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Home My WebLink AboutApplication and WC �. , a s«:�� ;; ,�, � � d � TOWN OF YARMOUTH BOARD OF HEALTH �, APPLICATIONFORLICENSE/PERMIT `2( 1��,�� DEC 0B PO�Z . * Please complete form and attach all necessary doct{m�nt�, y D ` 1��1�5 D[pT, Failure to do so will result in the return of yo�ap�c pac et. ESTABLISHMENTNAME: �V�S�L THg� eU� S�N� TAXID: LocaTiorr aDDxEss: 5"9`t '"� gi N 5 T, w� sT��+�c^�ov7�+ TEL.#: 5�- �'9 d-i9s� MAILING ADDRESS: S 9 `f M 9%�v S T. t^'�S'T y.s�e^*o vTH �, 9 �2 6 � 3 OWNERNAME: 7�"f-� fCl9T TftLt a'49 TT�g`'� T 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 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' rewrds. 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 Aealth Department will not use past years'records. You must provide new copies and maintain a file at your establishment. i. Y �^�c�L,� K P� ocgr►Po a. rEf�c3I�T H�ex.4?��- - _ Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. �._ yi r �, �� I� _ D�6 c9� �o --_ 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. �. P� �r cH9 So� �iTeH� ►��ve .� 2. 3. 4. RESTAURANT SEATING: TOTAL# �l 7� OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMTT# _B&B $55 _CABIN $SS _MOTEL $55 _INN $55 _CAMP $55 _SWIMMING POOL $80ea. _LODGE $55 TRAILERPARK $105 WHIRLPOOL $80ea. FOOD SERVICE: � LfCENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �0-�100SEATS $85 �I �O�J� _CONTINENTAL $35 NON-PROFIT $30 _>100 SEATS $160 I COMMON VIC. $60 3�Q _WHOLESALE $80 RETAILSERVICE: —RESID.KITCHEN $SO LICENSE REQUIRED FEE PERMIT N L[CENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $50 >25,000 sq.ft. $225 _VENDING-FOOD $25 _Q5,000 sq.ft. $80 _FROZEN DESSERT $40 TOBACCO $95 NAME CHANGE: $15 AMOUNT DUE _ $ I 4S ,d0 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** " r - 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. 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 sha11 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 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 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 Deparhnent to schedule the inspection three(3)days prior 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 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 Deparhnent,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: _____Quti e_�afes(i,e.Toutdo4r-seatingwith�aiter/waiirQssservice),musthaYaprio��nrnvalfrnTntlieHoazdofHealth_ _ ---- 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 31. IT IS YOUR RESPONSIBILITY TO RET[JRN 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 RE�iRE��ITE P�� DATE: I Z-- 6 � � �Z SIGNATURE: �' PRINT NAME&TITLE: � ''' e� �� '9 7 7l��n'`f� �T��T p w iv�rZ Rev. 10/09/12 I • I. � The Commonwealth of Massachusetts 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 Annlicant Information Please Print Leeiblv Business/Organization Name: �/g 9/L 7�� l C U ( s�N� Address: S 9 `t /'� � i n/ S T . oz6 � � �� City/State/Zip:WZ S i3� "''o v �j /"1 R Phone #: �o� — �� ' Are,you an employer?Check the appropriate box: Business Type(required): 1.�I am a employer with Z employees(full and/ 5. ❑ Retail or part-tune).* 6.�RestauranUBaz/Eating Establishment 2.❑ I am a sole proprietor or pazmership 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] g� ❑Non-profit 3.❑ We aze a corporation and iu officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4),and we have �0.