HomeMy WebLinkAboutApplication and WC . = �� � �
a . TOWN OF YARMOUTH BOARD OF HEALTH '
��� APPLICATION FOR LICENS�T/P T PiAY Z O ZO15
�"' * Please complete form and attach all nece ` mb PT
Failure to do so will result in the ret�`rn o "' `" a i ion
� ESTABLISHMENT NAME•�Kk Cu..�J4( CZ1 r �?- Y�.�. .-- � TAX ID:
'' LOCATION ADDRESS 32.�j .,�ia, ' S-�� ��civ d..-�-G. �e EL#•�g � �G 9 7�
� MAILING ADDRESS: � � � � �
E-MAILADDRESS: ;�ns�vr an �� � ��
� OWNER NAME: ��
CORPORATION NAME (IF APPLICABLE):
� MANAGER'S NAME: 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)arni attach a eapy of the certificatier�o this forrti.- --�-�–��=------�---�–t �– -�—
�. N /� �.
Pool operatars must list a minimum of rivo employees currently certified in basic water safety, standazd First Aid
and Community Cudiopulmonary Resuscitation (CPR), having one certified employee on premises at all times.
Please list the employees below and attach copies of theu certifications to this form.The Health Department will
not use past years' records. You must prov�de new copies and maintain a file at your place of business.
l. I��� 2'
3. 4.
FOOD PROTECTION MANAGERS - CERTIFICATIONS:
All food service establishments are required to have at least one fixll-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•
rEi2S�Iv��i,Hf1�GE: _ . _ _ _ _ . _ . _ _ – - _ _
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. "
1. 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. 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 a11 times. Please list your employees trained in anti-chokmg procedures below and
attach copies of employee certifica6ons 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#
B&B $55 CABIN $55 � MOTEL $110
—INN $55 CAMP $55 SWIMMINGPOOL$IlOea.
LODGE $55 _1RAILER PARK $105 _WHIRLPOOL $IlOea
FOOD SERVICE:
LICENSE REQIDRED FEE PERMIT�! LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE P R�S I l#9 .
0-100 SEATS $125 _CONTINENTAL $35 �NON-PROFIT $30 6
—>100 SEATS $200 _COMMON ViC. $60 WHOLESALE $80
— —RESID.KITCHEN $80 �
RETAIL SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE RE UIRED FE�1'BRMIT�--_S.ICENSE REQ�JIREA�FEE. - R^�.�-"..':-.-T�---- ..
-- � e5g-s�-,ft,�----$5$--�-----�-—���- > , sq.ft. $285 VENDING-FOOD $25
<25,0 Osb q.ft. $150 —FROZENDESSERT $40 _TOBACCO $ll0
NAME CHANGE: $15 AMOUNT DUE _ $ 30.op
*"***PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*****
j
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ADMINISTRATION
Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance ar 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 ta�ces and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
yES NO
MOTELS APiB O'FI�ER�ODGING ESTABLISHMENT�- _ - _
TRANSIENT OCCUPANCY: For purposes of the limitations of Motel 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 collection of Room Occupancy
Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, sha11 generally be considered Transient.
POOLS
POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected
by the Health 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.
' ' _wnd swimiri n��oo?must be drained or covered within seven(7)days nf _.
_ .4__ __ _ �-
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 priar to the catered event. These forms can be
obtatned at the Health Department,or from the Town's website at www.varmouth.ma.us under Health Department,
Downloadable Forms.
FROZEN DESSERT5:
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
-- �ssgrt-Permit untiLYhe aboye terms have been met.
OUTSIDE CAFES:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. .
_ _
_ _ _
_ - - - _ _
OUTDOOR COOHING:
Outdoar cooking,prepazation,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 ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT, ETC.), NNST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
DATE: SIGNATURE:
PRINT NAME&TITLE:
Rev. 11/03/14
' ' t� The Corrzmonwealth ofMassachusetts
Department of Industrial Accidents
Office oflnvesfigations
� 1 Congress Street, Suite 100
Boston,MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Annlicant Information Please Print Legiblv
�' Business/Organization Name:
i/Address:
'�City/State/Zip: Phone#:
Are you an employer? Check t6e appropriate box: Business Type(required):
1.�I�m a es�la�a xriU� -e,(a...��tD�.�es-(full and/.y. 5. ❑ Retail
or part-time).* 6. ❑ RestaurazitlBaz/Eating Establishment
2.❑ I am a sole pmprietor or partnership and have no �. � Office and/or Sales(incl.real estate,auto,etc.)
emp]oyees working for me in any capacity.
[No workers' comp.insurance required] $• �Non-profit
3.❑ We aze a corporarion and its officers have exercised 9. ❑ Entertainment
their right of exemprion per c. 152, §1(4), and we have 10.0 Manufacturing
no employees. [No workers' comp. insurance required]* 11.� Health Caze
4.❑ We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp. insurance req.] 12.❑ Other ,
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
•*If the coiporate officers 6ave exempted ihemselves,but the coxporation has other employees,a worke=s'wmpeusation policy is required and such an
organi�ation should check box#1.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy infnrmation.
�/Insurance Company Name:
�/Insurer's Address:
I/City/State/Zip:
✓"
��o�icy#vrSeki-iir.�ic.#— -- ---��piratioa-BsE.,: _ --- - --- _
Attach a copy of the workers' compensation policy declarafion page(showing tLe 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 penakies 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 DIA for insurance coverage verificarion.
