HomeMy WebLinkAboutApplication and WC � '� �
a TOWN OF YARMOUTH BOARD OF HEALTH
' ��� APPLICATION FOR LICENSE/PERMiT
_ � ;
., .,
ADMINISTRATION •
Under Chapter 152,Section 25C,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 WORKER'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR '
CERT. OF INSURANCE ATTACHED
OR '
WORKER'S COMP. AFFIDAVTI' SIGNED AND ATTACHED
Town of Yazmouth taxes and liens must be paid prior t renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES NO
M�TELS A1i1D OTFIER L`JDGiNG EST�LISI-�ivIENTS
TRANSIENT OCCUPANCI': 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, shall generally be considered Transient.
POOLS ,
POOL OPEIVING:All swimming,wading and whirlpools which have been closed for the season must be inspected
by the Health Deparunent prior to opening. Contact the Health Department to schedule the inspection three(3)days
pnor to opening.PI,EASE NOTE: People aze 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 standazd 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 OPENIIVG:
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 Yazmouth must notify the Yarmouth Health Department by filing the
required Temporary Food Service Application forni 72 hours prior to the catered event. These Forms can be
obtained at the Health Department,or from the Town's website at www.yarmouth.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:
Outs:ue cr.fcs(i.e.,��carseati:.g w;t�':wail�r/wai�ess se:viee),...ust ha�re g�ier a�rci��fi�oan the L4ard af Health.
OUTDOOR COOKING:
Outdoor 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 RESPONSIBILITI'TO RETURN
THE COMPLETED RENEWAL APPLICATION(S)AND REQUIItED FEE(S)BY DECEMBER 15, 2011.
Ai.i, RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQLTIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS M.AY REQUIRE A SITE PLAN.
DATE: ll( 3�l� SIGNATURE: L"F(�/u�
PRINT NAME &TITLE: � �"A�"L �����o �/Z�P-
Rev.]0/25A1
NOTICE � NOTICE
TO ; TQ
EMPLOYEES EMPLOYEES
The Cominonwealth of Massachusetts
DEPARTMENT OF INDUSTR7AL ACCIDENTS
600 Washington Street, Boston, Massachusetts 02111
617-727-4900 - http://www.mass.govldia
As required by Massachusetts General Law, Chapter 152, Sections 21,22&30,this will give you nodce
that I(we)have pmvided for payment to our injured employees under the above-mentioned chapter by
insuring with:
MA Retail Mvrchants WC Croup Inc.
NAME OF INSURANCE COMPANY
10 Brifisll A�aHGan Blvd. Latha�, NV 1211U
ADDRESS �F INSURANCE COMPANY
014005032775111 4/01/2031 - 1/U1/2012
POLICY NUMBER EFFECTIVE DATES
Rogers 6 6�ay Insurance Agency PU Bax 1601 434 Routa 134 Sou[h Dennis, MA 02660
NAME OF INSURANCE AGENT ADDRESS RHONE#
SsafooE Sa�'s 10�6 Rte 28 South Yar�outh. MA 02664
• EMPLOYER ADDRESS
EMPLOYER'S WORKERS' COMPENSATION OFFICER(IF ANY) DATE
MEDICAL TREATMENT
The above named insurer is required in cases of personal injuries arising out of and in the couise of
employment to fiunish adequate and reasonable hospital and medical services in accordance with the
provisions of the Workers' Compensation Act. A copy of the Fust Report of lnjury must be given to the
injured employee. The employee may select his or her own physiczan. The reasonabie cost of the ser-
vices provided by the heating physician will be paid by the insurer,if tbe treaUnent is necessary and
reasonably connected to the work related injury. In cases requiring hospital attention, employees are
hereby norified that the ins�er has arranged for such attention at the
NAME OF HOSPITAL ADDRESS
TO BE POSTED BY EMPLOYER