA p956d
;vESi YAIiN,C�']'H MF. 025i3
�i�5?�t�ti i4 ei LZ`kiZTFF 1,SAHT_LTTY COL�iPAIv'Y'
O:h�r evcrh Qlt cas anc i��ntifioa}ion nun�Ders are sY�iown in tE;� sehe;c!u!e(s}attaehc�d_
Z 1'he��ni�cy periad Is fr�m o5-a3-14 fo 05-23-15 12:01 A.M_ at the insured's mailing adtlress.
3. A: WORKERS COMPENSATIpN 4NSURANCE: P€irf C1�e�t the pulicy a�pltes?n the UVarkers
�vrnpansation L�w ra{ihe state(�}Iisted here_
Ma
8. EMP�QYERS�IABIllTY INSUFtANGE: Part Tw•a aP lhe;u�iir_.�appiies to werk in each state ti,ted�n
i[em 3.,'3._ ?Pte lirnits of our liat�ility under F8d Twn arg:
I;odily ��n,wy 6y Accident $ 10UU00 Fech AcciG�nt
G+adity !njut}�f�y G�is�sese: S ssOGi7o r�>aiicy Limit
0odily lnj�uy hy L�i52ase: $ 100G00 Eacit Eln�loyee
0, OTHER STA7�5 INSURANCE: ?nrt Three of the polioy applih's ta !he ��ntas if any, fistad here.
hL AR AZ C'F: Cp rT DC D£ Fi� GA HI IA TD IL IN R° KY I�,A t?b ME MI MN
ht0 ?28 @22` NC NB h'H AT3 N'�.4 Nl' ?+PC 6S QR PB RT a"C SA T:i �F. J1 Z?1 6'T WI
;v"�.'
t7. '��"hs ,��tcy inciudc s these enclor�en�ents anci �chedula;.
SrE T,TSTIN'G OF Et�ilORSr�MENTS - EXT$NEION OF TNFO FAGE
4 i�Y= �rta��u '�f=�F Sttis Sallcy���lif'he��'termir�ed �y ou�?i,tan�ais nf Ruies. C;ias,if�,�;r0"as. RateS 2nt# Rating
�"���r�,, A iE-yGirea i� `or.i atinn i;�ubject to veriPicatian arrd change by audit to;,e rnade nrrxuALLx.
DATEQFISSUE: Q4-1_-`_3 VR
OFFICE; PAYROLL 7oA
PRCSFS(it'.Fq� rRan:FTF. ?>nf�pRGRTCitdAi. TN4 X'��Si,
TRAVELERS� waaKe+zs camP�r�sariarr
AND
cn3 T`�ras� etiup��� EMPLOYERS LIABILITY P6tiCY
NA3TF�&D, CT Gs"151
E3TENSIOEF OF SNF� P:9GE-SCHGDULE WC 40 04 62 ( Ai
POLICYNU�tISER' (Sa^.t6-1A758h7-1-19)
:N3URER: T'sSE 'PRAV�LERS ZNDEMNITY" COMPANY OF C�NNECTTi'.IIT
1.�.437-�'S�1
TNSURESI'S fJAME: SWAh!I SHREE LS�C
DHA THE TACiNDERBIRD M�TPsL
pREMSUM BA6IS
ESTTMxTED ftATfiS ESTIMATED
' TOTA2� APINUAL PER $1�4 OE' ANNUAL
CLA£�IFICATZON� CODE REMUNSRATS013 REMUNSRATION FREMZi7M
T:0!'.AT'DN 9(fl Dl.
F:IPt �tv"PTfiY (:D 601
�v'r.Fs:: S::REE L�L'.�
nS3 TF3� fiHt7[�ER&ZRL� MOTSL
Zjp ,u,pZN 51"kEET
i$EST YARIdOUTA, MA G2573
S=C CODE: 7011 NAIC3: 721199
M.GTFL: ALL GTEIF.B EMPLGYEES
� „-'„ . 9452 .�SIEo 1,58 39S
6fA MANtiAL PRWb1�'.UM. a" 398
-"'--"'--'--"_-'_'-"-"'--"--"""--"'-'--"'-"------"-"'--""'--^--"--`
F,XPFF.TEN^E M07SFICATION: NONE MOD2FIFD PREMITThf $ NONfi
T�TAL k;;:TIT�FaT&U tsNNttAL 5TANDeSRD PR&�ZUM 399
L095 CONSTANT (0032) 20
ERPEtdSE CQN3fiANTt@906} Z56
TERROxSSM (9740) 9
M.�l k7C SPk'sCZAL FU2tD A?7D TRUST FUN➢ 14
TOTAL ESTSMATF.D PR�MIt,iN. 6`+0
DEFflSTS ��f6iFN2 DLiE fiN('
"lATF i�� lVSI i4-� :t1-t:_1d ;�z SC'.FtFhi It F.'v(7� 1 r�F T-n.wR