I do hereby eertify,under the pains and penalties of perjury that the informa[ion provided above is true and correct.
Si�nature• Date:
Phone#:
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 O4'fice
6. Other
Contact Person: Phoue#:
www.mass.gov/dia
STATE OF NEW YORK
WORKBRS'COMPENSATION BOARD
CERTIFICATE OF NYS WORK�RS' COMPENSATION INSURANCE COVERAGE
la. Legal Narue&Address of Insured(Use strect address only) lb. Business Telephone Number of Insured
FIRST CONGRECATIONAL (508)-362-6977
CHURCH OF YARMOUTH
329 ROUTE 6A
YARMOUTH PORT,A�t 026 75-1 81 7 ic. NYS Unemploymenf 7nsurance Employer
Registration Number of Insured
Work Location of Iusured(Only nquired tjcnvernge is apec�calry ld. Federal Employer ldeutiCcaHon Number of Insared
1huHal to cerlatx 7ncaltousln New YorkSYate,l.e n WmµUpPoJlcy9 or Socinl Security Number
04-6110040
2. Name and Address of thc Entity Requesting Proof of 3a. Name of Insurance Carrier
Coverage(Entity Baing I,isted As tLe Certificate Holder)
CHURCHMIITUAL INSDRANCE COMPANY
TOIYNOF YARMO(ITA
HLALTH DEPARTbflc'NT
1146 ROUTG 28 3b. Policy Number of entlty listed ln box "la"
SOUTH YARAIOUTH,MA 02669
018760&07-742369
3e. Policy effective period
IZ/13/14 to 12/23/IS
3d. The Proprtetor,Partners or Executive OfOcers are
❑ inetuded. (Only eheck boc ifall pnMers/officers included)
� all excluded or certaln partners/ofticers excluded.
This certifies tUat Hie insurance carrier indicated above in box "3" insures the business referenced above in box "la" for workers'
compensation under the New York State Workers' Compensation Law. (To use this form,New York(NY) must be listed under
Item 3A on the INFORMATION PAGE of the workers' compensation insnrence policy). The Insurance Carricr or its licensed
agent will send this Certificate oF Insurance to the entity listed above as the cert�cate holder in box"2".
The Znsurance Carrier wil!a/so notlfy the nbove cra•1�cate Itolderwtthin 10 days IF apolfcy is canceled due lo no�tpayment ofpremrums
or witkin 30 rlcrys/F Nte�•e are reasous other than no�rpaymei�f of premiums thal cai�ce!tHe polre��or eliminale i1:e ii�sured fi•om Ihe
coverage indicated on dzis Cer/ificate. (Tl�ese nolices may be sent by regular mnil.) OfMenntse,/his Cerl�/tcrtle is vn/Id fnr one year
njter t/ris fornr !s npproved by iLe i�rsrrrnnce canler or ils(iceused nge�tt, or nnN!1he yolicy eapimtlou dnte listed in box "3c",
whkl�ever Is earller.
Please Nofe: Upon the cancellation of t6e warkers'compensation policy indicnted on this form,it the business conflnues to be
named on a permit, liceuse or contract issued by a certificate holder,the business must provide tliet certificate holder with a
new Certiffcete of Workers' Compensetiun Covcrage or otLcr authorized proof thet the business is comptytng with the
mandatory coverage requiremevts of the New York State Workers'CompensaHon Law.
Under penalty of perjnry,I certi[y fhat I am an suthorized repirsentat[ve or lieensed agent of tite insnrance earrier refereuced
abovc and that the named insured has the cwerAge as depicted on this form.
Approved C/trlstoplrerA. Tetzloff
by:
(lRint neme of etuhorized represenlslire or licensed egent of insurence certia)
Ap�xnved /� ���A � Fe6ruary 18,2015
by: C � i) lfoY V
(Signature) (�)
Title: Servlce Representalive
Telephone Number of aathorized representative or licensed agent of ins�irance carrier: (800)-554-2642
Plense Note: Orrly irtsurance carriers mrd tTteir licwrsed agents are n:dhorized/o issue Form GIOS.2. Insurarrce 6rokers are NOT
nutlrorized!o issue it.
C-105.2(9-07) www.wcbstate.ny.us
Workers' Compensation Law
Sect[on 57. Restrtetiou on issue of permits and the entering into contraets unless compensation is seeured.
1. 17ie l�ead of a state or municipat department,board,commission or o�ce authorized or required by la�v to issue any permit for or in
connection �vith any work involving the employment of employees in a hazardous emplo}went defined by this chapter, and
notwithstanding any general or special staarte requiring or authorizing the issue of such permits,shall not issue such pemiit unless proof
dttly subscribed by an insurance carrier is produced in a forrn satisfactory to tl�e cha'v,that compensation for ait employees has been
secured as provided by this chaptec Nothing herein,however, shall be conshved as creating any liabiliry on the part of such state or
municipal departmertt,board,commission or office to pay any compensation to any such employee if so employed.
2. The head of a state or mnnicipal department,board,commission or office authorized or required by law to enter into any contract for
or in connection with any work involving the employment of employees in a hazardous employment dafined by this chapter,
nonvithstanding any general or special statute requiring or euthorizing any such contract,shafl not enter into any such contrect unless
proof duly subscribed by an insutance canier is produced in a forru saNsfactory to the charc,that compensation for ait employees has
been secured as provided by this chapter.
G105.2(9-07)Reverse