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Home My WebLink AboutApplication and WC 8�' S ' � d TOWN OF YARMOUTH BOARD OF HEALT �� _��!�'D% �!� � � APPLICATION FOR LICENSE/P'�kthlI�',z�0� ; � � a �, ' ��p DEC 10 201� ,�,�� ' * Please complete form and attach all necessai�iocu��s y Decemb I S 2012. Failure to do so will result in the return of your application pac � Q�PT� ESTABLISHMENT NAM � TAX I • ' LOCATION ADDRESS: I� ' TEL.#. – � MAILING ADDRESS: OWNER NAME: CORPORATION NAM�F APPLIC LE): �1' 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, standazd First Aid and Community Cazdiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Department wi►1 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. 1�1 1� �/�l�� 2. i'CI:3f1�' �'\� eF.AF.GE: _ — — - --- _ _ _ -- Each food establishment must have at least one Person In Chazge (PIC) on site during hours of operation. �-�� ,lC�r k � 2. Su I � r'Y��cz� � 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-chokmg 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# LICENSE REQUIRED� FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 _CABIN $55 _MOTEL $55 INN $55 _CAMP $55 _SWTMMING POOL $SOea LODGE $55 _TRAILERPARK $105 _WHIRLPOOL $80ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �0-100 SEATS $85 �I �OJ?B _CONTINENTAL $35 _NON-PROFIT $30 >]00 SEATS $160 COMMON VIC. $60 _WHOLESALE $80 RETAIL SERVICE: —RES[D.KITCHEN $80 LICENSE REQUIRED FEE PERMIT# 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 NAMECHANGE: $IS AMOUNTDUE _ $ HS• OO *****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 pernut 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 Yazmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: \ / YES `C, NO :VIOTELS AND OTHER LODGING ESTABLISI3I�AITS - . �-�. - .,- . TRANSIENT OCCUPANCY: For purposes of the limitations 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 shall generally refer to continuous occupancy of not more than thirly(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 Depar[ment to schedule the inspection three(3)days prior to opening. PLEASE NOTE: People are NOT allowed to sit m the pool azea un61 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 Department,or from the Town's website at www.varmouth.ma.us under Health Departrnent, Downloadable Forms. FROZEN DESSERTS: Frozen desserts must be tested by a State certified lab priar 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••Qut�r se ing wi�h�aiter/lvaitress��vic.�),musthave priQrapprQy�froi�itlae 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 I 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: �� SIGNATU : �� PRINT NAME& TITLE: � Rev. tO/09/12 � ', C� The Commonwealth ofMassachusetts Dep¢rtment of Industrial Accidents Office of Investigations 1 Congress Street,Suite 100 Boston,MA 02119-20U , , www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses A ticant Information Please Print Le 'bl Business/Organization Name: Address: � Ic�c —c� �/�Y I IZC `K�-Y ) City/State/Zip��!c�� Phone#:�JIJ C�— � I�"� � � �-/ L� � � Are- Au an employer?CLecic e appropri�te box: : .,__ ,.,; . . Business T�pe(req,wredl;_ __„ 1.� I am a employer with�employees(full and/ 5. �Retail or part-time).* 6. ❑RestaurantBar/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 requued] 8• ❑Non-profit 3.❑ We aze a corporation and its officers have exercised 9. ❑ E�tertainment their right of exemption per c. 152, §1(4),and we have 10.� Manufacturing no employees. [No workers' comp. insurance requiredJ* 11.0 Health Caze 4.❑ W e aze a non-profit organization,staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.❑Other 'My applicant that checks box N I must also fill out the section below showing their workers'compeasation policy information. **If Ihe corpolate officers have exempted themselves,but the corpofation has other employees,a workers'compensation policy is required and such an orga�ization should check box#1. I am an emp[oyer that is provid�' �w�york�ers'co,m�ype�sation ins'unrance f,�o-r�mpy e(��lo ees.n�elo is the poGcy in tyio�n.,� Insurance Company Nam�X_J� "ZI l��1T,�g l�C� I"1� 1`1�L�IC,U �l� � Insurer's Address��' �,1 T�]��1�'C� � City/State/Zi � \ L.J� _ - P i'� #arSe�f-ar.-�ic�� —� - - -�c�iratien Dater �I --- -- Attach a copy of the workers' compensation policy declaration page(showing the policy numbe and expiration date). Failure to secwe cwerage as required under Secrion 25A of MGL c. 152 can lead to 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 Invesrigations of the DIA for insurance coverage verification. I do he rti ,u�der the pains a»d penalties of perjury that the injarmaJion provided ove is true and correct. Si a Date: J I � ��/�� Phone#: `.�11 C� —�V'�"l�l�t / Officia[use only. Do noi write in this a�ea,to be comp[eted by city or town official CiTy or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.CitylTown Clerk 4.Licensing Board 5. Selectmen's Office 6.Other Contact Person: Phone#: � www.massgcv/tiia � �� NOTICE . � NOTICE v TO � ` TO A EMPLOYEES �; EMPLOYEES � �.� The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 60(1 Washington Street, Boston, Massachusetts 02111 617-727-4900 As required by Massachusetts General Law, Chapter 152, Sections 21, 22, &30, tlus will give you notice that I(we)have pmvided payment to our injured employees under the above menfioned chapter by insuring with: A.I.M. Mutual Insurance Company NAME OF INSURANCE COMPANY P.O. Box 4070 BuAington, MA 01803-0970 ADDRESS OF INSURANCE COMPANY VWG100-6015935-2013A 07/30l2013-07/30l2014 POLICY NUMBER EFFECTIVE DATES P O Box 836 Marshall K Lovelette Ins Agcy West Yartnouth, MA 02673 (508)775-4559 NAME OF INSURANCE AGENT ADDRESS * PHONE Bagels& Beyond LLC 12-2 Whites Path So Yarmouth, MA 02664 ENIPLOYER ADDRESS 07/16/2013 DATE MEDICAL TREATMENT T6e above named insurer is required in cases of personal injuries arismg out of and in the course of employment.to farnish adequate and reasonabie hospital and medical services in accordance with the provisions of the Workers Compensation Ac�t. A copy of the First Report of Injury must be given to the iqjured employee. The employee may select lus or her own physician. The reasonable cost of the services pmvided by the treating physician will be paid by the insurer, if the h�eatment is necessary and reasonably connected to the work mlated injnry. In cases requiring hospital attention, employees are hereby notified that the insumr has arranged for such attention at the NEAREST AND BEST MEDICAL FACILIN EMPLOYER ADDRESS