HomeMy WebLinkAboutApplication and WC � '�i A4._!�:���[�Ne.
. ��� TOWN OF YARMOUTH BOARD OF HEA�,���s
APPLICATION FOR LICEIV�S ` 6�' C�� 0 2 2013
* Please complete form and attach all ne c4�ss s�y`y� ce 3.
Failure to do so will result in the r6t4irn o your applicah •
ESTABLISHMENT NAME: q"y L �i Gi,'( /N (, �
LOCATIONADDRESS: h 9 `I" /`��ii✓ �'j T•. �F57 �'��^'d r,7(� TEL.#: 50�"' �C/U "l�f��`
MAILINGADDRESS: 7�l �f �'1 !ii� 97 �^'R5T Y�r'^'a�Tlt . �7ih bZ � � 3
E-MEIiLADDRESS: baSrrti,arcurSiN� @ ho��,o, i/, co�^�
OWNER NAME: 7 w�t K% ? T 7lt�E � 9 � T T.��K %
CORPORATION NAME (IF APPLICABLE):
MANAGER'S NAME: TEL.#:
MAILING ADDRESS:
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool
Operatar(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),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:
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.
i.�in� c�Ak D� ocp^� P� a.
PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
�. vi���,� �K b�ac �- �, p� 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 attack 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.
i. `� iN �LArc b�Qc � �,po a.
�
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-chokuig procedures below and attach
copies of employee certifications to ttus form. The Health Department will not use past years' records. You must
provide new copies and maintain a file at your place of business.
i. � r� Cff � Sv �"� �c �� TChFJkoK-"� 2. �`gow�, r�-7If 9LO7�n"�So�v7c�.
3. 4.
RESTAURANT SEATING: TOTAL# ,?l' �
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 SWIMMINGPOOL $80ea
LODGE $55 TRAILERPARK $105 WHIRLPOOL $80ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUtRED FEE PERMIT#
1 0-100SEATS $85 ��I=I�F-09.3' _CONTINENTAL $35 NON-PROFIT $30
_>I00 SEATS $160 �COMMON VIC. $60 �J _WHOLESALE $80
—RESID.KITCHEN $80
RETAIL SERVICE:
LICENSE REQUIRED FEE PERM[T# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
<50 sq.ft. $50 >25,000 sq.ft. $225 � VENDING-FOOD $25
=<25,000 sq.ft. $80 _FROZEN DESSERT $40 _TOBACCO $95
xnnzE cHaNCE: $t s AMOUNT DUE _ $ I�5. 6C?
*•**•PLEASE TIJRN OVER AND COMPLETE OTHER SIDE OF FORM*A*t*
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 Compensarion
Insurance. THE ATTACHED STATE WORK�R'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 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 shall 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 tliirty(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. a 64G or 830 CMR 64G, as amended, sha11 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 priar to opening. Contact the Health Department to schedule the inspecHon three (3) days
prior to opening.PLEASE NOTE: People are NOT allowed to srt in the pool area until the pool has been inspected and
opened.
POOL WATER TESTING: The water must be te;sted 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 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.varmouth.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 Board of Health.
OUTDOOR COOHING:
Outdoor cooking, preparation, 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 RETUI2N
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 SIT PL N.
DATE: 1� —Z�` 2 G/j SIGNATURE: �n-�t ^'v '���
PRINT NAME& T'ITLE: 7�"�� � Ki�3 T 7/*L� Qf q T T a w� T e �^+N,2 j2
Rev. 10/OS/13
� The Commonwealth ofMassachusetts
. Department oflndustria[Accidents
Office of Investfgations
1 Congress Street,Suite 100
Boston, MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Le�blv
Business/Organization Name: �� �7/L 7H q � c V � S/��
Address: ��� � 91N S � t-.�2 ST y,<}.e ^�c� GTrf ^7 � �Z 6 � �'
City/State/Zip: Phone #: ��%� — ��7'� " � 9 5 �
Are you an employer? Check the appropriate box: Business Type(required):
1.� I am a employer with � employees(full and/ 5. ❑ Retail
� or part-time}.' 6.�KestaurantBaz/Eating Estabiishment
2.❑ I am a sole proprietor or partnership 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 corporation and its o�cers have exercised 9. ❑ Entertainment
their right of exemption per c. 152, §1(4), and we have 10.❑ Manufacturing
no employees. [No workers' comp. insurance required]* i l.� Health Caze
4.❑ We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' wmp. insurance req.] 12.❑ Other
•My applicant that checks box#1 must also SII out the secHon below showing the'v workers'compensation policy informffiion.