❑Manufacturing no employees. (No workers'comp. insurance required]* 11.❑ Health Caze 4.❑ We aze a non-profit organizarion,staffed by volunteers, with no employees. [No workers' comp.insurance req.] 12.❑ Other "My applicant[hat checks box#1 must also fill out the sec[ion below showing their workers'compensa[ion policy informa[ion. **If the wrpornte officers have exempted themselves,bu[the corpora[ion has o[her employees,a worken'compensation policy is required and such an organi�ation should check box#L . I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. InsuranceCompanyName: !'NC9nl � �NSUk9/YC� CO''9P9r'( ,I Insurer's Address: f - � ,/OX j� �� /"1/ N�vLFj P 0 LI S M °� 7/ I �Q '–lI�� CiTy/State/Zip: Pci4ie�#of�l£-�s:��,# �v L-'_--Z��ZO_-.00 j$�ZO ` d� Expira�ior Date: --� ` - eZ -- Z�r/ Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL a 152 can lead m the imposition of criminal penalties 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,und ./t�le pai��d enalfies of perjury that the informakan provided above is true and correct. Sienature: �"'"° �(I l Date• �Z— �'� �O1 Z Phone#: ��Y� �j66 ~ 1��3 Ojficial use only. Do not write in this area,to be completed by city or town official City or Town: yA-�(LMo�"f't4 Permit/License# Iss ' uth � ircle one): 1. oard oF Health . Building Department 3. City/Town Clerk 4.Licensing Board 5.Selectmen's Office 6. Contact Person: Phone#: $��-3 Qa–aa3l k�Z�[� . . . wv.tiv.masa.gov/aia � . t '�s\ NOTICE ;� NOTICE TO �� TO EMPLOYEES � EMPLOYEES �� The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston, Massachusetts 02111 617-727-4900 — http://www.mass.gov/dia As required by Massachusetts General Law,Chapter 152, Sections 21,22&30,this will give you notice that I(we)have provided for payment to our injured employees under the above-mentioned chapter by ' insuring with: Acadia lnsurance Canpany NAME OF INSLIRANCE COMPANY P.O.Box 1100,Mi�neapolis,MN 55440-1700 ADDRESS OF INSURANCE COMPANY wc-zazo-ooaszo-0o osrovzo�z POLICY NiJMBER EFFECTIVE DATES Kerrylnsurance Agencylnc PO Box 1945, North Eastham,MA 02651 (506)255-6000 NAME OF INSURANCE AGENT ADDRESS PHONE# Tweekiat Theereatwet 594 Main Street,West Yarmouth,MA 02673 EMPLOYER ADDRESS mwzo�2 EMPLOYER'S WORKERS' COMPENSATION OFFICER(IF ANl� DATE MEDICAL TREATMENT The above named insurer is required in cases of personal injuries 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 BE POSTED BY EMPLOYER MA 2585(8lt, J� Massachusetts Workers'Compensation Insurance Plan Acadia lnsurance Company Administered by Berkley Risk Administrators Company, LLC PO Box 1100,Mpis, MN 55440-1100 222 S 9th St, Mpls, MN 55402 Acadia lnsurance� Pho°e csos> s�s-2,�a Fau(866)215-8118 Toii Free (800) 634-4589 NCCI Carrier Code 33391 STATEMENT OF PREMIUM 1. The Insured: NOIT11a1 /�/R Policy Number. WC-20-20-003820-00 Risk ID: 0891489 Tweekiat Theeraatwet dba: Besil Tha Cuisine Tau ID#: 594 Main Sheet Policy Period: From: 9l2/2012 West Yartnouth, MA 02673 To: 9/2/2013 Date of Mailing: TN6l2012 StarMard Premium 5161.00 Loss Cormfant jZp,pp Expense Co�tark j159.00 Terrorism Stat Code 9740 55.00 Total Esdmated Amual Premium 5345,pp DIAAsseasment 7,042 s7,00 TWaI Fees 8 Premium 535206 Net Deposit Premium Required y35200 Premium Paid to DaOe (5352.00) Tofal Premium Dtre sp_pp Aqencv Name and Address Kertylnsurance Agencylnc PO Box 1945 North Eastham, MA 02651 BA3200 (11/95)