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Home My WebLink AboutApplication and WC + � � TOWN OF YARMOUTH BOARD OF HEALTH ��j'-�� , APPLICATION FOR LICEN�SE/PE T�"¢0'L� NOV Z 9 2O�Y � * Please complete form and attach all nec�s��t`y dd��Q� m Failure to do so will result in the rbt�rn o#�yo z�hcahon T� ESTABLISFIMENT NAIvIE: l� �K - N - /�D L-L T • --%� LOCATIONADDRESS: 1 , �� Cirl�4 EL.#: �S- � � D• MAILING ADDRESS: � ..'�: � dm o z d '� OWNERNAME: bt�N' S' _ L D CORPORATION NAME IF APPLICABLE): �-hl DI�I -�n G . MANAGER'S NAME: r� �u Pl1(� TEL.#: - d �_ MAILING ADDRESS: l3 i f � �' arm�i, 0� h` 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. -, L _— - --- ----- - -_=----- -- --—=2--=——-- Pool operators must list a minimum of two employees currently certified in basic water safety, standazd First Aid and Community Cazdiopulmonary Resuscitation (CPR). Please list these employees 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. L 2. 3, 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are 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. 4I ��1�f g � • �-� i.J 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. 1.�Y��_�l��_ S - �� n..) . 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 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# _B&B $55 _CABIN $55 _MOTEL $55 INN $55 CAMP $55 _SWIMMING POOL $80ea _LODGE $55 _TRAILERPARK $105 _WHIRLPOOL $80ea. FOOD SERVICE: �LICENSE REQUIRED FEE �PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# � I 0-100SEATS $85 (J'�^Z' —CONTINENTAL $35 _NON-PROFIT $30 >100 SEATS $160 I COMMON VIC. $60 1 'O�� _WHOLESALE $80 RETAIL SERVICE: —RESID.KITCHEN $80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $50 >25,000 sq.8 $225 _VENDING-FOOD $25. __<25,000 sq.ft. $80 —FROZEN DESSERT $40 _TOBACCO $95 _ � NAMECHANGE: $l5 AMOUNTDUE _ $ L�Ci•OCl ***•*PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*"*•* , : ADMINISTRATION • , Under Chapter 152,Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or pernut 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 taaces 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 sha11 be limited to the temporary and short term occupancy,ordinarily and customazily 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 CNIR 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 Department prior to opening. Contact the Health Department to schedule the inspecdon three(3)days pnor to opening.PLEASE NOTE: People are NOT allowed to sit m 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 priar 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 SERVIGE _ . _ SEASONAL FOOD SERVICE OPE1vING: 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 priar 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 prior to the catered event. These forms can be obtained at the Health Department,or from the Town's website at www.yannouth.ma.us under Health Depariment, 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 Board of Health. OUTDOOR COOKING: Outdoor cooking,prepazation,or display of any food product by a retail or food service establistunent 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, 2012. 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. RENOVA"I'IONS MAY REQ I A SITE PLAN. DATE: �� a� �L SIGNATURE: PRINT NAME& TITLE: ��1 I-E)� ��R�$) Rev. 10/09/12 I Y � � The Commonwea[th ofMassachusetts ' Department of Industrial Accidents � Offtce of Investigations I Congress Sbeet,Suite I00 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Aoolicant Information Please Print Le¢iblv Business/Organizarion Name: W 0 K - 'j�1 - fZ�Ll- . Address: �� 1 Q1 , R� �C , City/State/Zip: 3 . �(G1�M�� , YV1� D��"phone#: �� - �b0 —�?061� Are you an employer?Check the appropriate box: Business Type(required): __ L� I am a employer with employees(full and/ 5. ❑ Retail orpart-tune). . estaurani azi a g s�en�` ___---- --__ 2.