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Home My WebLink AboutApplication and WC� . _ g»c�.a +,�i+crv . d TOWN OF YARMOUTH BOARD OF HEALT " � ' � APPLICATION FOR LIGE r I -201 Utf,; O Z L013 ` * Please complete form and attach all neees ' t� c � ents b Dec 13. Failure to do so will result in th�retiiin o�yout applic tio ESTABLISHMENT NAM : TAX • � LOCATION ADDRESS: TEL. — — MAILING ADDRESS: E-MAIL ADDRESS: OWNERNAME: ' CORPORATION NAME F A� IC E : 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),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 C►le 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 £le at your establishment. 1.� l IS—=—�^1-1�+�-�t�� 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1�� ('E' I I [ J[ C�f.f J 2. ALLERGEN CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who has Allergen certification,as def�ed 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. i.c�(�I I ^ �(-� (� z. 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. L 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# L[CENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $55 INN $55 CAMP $55 SWIMMING 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 �k 14-0`73 CONTINENTAL $35 NON-PROFIT $30 >100 SEATS $160 �COMMON VIC. $60 -� _WHOLESALE $80 — —RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERM[T# <50 sq.ft. $50 >25,000 sq.ft. $225 _VENDING-FOOD $25 _Q5,000 sq.ft. $80 �ROZEN DESSERT $40 _TOBACCO $95 NAME CHANGE: $15 � AMOUNT DUE _ $ ��F J�CC ***"*PLEASE TiJRN 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 STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHE Town of Yarxnouth 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 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 thiriy(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:Ali 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 outdoar in ground swimming pool must be drained or covered within seven (7) days of closing. _ _ _. _ _ _ - FOOD�ERVICE _ _ 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 Heakh Deparhnent, Downloadable Forms. FROZEN DESSERTS: Frozen desserts must be tested by a State certified lab prior to opening and monthiy 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 CAF'ES: Outside cafes(i.e., outdoor seating with waiter/waitress service),must have prior approval from the Boazd of Health. OUTDOOR COOHING: 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 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 MA UIRE A SITE PLAN. DATE: r �I SIGNATU • PRINT NAME&TITL : (/{ � Rev. 10/OS/13 � � � 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 Aftidavit: General Businesses A licant Information Please Print Le ibl Business/Organization Name: � Address: � \ � 1 IVI � City/State/Zip: r w7I0 �one #:�71��___�_C�� Are you an employer? Check the appropriate box: Business Type(required): 1.� I am a employer with�_employees (full and/ 5. ❑ Retail or part-rime).* 6. �RestauranUBaz/Eating Establishment 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 are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §I(4), and we have 10.Q Manufacturing no employees. [No workers' comp. insurance required]* I 1.❑ Health Caze 4.❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.� Other *Any applicant that checks box#l must also fill out the section below showing the'v workers'compensation po(icy information. *•If the wrporate officers have exempted themselves,but the cotporafion has o[her employees,a workers'compensafion policy is required and such an organization should check box#1. I am an emp[oyer that is providing wor,k�eyrs�'com ensfa�tio_n in/su�r,Pnce fo'/r em 1 ees. elow is e policy information. Insurance Company Name'�� . 1 1 I • �l.4 l ��U.l �1�� . Insurer's Address: City/State/Zip: � � Policy#or Self-ins.Lic. # piraUon Date: � Attach a copy of the workers' compensafion policy declaration page(showing the policy number and espiratiou date). Failure to secure coverage as required under Section 25A of MGL c.152 can lead to the irnposition of criminal penalries of a fine up to $1,500.00 and/or one-year 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 hereb certify, under the pains and penalties ofperjury that the information provided above is true and correct. Si atur . Date: Phone#: � Offtcial use only. Do not write in this area,to be completed by city or town officiaL City or Town: YPri2AA0J i}� PermitlLicense# Iss iug-A�the ' circle one): Board of Health 2. uilding Department 3. City/Town Clerk 4.Licensing Board 5. Selectmen's Oftice 6.Ot�er Contact Person: Phone#: ,�,�,-=�,QB—a�l X/Z�� www.mass.gov/dia � NOTICE � � NOTICE . TO � • TO A EMPLOYEES � ,, EMPLOYEES �, ...,� The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston, Massachusetts 02111 617-727-4900 As required by Massachusetts General Law, Chapter 152, Sections 21, 22, & 30, this will give you norice that I(we)have provided payment to our injured employees under the above mentioned chapter by insuring with: A.I.M. Mutual Insurance Company NAME OF INSURANCE COMPANY P.O. Box 4070 Burlington, MA 01803-0970 ADDRESS OF INSURANCE COMPANY VWC-100-6015935-2013A 07/30/2013-07/30/2014 POLICY NUMBER EFFECTIVE DATES P O Box 836 Marshall K Lovelette Ins Agcy West Yarmouth, MA 02673 (508)775-4559 NAME OF INSURANCE AGENT ADDRESS . PHONE Bageis& Beyond LLC 311 Main St West Yartnouth, MA 02673 EMPLOYER ADDRESS 07/16/2013 DATE MEDICAL TREATMENT The above named insnrer is required in cases of personal injuries arising oat of and in the course of employment to fnrnish adequate and reasonable h�pital and medical services in accordance with the pmvisions of the Workers Compensation Ac�t. A copy of the �rst Report of Injury must be given to the injared employee. The empioyee may select Lis or her own physician. The reasonable c�t of the services provided by the treating physician will be paid by the insurer, if the treatrnent is necessary and reasonably connected to the work related iqiury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the NEAREST AND BEST MEDICAL FACILITY EMPLOYER ADDRESS T!1 RP� Pl1CTFil RV F1V(PT (1VPR