HomeMy WebLinkAboutApplication and WC .
�� TOWN OF YARMOUTH BOARD OF HEALTH ���y��;�, .�
� APPLICATION FOR LICENS E IT-2014 t�p t, ;,-t_� �r
* Please complete form and attach all nece�����m�nts by ec�eA�31SUY3. �
Failure to do so will result in the return of your applica onp� ckeL
, � li�AITH DEPT.
ESTABLISHMENT NAME: F TAX ID:
LOCATION ADDRESS: � D T£ TEL.#: —17 � 9
MAILING ADDRESS: N
E-MAIL ADDRESS: �` m g ,
OWNER NAME:
CORPORATION NAME (IF APPLICABLE :
MANAGER'SNAME: TEL.#: 3� DU
MAILING ADDRESS: D � 5
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.
i. 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. 2.
3. 4.
FOOD PROTECTION MANAC,ERS - CERTIFICATIONS:
A11 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 applicaUon. 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 establishxnent must have at least one Person In Charge (PIC) on site during hours of operation.
1. 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 Heatth 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 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# LICENSE REQUIRED FEE PERMIT#
B&B $55 CABIN $55 MOTEL $55
INN $55 —CAMP $55 SWIMMINGPOOL $80ea.
_LODGE $55 TRAILERPARK $]OS WHIRLPOOL $SOea.
FOOD SERVICE:
LICENSE REQUIRED FEE �ERMIT# LICENSE REQUIRED PEE PERMIT# LICENSE REQUIRED FEE PERMIT#
I 0-100SEATS $85 t;i�- i•-�c _CONTINENTAL $3S NON-PROFIT $30
_>100 SEATS $160 _COMMON VIC. $60 WHOLESALE $80
—RESID.HITCHEN $80
RETAIL SERVICE:
LiCENSE REQUIRED FEE PERMIT# L[CENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_<50 sq.ft. $50 >25,000 sq ft. $225 VENDING-FOOD $25
_<25,OOOsq.ft. $80 1.FROZENDESSERT $40 -�;ti-�L:<-� —TOBACCO $95
NAME CHANGE: $15 AMOUNT DUE = S J!-`� t_C
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM**•**
T �
ADMINISTRATION -
Under Chapter 152, Section 25C, Subsection 6,the Town of Yannouth is now required to hold issuance or renewal of
any license or permit to operate a business if a person ar company does not have a Certificate of Worker's Compensation
Insurance. THE ATTACHED STATE WORK�R'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 taYes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES�_ NO
MOTELS AND OTHER LODGING ESTABLISHMENTS
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 generaliy 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, shall generally be considered Transient.
POOLS
PO�L OPENII�IG:Ail swimmi�,wading and whir�poo}s��hieh-hav�-been clased for the season must be inspected by
the Health Departrnent prior to opening. Contact the Health Departrnent to schedule the inspection three(3) days
prior to opening.PLEASE NOTE: People are NOT allowed to sit in the pool area until the pooi 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.
POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven (7) days of
closing.
FOOT7 SERVICE
SEASONAL FOOD SERVICE OPENING:
All food service establishments must be inspected by the Health Department prior to opening. Please contact the
Health Departrnent to schedule the inspection three (3) days prior to opening.
CATERING POLICY:
Anyone who caters within the Towri 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 obtained at the
Health Department, or from the Town's website at www.varmouth.ma.us under Health Department, Downloadable
Forms.
FROZEN DESSERTS:
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 Dessert
Permit unril the above 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:
Outdoor cooking, preparation, 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 13, 2013.
ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO
COMMENCEMENT. RENOVATIONS MAY REQUIRE SITE PLAN.,
DATE: � j� ��� • ��j SIGNATURE: .�'1 �
PRINT NAME&TITLE:
;
Rev. 10/OS/13
. ^ � The Commonwealth ofMassachusetts
� Department oflndustrialAccidents
Office of Investigations
' I Congress Street, Suite I00
Boston, MA 02114-20I7
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print LeEiblv
Business/Organization Name: P[,�'�,1'�� Q�lY�Q rn (� 1 C�p L�
Address: .� ���rY1,glA.�;—IV�-�- (�c�`/ 3
rni+-i��NC�', . p3�47 � ..��.,'/�
C�t�{�tate/�rp: � r Phone #: (� 3 /�O
Are you an employer? Check the appropriate box: Business Type(required):
I.� I am a employer with�_employees (full and/ 5. ❑ Retail
or part-tii�:e).* 6. ❑ RestauranUBaz/Ea[ing 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 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. I 52, §1(4), and we have 10.❑ Manufacturing
no employees. [No workers' comp. insurance required]*
4.❑ We are a non-profit organization, staffed by volunteers, ll.� Health Care
with no employees. [No workers' comp. insurance req.] 12.�]Dther �.ra< ( d �t E �f:e-�+-V�-.
*Any applicant that checks box#1 must also fil]out the section below showing their workers'compensation policy infom�ation.
*•If the cocporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an
organization should check box#L � . � .
I am an employer that isprovidi�workersI'compensation insurance for my employees. Below is thepo[icy information.
Insurance Company Name: I�'LQ�1��
Insurer's Address: r � �� ,y �
City/State/Zip: t d(`�l.Q Y�Y`D ���( �-�j �� � � �{,5 U
Policy#or Self-ins. Lic. # ��U_� �o��� �O�( 3�i-3 - l3 Expiration Date: �-O �- I�I
Attach a copy of the workers' compensation policy declaraHon page(showing the policy number and ezpiration date).
Failure to secure coverage as required under�ection 25A of N1GL c. 152 can lead to the imposition of criminaI penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penal$es 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 forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certi under the pains andp na/ti ofperjury that the information provided above is true and correM.
Si ature: �I Date: ��� 3 1 � 1�
Phone#•`
Official use only. Do not write in this area,to be comp[eted by city or town officiaL
City or Town: �!h{C(V1p�TT!} Permit/License#
' � ' cle one):
1.Board of Health Building Department 3. City/Town Clerk 4.Licensing Board 5. Selectmen's Office
Contact Person: Phone#: 5�8-3�18-d-a 3/ X �2`1�
www.mass.gov/dia
;
1
'' TRAVELERS/w� WORKERS COMPENSATION
�� p1E TOflER SQUARE AND
�' HARTFORD� cr 06183 EMPLOYERS LIABIUIY POLICY
TYPE V INFORMATION PAGE WC 00 00 01 ( A)
POLICYNUMBER: (IEUB-2676X33-3-13)
RENEWAL OF (IEUB-2676X33-3-12)
INSURER: THE TRAVELERS INDEMNITY COMPANY OF CONNECTICUT
t.
NCCI CO CODE: 12637
INSURED: PRODUCER;
JAMES HURLEV HART INS AGENCY INC
DBA PUTTERS PARADISE � P 0 BOX 700
PO BOX 48 BUZZARDS BAY MA 02532
HYANNISPORT MA 02647
Insured is AN INDIVIDUAL
Other work places and identification numbers are shown in the schedule(s) attached.
2. The policy perlod is from Ot -01 -13 to Ot -Ot -14 12:01 A.M. at the insured's mailing address.
3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers
Compensation law c=!the stat�!s) !?sted here:
MA
o�
— B. EMPLOYERS LIABILII'Y iNSURANCE: Part Two of the policy applies to work in each state listed in
= Rem 3.A. The Iimits of our liabiliiy under Part Two are:
m=
,= Bodily Injury by Accident: $ 500000 Each Accident
� Bodily Injury by Disease: $ 50000o policy Limit
� Bodily Injury by Disease: $ 50000o Each Empioyee
= C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, 'rf any, listed here:
� AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY l.A MD ME MI MN
� MO MS MT NC NE NH NJ NM NV NY OK OR PA RI SC SD TN TX UT VA VT WI
4� WV
��
'= D. This policy includes these endorsements and schedules:
��
a� SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE
�
o�
— 4. The premium for this policy will be determined by our Manuals of Rules, Ciass'rfications, Rates and Rating
= Plans. All required information is subject to ver'rfication and change by audit to be made aNNUa��v.
DATE OF ISS ��i�l=7i"-i 2 RK
OFFICE: HUDSON/BOSTON 126 DIRECT BILL
PRODUCER: HART INS AGENCY INC XJ289
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