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HomeMy WebLinkAboutApplication and WC a TOWN OF YARMOUTH BOARD OF HEALTH ��������° � � APPLICATION FOR LICENSE/� I �0 ,y�,JN 1 � 20f5 � ' , ��`; * Please complete form and attach all necessaiy„d�oc� `' er IS 20I4. Failure to do so will result in the return of your apphcation pac et. HEA�TH DEPT. ESTABLISHMENT NAME: T ✓ � � T�' D• LOCATION ADDRESS: I$ �o w e�eS /,e� lurs� ,oit.a� �e . TEL.#: MAII,INGADDRESS: �� G�' 8`� W • au o E-MAIL ADDRESS: ,� A � OWNERNAIvIE: -rO rrrc o��✓P�4'S a�ig ia� -r �. CORPORATION NAME (IF APPLICABLE : MANAGER'S NAME: Ie �e Jc TEL.#: /- - �5'� MAILING ADDRESS: � j�e P �/ ,t}N/c lo. � +,�o �J.�_�.�� �3 POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please lis the designated Pool Operator(s) and attach a opy of the certification to this form. �i--�� /� r �'L-/\ 2. - v�— Pool operators must list a minimum of two employees currently ce 'fi d in asic er safety, stand First Aid and Community Cardiopulmonary Resuscitation (CPR), having one certified emp yee 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. J I��1 e S �2SS2�12i2 2. h'A��/�e+"� �SAn/�P 2�Q e 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments aze required to have at least one full-Ume 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. Yo��s�provide new copies and maintain a file at your establishment. L � rr 2. PERSON IN CHARGE: Each f��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 establishxnents 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-choking procedures below and attach copies of employee certifications to this form. The Health Deparhnent 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 M01'EL $110 �NN $55 —CAMP $55 ,=SWIMMINGPOOL$110ea� _LODGE $55 _TRAILERPARK $105 _Wf{IRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 _CONTINENTAL $35 NON-PROFIT $30 >100 SEATS $200 COMMON VIC. $60 WHOLESALE $80 —RESiD.KITCHEN S80 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 _QS,OOOsq.ft. $150 � _FROZENDESSERT $40 —�TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE _ $ �I b.00 *'•**PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM••*** ADMINISTRATION Under Chapter 152,Section 25 C, 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 person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WOIiKER'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: ygg NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes ofthe limitations ofMotel 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 sha11 generally refer to continuous occupancy of not more than tUirty(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 POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Departrnent prior to opening. Contact the Health Departxnent to schedule the inspection three(3) days prior to opening. PLEASE NOTE: People are NOT allowed to sit in the pool azea 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. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of 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 Yannouth must notify the Yarmouth Health Deparhnent by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtauied at the Health Deparhnent,or from the Town's website at www.�armouth.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 until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Boazd of Health. OUTDOOR COOKING: ' _ Outdoor_cookinQ preuazation or display of any food rp oduct b�a retail or food service establishment is prohibited. NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RET'URN 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.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY UIRE A SITE PLAN. DATE: (" �S r de/> SIGNATURE: � PRINT NAME & TITLE: Rev. l l/03/14 ' " � The Commonwealth ofMassachusetts �� Department of Industrial Accidents Office oflnvestigations ' l Congress Street, Suite 100 ', Boston,MA 02I14-2017 www.mass.gov/dia l Workers' Compensation Insurance Affidavit: General Businesses ' AppGcant Information Please Print Le¢iblv ' Business/OrganizationName: Caca-� rs�.B+✓c� �ceBn� l:�N,b �.ye ��'P�.S' /�s�. ��vC� / � Address: l Fl � w e l� S /.