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Home My WebLink AboutApplication and WC , ; ,�� v�� ' � � � TOWN OF YARMOUTH BOARD OF HEALTH � APPLICATION FOR LICENSE/PER11��' -�LO•1�� ,; p,!�yr � ; L012 � * Please complete form and attach all necessary c�Qcume ts by.lD�cein er Failure to do so will result in the return of�our a�plication pac . 'DEPT. ESTABLISHMENT NAME: � TISU(' l� C-�Q CDJ7 TAX ID• LOGATION ADDRESS:�� a$. I�1 yF�M�11�,u� Da(a�3 TEL.#: JDS�'I7/-(o y��' MAILING ADDRESS: �— OWNERNAME: NC 1 � � CORPORATION NAME (IF APPLICABLE): A- MANAGER'SNAME: C (,v�l�U TEL.#: JD - �1 • �IOS MAILING ADDRESS: �OrNN O c�I M�f TDA15 lLCS (rlA Oa�Y POOL CERTIFICATIONS: N'Q- 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. 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). 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 Cle at your place of business. l. 2• 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: Nl� 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. 2• PERS.�;D? ?I3�F�P.^�GE:– - ._- _ Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. 2• HEIMLICH CERTIFICATIONS: ��A' All food service establishments with 2 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please ]ist your employees trained in anti-chokmg procedures below and attach copies of emplayee 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 _SWIb(MING POOL $80ea. LODGE $55 TRAILERPARK $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 >I00 SEATS $160 COMMON VIC. $60 WHOLESALE $80 RETAIL SERVICE: � � —RESID.KITCHEN $SO . LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERM[T# LICENSE REQUIRED FEE �� PERMIT# � <SOsq.ft.�-� $50 �(3� >25,OOOsq.ft. � $225 VENDING�-FOOD $25 <25,000 sq.ft. $80 _FROZEN DESSERT $40 _TOBACCO $95 NAME CHANGE: $15 . AMOUNT DUE _ � SO.00 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** , ADMINISTRATION � Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. TAE ATTACHED STATE WORKER'S COMPENSATION INSURANCE , AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yannouth tases and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES � NO -- — --- �. ,...�.Tt.r c w m n�rLmu r nn!`IIYG�STA$��II1l�IE11LUT-S �v:�n �»" ��Q __ __ ; - TRANSIENT OCCUPANCY: For purposes of the limita6ons 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 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 sha11 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 Departrnent prior to opening. Contact the Health Departxnent to schedule the inspection three(3)days prior to opening.PLEASE NOTE: People aze NOT allowed to sit m 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 outdoar 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 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.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 Deparhnent. 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: p iiaide cafecll z._n f Ao�*s tin�yyj�waiter/w i* e�c. Pn�icP,l mnct y?v�nrinr�nnrnyal m the Rnard ofIjEal$�__ ____ OUTDOOR COOHING: Outdoor cooking,prepazation,or display of any food product by a retail ar 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 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. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE:JDI31 j�� SIGNATURE: �/}{,C(�, C(,I,�Q(fUJU PRINT NAME& TITLE: /�� N C�{ �. � �� C,�U� D C(J N�, Rev. 10/09/12 r� The Commonwealth ofMassachusetts Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 - Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Le¢iblv Business/OrganizationName: }� -(h�/�N ��r C'�4P� �� Address: .�Ja� �1� UT� o�� c�c�istateiz�p: �J��r yp�iwoU-f h . MA 6�6�3rnone#: �bg � `7?1 -� yg8 - - - - rlre you_an employxr?�he¢k�a�pcngciat�4oa�. .. - .Besiq s-TYP��49ired):,r- -- 1.❑ I am a employer with � employees(full and/ �• �Retail or part-time).* 6. ❑ Restaurant/BazBating Establishment 2.❑ I am a sole proprietor or pazmership 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 aze a corporation and its officers have exercised 9. ❑Entertainment their right of exemption per a 152, §1(4),and we have �0.❑Manufacturiug no employees. [No workers' comp. insurance requiredj' 11.❑ Health Caze 4.❑ We aze a non-profit organization,staffed by volunteers, with no employees. [No workers' comp.insurance req.] 12.❑ Other *My applicant that checks box#1 must also fill out the section below showing their workere'compensation policy information. **If the wrporate officers have exempted[hemselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#1. I am an emp/oyer that is providing workers'compensation insurance for my emp/oyees. Below is thepoUcy injormatinn. Insurance Company Name: I 1� A V��S ( f�l��hA N � ('O IlA (�AN Cl Insurer'sAddress: a�I�+D (.f��C.ElV1bl�'( �� S�� C City/State/Zip: � 1lXYC "FL �%�O �T _ _ Dol:ey��s�f�s.�,�.# ta K11_ �_ �6_313 8��3_'la _ _� � �D�: __ `� a 8 i3 �- - --�— ---- - ----__ Attach a copy oFthe workers' compensation policy declaratiou page(showing the policy number and expiration date). Failure to secure coverage as required under Secrion 25A of MGL a 152 can lead to the imposition of criminal penalties of a fine up to$I,SOU.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 O�ce of Investigations of the DIA for insurance coverage verification. I da hereby certify,under the pains and pena[ties ojperjury that the injormation provided above is true and correct Si ature: V[�v Date: �� l�a Phone#: � ��6 ' � � � �- l0 Y 0 ll � � . Official use an[y. Do not write in this area,to be completed by city or town o�ciaL City or Town: y/�Q,MOtJ l}f- Permit/License# ��.3 �� I ircle one): F He . Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office 6.Other ContactPerson: Phone#: �8-�j`t'8-o�-`3( KIZ�j� - - � w'n�..mas�.ysnidia . _ . ._ ...—. - _. _.—..-_"— _. "__ - . . �A, TRAVELERS J WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY TYPE AR INFORMATION PAGE WC 00 00 Ot ( A) ' POLICYNUMBER: (6KU6-5637385-3-12) NEW-12 INSURER: THE TRAVELERS INDEMNITY COMPANY NCCI CO CODE: 11347 1. INSURED: PRODUCER: WILBUR, NANCV� � � � �"� �� OCEANSIDE INS AGCY INC � � DBA A TOUCH OF CAPE COD 52 WEST MAIN ST 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 policy period Is from 07-28-t 2 to p7-Zg-1 3 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 of the state(s) listed here: MA � = B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed In � item 3.A. The limits of our liability under Part Two are: ,= Bodily Injury by Accident: $ 100000 Each Accident � , Bodily InJury by Disease: $ 500000 Policy Limit � Bodiiy lnjury by Disease: S t 00000'Eacfi'Employee � C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, Ifsted here: — COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06A �� ' = D. This policy includes these endorsements and schedules: � SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE ` �� - 4. The premium for this policy wiii be determined by our Manuals of Rules, Classifications, Rates and Rating — Plans. All required information is subject to verification and change by audit to be made ANNUALLY. DATE OFISSUE: 07-13-12 MF ST ASSIGN: MA OFFICE: ORLANDO INDUS AFF 161 . PRODUCER: OCEANSIDE INS AGCY INC 28GDS ooia