❑ I am a sole proprietor or parhiership and have no 7, � Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. (No workers' comp. insurance required] 8• ❑Non-profit 3.❑ We aze a corpontion and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §I(4),and we have 10.❑Manufacturing no employees. [No workers' comp. insurance required]* 11.❑ Health Caze 4.❑ We are a non-profit organizarion,staffed by volunteers, with no employees. [No workers'comp.insurance req.] 12.❑ Other *My applicant that checks box#I must also fill out ihe sec[ion below showing thev workers'cqmpensalion policy infortna[ion. *'If the coryorete officers have exempted themselves,but the coryorntion has other employees,a workers'compensation poiicy is required and such an � organiTation should check box#1. I am an employer that is provniding worke1rs'compensation insurance for��employees. Be[o�w�+�is t�h,e!policry information./� IvsuranceCompanyName: ttYSGC'C�.12� �tl��f'QS ,(°$ �� 1�u;7t,�LU .1v15'�lfi,�y1�2 Co• Insurer'sAddress: �'� 1 I �if�l �JQ, , �- Q. ��( �-}tj�p City/State/Zip: i �0�'1 V�(-At � 1�j�3 Policy#or Self-ins.Lic.# �� G 1�3��0��'� .�- Expiration Date: � � �G _ Attach a copy of the workers' compensaHon policy declaration page(showing the poGcy number and expiraHon date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposirion of criminal penalties of a _ fin�un t4_$1,�09;00 and/or onexear imprisonment as well iviL�enalties in the form o£a STOP WORK ORDER and a_fipe _ - — —— -- 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 cestify,unde t e pains and penalties of perjury that the information provided above is true and corretx Si�nature: �' Date. 16��(j l �2 . Phone#: � �� "�Ob� Official use only. Do not write in this area,to be completed by city or town o�ciaL City or Town: �Q�CWI�it'�! Permit/Liceuse# circle one): .Board of Health .Building Department 3.City/I'own Clerk 4.Licensing Board 5.Selectmen's Office 6. Contact Person: Phone#: 6Dt4 3 rLR e�3/ X l 2-�/� www.mass.gov/aia . i NOTICE � NOTICE ' TO T� EMPLOYEES EMPLOYEES ' ; , ; The Commonwealth of MassachuseTts ' DEPARTMENT OF INDUSTRIAL ACCIDEN S 600 Washington Street, Boston, Massachusetts 02111 i 617-727-4900 � As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this will give you f notice that I(we) have provided for payment to our injured employees under the above menaoned � chapter by insuring with: ASSOCIATED INDUSTRIES OF MASSACHUSETTS MUTUAL INSURANCE COMPANY NAME OF INSURANCE COMPANY 54 THIRD AVENUE P.O. BOX 4070 BURUNGTON MA 01803-0970 ADDRESS OF INSURANCE COMPANY AWC 7025372012012 02(03/2012 - 02/03/2013 POLICY NUMBER EFFECTIVE DATES Murray& MacDonald Insurance 550 MacArthur Blvd Services inc Boume MA 02532 (8001500-$990 � NAME OF INSURANCE AGENT ADDRESS PH�� Braodon Inc 7310 Route 28 South Yarmouth, MA 02664 i EMPLOYER ADDRESS 01/20/2012 EMPLOYER�s wox�cERs co�NsMEDICAL T�iFATMENT DA� i The above named insurer is required in cesea uf Pe►'sonal iqjar�es a��g�n8 ont of and in the course of employment to furnish � adequate and reasonable hospital and medical sec'vices in accordance with tbe Provisioms of the Workers Compensation AM. ! A copy of t6e Fust Report of Iqjury mnst ice given to the iqjured employee• The employee may select ltis or her own physician. I T6e reasonable cost of the serviccs provlded by the treating physlcian wi11 be Paid by the insurer,if the treatment is necessary , and reasooably connected to t6e work related injury. In csses requiring h�P�tal attentioo,employees are hemby notified that the insurer hes arranged for such attention at the NEAREST AND BEST MEDICAL FACILITY � NAME OF HOSPITAL ADDRESS I TO EE r�STED BY EMPLOYER