The URL can be used to link to this page

Home My WebLink AboutApplication and WC �� ._' .,.�. .. > ., T�WN OF YARMOUTH BOARD OF HEALTH '4 '°�`�' ��'A . �� APPLICATION FOR LICENS� f:E:; 0 2 2013 �" * Please complete form and attach all necessary s�Ae : mb 20I3. Fai lure to do so wi l l resu l t in t he re t u rn o b t 7 r pp l ica hon PT• ESTABLISHMENT NAME: � � TAX ID: - ' LOCATION ADDRESS: _�l 7 R6U� �$i LU�t A�,uQ/}�'h ,U�A- ` !/3 TEL.#: �D$ • '171�(o�{A� 1v�an,nvGaDDxEss: SflnaE ' E-�L aDD�ss: in�o an a-Mvchr�raPe cad. c6rrt OWNERNAME: li� NCy ( 111 Ltfl UP CORPORATION NAME (IF APPLICABLE): N IA� MANAGER'SNAME: NC I.�IGC�JU TEL.#: • 7 MAILINGADDRESS: l0'7 N�YUTbWN DACIr rUARS7�/JAJS �l� AAA !7�(oS��T POOL CERTIFICATIONS: J� The pool supervisor must be ce fed 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. 1. 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 MANAGERS - CERTIFICATIONS: NlA All food service establishments are required to have at least one full-fime employee who is cert�ed as a Food Protection �_Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of cerJi�CSfion 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. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. 2. ALLERGEN CERTIFICATIONS: .�1� All food service establishments are require$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 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 k LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $55 INN $55 CAMP $55 SWIMMINGPOOL $80ea. LODGE $55 TRAILER PARK $105 WHIRLPOOL $80ea FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $85 _CONTINENTAL $35 NON-PROFIT $30 >]00 SEATS $t60 COMMON V[C. $60 WHOLESALE $SO —RESID.K[TCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# L[CENSE REQUIRED FEE PERMIT# � LICENSE REQUIRED FEE PERMIT# 1 <50 sq.ft. $50 � �t —C"L >25,000 sq.ft. $225 VENDING-FOOD $25 <25,000 sq.ft. $80 _FROZEN DESSERT $40 _TOBACCO $95 NAME CHANGE: $15 AMOUNT DUE _ � ,�iCi. OZ: *****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 permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED 5TATE 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 taxes and liens must be paid rior to renewal ar 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 ar 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 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 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 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 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 Departrnent by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health Deparhnent, 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 Departrnent. Failure to do so will result in the suspension or revocation ofyour Frozen Dessert Permit unfil 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 3 L 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 A SITE LAN. , DATE: q L�J SIGNATURE: (,{�l,(.�ULUU PRINT NAME&TITLE: � � Rev. 10/08/13 �� / .�� r T�Ze Commonwealth ofMassachusetts • Department oflndustrial Accidents Office ofinvestigations ' 1 Congress Street, Suife I00 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance �davit: General Businesses Applicant Information Please Print Le¢iblv Business/Organization Name: 1-C �D��I� b� C�f� �D Address: �� h( d� �� City/State/Zip: U1�A'(M,O�I-I�/1 , M/k D��J" Phone#: 5D�' �'ll" (9u�bg Are ou an employer? Check the appropriate box: Busi ss Type(required): 1.� I am a employer with�_employees(full and/ 5. Retail or part-time).* 6. ❑ RestauranUBaz/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no �, � 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 are a corporation and its o�cers have exercised 9. ❑ EnteRainment their right of exemption per c. 152, §1(4),and we have 10.❑ Manufacturing no emptoyees. [No workers' comp. insurance required]* 4.❑ We aze a non-profit organization, staffed by volunteers, 11.❑ Health Caze with no employees. [No workers' comp. inswance req.] 12.❑ Other *My applicant that checks box#1 must a(so fill out the section below showing their workers'compensation policy infomiation. '*If the coipornte officers have exempted themselves,but the cotporafion has other employees,a workers'compensaflon policy is required and such an organiza[ion should check box#1. - � I am an employer that is providin,/g workers'comnpensation insurance for my emp[oyees. Below is the policy information. Insurance Company Name: 'I R A V�L�t�S i N��M N iT`l C n n,t(�� Insurer's Address: l�`�O�d ��l d l�1 �� STE � � City/State/Zip: D R�A N u D, �L 3a�� Policy#or Self-ins.Lic. # �0�l�� 5 a��3 S5�� Expiration Date: I �� Attach a copy of the workers' compensation policy declaration page(showing the policy number a d espiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penat6es 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 fonvarded to the Office of Investigations ofthe DIA for insurance coverage verification. I do hereby certify,under the patns andpenalties oJperjury that the information provided above is true and correct. Si¢nature: �� .1 Date• I I/i�III� Phone#: ��tl - �7 f ' ��p p � Official use only. Do not write in this area,to be completed by city or town officiaL Ciry or Town: yQ/L�mfTy Permit/License# Issu' circle one): .Board of He. . Building Department 3. City/Town Clerk 4.Liceusing Board 5. Selectmen's Office 6. Other Contact Person: Phone#: 5UR-34B-�d�31 X/.Z�/ www.mass.gov/dia • C � • .� � TRAVELERS/�, WORKERS COMPENSATION • AND EMPLOYERS LIABILITY POLICY TYPE AR INFORMATION PAGE WC 00 00 Ot ( A) POLICY NUMBER: (6HU6-5837385-3-13) � RENEWAL OF (6KU6-5637385-3-12) INSUREfl: THE TRAVELERS INDEMNITY COMPANY OF A�tERICA �, NCCI CO CODE: 13439 INSURED: PRODUCER: WILBUR, NANCY OCEANSIDE INS GROUP DBR A TOUCH OF CAPG COQ 52 Wc'ST �i�;AIN 5T „ 327 ROUTE 28 HYANNIS MA 02601 WEST YARMOUTH MA 02673 Insured is AN INDIVIDUAL Other work places and Identification numbers are shown in the schedule(s) attached. 2. The po0cy perlod is from 07-28-1,3 to p7-2g-�q 12:01 A.M. at the insured's mailing address. 3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers Compensatlon Law of the state(s) Iisted here: MA � .� = B. EMPLOYERS LIABILI7Y INSURANCE: Part Two of the policy applies to work in each state listed in � ftem 3.A. The IImRs of our Ilability under Part Two are: a= Bodily Injury by Accident: S 100000 Each Accident ,= Bodily InJury by Disease: $ 500000 polfcy Limit � Bodily InJury by Disease: S t 00000 Each Employee = C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, H any, Iisted here: �� COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06A _� m� = D. This policy includes these endorsements and schedules: � a� SEE LISTING DF ENDORSEMENTS - EXTENSION OF INFO PAGE ` o� . � 4. The premium for this pdicy wlll be determ(ned by our Manuals of Ruies, Classifications, Rates and Rating = Plans. All required information is subJect to verification and change by aud(t to be made ANNUALLv. DATE OFISSUE: 07-18-13 WC ST ASSIGN: MA OFFICE: ORLANDO INDUS AFF 161 PRODUCER: OCEANSIDE INS GROUP 28GDS oozas