. **If the corporate officers have exempted themselves,but the cotporafion has other emp(oyees,a workers'comprnsation policy is required and such an
organization should check box#1. � - �
I am an employer that isp�oviding workers'compensation insurance for my employees. Below is thepo[icy information.
Insurance Company Name:_ g (;g ry! 9 � �S f/ � ��`/e� Co ''�/�'S"' y
Insurer's Address: ��1 � ^'� '� I "� S T • � - , , , � � �
City/State/Zip: _ _ W2 l`�' 7 �' A �C rt O �'71f '`�l � UZ G �`3
i
Policy#or Self-ins.Lic. # w C -"� O '-2 O -�O j �2 O - (J I Expiration Date: �( � � Z ' 2���
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failwe to secure coverage as required under Section 25A of MGL c. 152 can lead to the irnposition of criminal penaities 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 certify,un�r the pains a d penalties ofperjury that the information provided above is bue and correct.
Si ature: �"`� � /' � Date: II ' 2� - Z o13
Phone#: /F' Q b' �9 C'' /9 �J�
Official use only. Do not write in this area,to be completed by city or town officiaL
City or Town: yA2.M0�4 Permit/License#
I ' g ut o ircle one):
.Board of Health . Building Department 3. City/Town Clerk 4.Licensing Board 5. Selectmen's Office
6.
Contact Person: Phone#: �3 S8-�-3 � X 12Y�
www.mass.gov/dia
' (�
� NOTICE �� NOTICE
i� V,��>.
TO ,,� �� TO
EMPLOYEES �'��:�! EMPLOYEES =
.�..;�:.�',
t
The Commonwealth of Massachusetts
DEPARTMENT OF INDUSTRIAL ACCIDENTS
1 Congress Street, Suite 100, Boston, Massachusetts 02114-2017
617-727-4900 — http:1/www.state.ma.us/dia
As required by Massachusetts General L,aw,Chapter 152, Sections 21, 22&3Q this wili give you notiee
that I(we)have provided for payment to our injured empioyees under the above-mentioned chapter by
insuring with:
Acadia lnsurence Company
NAME OF INSURANCE COMPANY
P.O.Box 1100,Minneapolis,MN 55440-110U
ADDRESS OF INSURANCE COMPANY
WC-20-20-003820-01 09/02l2013
POLICY NUMBER EFFECTIVE DATES
Kerry Insurance Agency Inc PO Box 1945, North Eastham,MA 02657 (508)255-8000
NAME OF INSURANCE AGENT ADDRESS PHONE#
Tweekiat Theeraatwet 594 Main Street,West Yarmouth,MA 02fi73
EMPLOYER ADDRESS
7l912073
EMPLOYER'S WORKERS' COMPENSATION OFFICER(IF ANY) DATE
MEDICAL TREATMENT
The above named insurer is required in cases of personal in}uries arising out of and in the course of
employment to fumish adequate and reasonable hospital and medical services in accordance with the
provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the
injured employee. The employee may select his or her own physician. The reasonable cost of the ser-
vices provided by the treating physician will be paid by the insurer, if the treatment is necessary and
reasonably connected to the work related injury. In cases requiring hospital attention,employees are
hereby notified that the insurer has arranged for such attention at the
NAME OF HOSPITAL ADDRESS
.
TO �E POSTED BY EMPLOYER