�N 2 0 aS-�-? City/State/Zip: �.r � ,�? o a Phone#: �" 5'��- (� � S-� Y 3 Are yop an employer?Check the appropriate boz: Bnsiness Type(required): 1.��I am a employer with 6 p y ( 5. Retail em lo ees 1 and/ � orpart-rime).* (SPq.SoN ,�� � 6. ❑ RestaurantBaz/EatingEstablishment 2.❑ I am a sole proprietor or partnership and have no 7, � Office and/or Sales(incl.real estaze,auto, etc.) employees working for me in any capaciry. [No workers' comp.insurance required] 8• ❑ Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per a 152, §1(4), and we have 10.� Manufacturing ! no employees. [No workers' comp. insurance required]* 4.❑ We aze a non-profit organizauon, staffed by volunteers, 11.0 Heakh Caze with no employees. [No workers' comp. insurance req.] 12.0 Other •Any applicant that checks box#1 must also 5ll out the section below showing iheir workeis'compensation policy infoimation. •'If the coipotate officets ttave exempted themselves,but the cocporation has other employees,a wotkecs'compensation policy is required and such a¢ otganizelion should check box#I. I am an employer that is providing workers'comp�sation ig.rurance for my e�p[oyee.s. Below is the policy iajormation. Insurance Company Name: L M N+�t ltl�"� 1 N s �a , Insurer's Address: s`� 2N V e.` k/u/2��N fa N �y o � f�a 3- 0 9 � D City/State/Zip: /�7 d /Z /� �Q /-o .�- �q , O I & � � � �� � 0 �/ �� �S, _ Policy#or Self-ins.Lic.# A W � � y 6 � — �0 O•�� "/� �Expuation Date: `� oZs d � Attach a copy of the workers' compensation policy declaration page(showing the policy number and espu�ation date). Failure to secure coyerage as required under Section 25A of MGL c. 152 can lead to the imposidon of criminal penal6es 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 verification. I do hereby certi ,under the pains and enalties ojperjury that the information provided above is true and conect. Si ature: Date: 6 �.5� d /s' Phone#: � & ^ � ' Y6 � ( Official use only. Do not write in this area,to be completed by city or town offtciaL 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 Office 6.Other Contact Person• Phone#• www.mass.gov/dia -- I WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE A.I.M. Mutual Insurance Company 54 Third Avenue, Burlington, Massachusetts 01803-0970 I (800) 876-2765 NCCI NO 26158 i POLICY NO. 'AWC-400-7008176-2015� PRIOR NO. i qyyC-400-7008176-2014A ITEM 1. The Insured: Great Isiand Ocean Club Homeowners Association Inc �I DBA: f Mailing address: P O Box 684 FEIN:"-"' � W Yarmouth, MA 02673 � i Legal Entity Type: Corporation ' Other workplaces not shown above: See Location 2. The policy period is from OSl25/2015 to OS/25/2016 12:01 a.m. standard time at the insured's mailing address. � ---__ I 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers'Liabiliiy Insurance: Part Two of the policy applies to work in each state listed in item 3.A. The limits of liability under PaA Two are: Bodily Injury by Accident $ 100,000 each accident -- _ - ---. . Bodily Injury by Disease $ 500,000 policy limit Bodily Injury by Disease $ 100,000 each employee ' _ ._. ____ — C. Other States Insurance: Coverage Replaced by Endorsement WC 20 03 O6 B D. This Policy includes these Endorsements and Schedules: SEE SCHEDULE 4. The premium far this policy will be determined by our Manuals of Rules,Classifications, Rates and Rating Plans. All informatlon required below is subject to verification and change by audit. ---- — -___ —_ I Classfications Premium Basis Rates _� ; -- -- — -- _ _— _.__ Code Estimated �'I � Per$100 I EsAmated i I No. Total Annual Of Mnual I Remuneralion � Remuneration � Premium � — ------ -- _... _ _.... .._.. ___—� INTRA 295860 I I j I INTER SEEI'CLASS CODE SCHEDULE I I � I I . . �._. ...._.___.—� �, ----... . .. _ ... .__ .___.. . . .._ i Minimum Premium $284 Total Estimated Annual Premium $638 GOV GOV Deposit Premium $659 STATE CLASS MA 9015 State Assessments/Surcharges $364.00 x 5.8000% $21 This palicy,including all endorsements, is hereby countersigned by ���-`--'-�'� 04/73/2015 ; _- --- --- Authonzed Signature Da�e Service Office: A N Nunes Agency Inc 54 Third Avenue P O Box 627 Burlington MA 01803 Bristol, RI 02809 WC 00 00 01 A(7-11) Includes copyrighted matarlal of the National Council on Compensadon Insu�ance, usad wiM ib parmission.