Loading...
HomeMy WebLinkAboutApplication and WC � ^' � TOWN OF YARMOUTH BOARD OF HEALTH ��SS I-�'!v�P22A� � APPLICATION FOR LICENSE/PERMIT-2014 n�,�,i3�� � * Please complete form and attach a11 necessary documents by Decem�er�13 2013. Failure to do so will result in the return of your applicahon pac cet. ESTABLISHMENT NAME: r 2Z� - � LOCATION ADDRESS: '$ - - MAILING ADDRESS: o E-MAIL ADDRESS: OWNER NAME: � . _. . _ ; � CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: MAII,ING 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 ttus form. L 2. Pool operators must list a minimum of two employees currently certified in basic water safety,standard First Aid and Community Cardiopulmonary Resuscitation(CPR),hauing one certified employee on premises at a11 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 - CERTIF'ICATIONS: 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 ase past years' records. You must provide new copies and maintain a file at your estab6shment. l. I�e�.�t� �o.rt �..`.. � . 2. PERSON IN CHARGE: Each food establishment must haue at least one Person In Charge (PIC) on site during hours of operatibn. 1• ��`\h�l `���iw4 O �� 2. �?C'�.B.�tX � \ �a,_rh:��na t)t � ALLERGEN CERTIFICATIONS: � All food service establishxnents 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 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. HEIMLICH CERTIFICATIONS: I' 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. T6e Health Department will not use past years'records. You must provide new copies and maintain a tile at your place of business. 1. l7 e,rnr�� ��..+...n..V� � (� 2. � 3• 4. ! RESTAURANT SEATING: TOTAL# ` I __ I OFFICE USE ONLY LODGING: I LICENSE REQLiIRED 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 SERV[CE: � LICENSE REQU[RED FEE PERMIT# � LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �0-100 SEATS $85 /N-/�j�/ CONTINENTAL $35 NON-PROFIT $30 >100 SEATS $160 ' �COMMON VIC. � $60 � _WHOLESALE $80 —RESID.KITCHEN $80 RETAIL SERVICE• . LICENSE REQUIR6D FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <SOsq ft. $50 >25,000 sq.ft. $225 VENDING-FOOD $25 � �<25,000 sq.@. $80 =FROZEN DESSERT $40 _TOBACCO $95 NAMECHANGE: $15 AMOiJNTDUE _ $ 15�5�. On "*••*PLEASE TUAIY OVER AND COMPLETE OTHER SIDE OF FORM*"+*• ADMINISTRATION � Under Chapter 152, Section 25C, Subsection 6,the Town of Yannouth is now required to hold issuance or renewal of I 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 MLJST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yazmouth taaces and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK � APPROPRIATELY IF PAID: �' YES NO �I 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 mor�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 OPEPIING: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 Department to schedule the inspection three (3) days prior to opening.PLEASE NOTE:People are NOT allowed to sit in the pool azea until the pool has been inspected and opened. j 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 ('n 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 Departrnent, or from the Town's website at www.yarmouth.ma.us under Health Deparhnent, 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 Departxnent. 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, preparation, or display of any food product by a retail or food service establishment is prohibited. NOTICE: Permits run annua!ly 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 MAY REQUIRE . Dt�T�' � ' I '��IGNATURE: � _, �ME&TITLE: Ci/G!/ Rev. 10/08/13 � j` � � The Commonwealth ofMassachusetts � Department of Industrial Accidents � Offzce ofinvestigations ' I Congress Street, Suite Z00 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Le�blv c Business/Organization Name: 1 Address: Q City/State/Zip: Phone#: ��6�`j� — �]�_ Are you an employer? Check the appropriate boz: Business Type(required): 1.❑ I am a employer with�_employees(full and/ 5. ❑ R tail or part-time).* 6. �RestaurantBaz/Eating Fstablishment 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. inswance required] $� ❑ Non-profit 3.❑ We aze a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §I(4),and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]* 11.❑ 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#1 must also fill out ffie section below showing the'v workers'compensation policy information. •*If the co�porate officers have exempted themselves,but tlte cofporation has other employees,a workecs'compensation policy is required and such an mganization shou(d check box#1. . . . .. . .. . . _ . _ . . I am an employer that is providing—w{o'rker^sn'campens n insurance for my emp[oyees. Below is the policy information. Insurance Company Name: �- + l V , ���"� �,� �� Insurer's Address: �o ���� I City/State/Zip: ,�ea�v.p.(�Q� , ,�,�_���"—'� �, Policy#or Self-ins.Lic. # v Ci-1�(��plQ(jJ —r��� Expiration Date: ; Attach a copy of the workers' compensation policy declaration page(showing tLe policy number and eapiration date). ', Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposirion of criminal penalfies ota - I 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 Invesrigations of the DIA for insurance coverage verificarion. I do hereby c ' , r the pains and penalti ofperjury that the information provided above is true and correct. Si ature: Date: -� � � Phone#: � - i Official use only. Do not write in this area,to be completed by city or town officiaL I I City or Town: yQ��p� Permit/License# 4 Is u ' cle one): 1. Board of Health .Building Department 3.City/Town Clerk 4.Licensing Board 5. Selectmen's O�ce 6. ContactPerson: Phone#: ,�3Q�� y JZy� I www.mass.gov/dia ( \ � IN • Policy Number: BPI2600Z SI'REEI' AMERICA GROUP BUSINESSOWNERS COMMON DECLARATIONS MAIN STREETAMERICAASSURANCE COMPANY � 4601 TOUCHTON ROAD EAST,SUITE 3400,JACKSONVILLE, FL 32245-6000 Item 1. Named Insured and Mailing Address Agent Name and Address ' GERALD A DOWNING SCHLEGEL & SCHLEGEL INSURANCE (SEE NAMED INSURED ENDT) 1311 ROUTE 28 34 ROUTE 28 SOUTH YARMOUTH MA 02664-4453 WEST YARMOUTH, MA 02673 HgeniPhoneNo. (508) 771-5381 Agent No. 201060 I�m2 PolicyPeriod Erom: 03-10-2013 To: 03-10-2014 at 12:01 A.M., Standard Time ai your mailing address shown above. Item3. Form of Business: INDIVIDUAL Item 4. In return for the payment of the premium, and subject to all the terms of this policy, we agree with you to provide the insurance as stated in this policy. This policy consists of the following coverage parts for which a premium is indicated. Where no premium is shown, there is no coverage. This premium may be subject to adjustment. COVERAGE PREMIUM . , Section I —Property $ l, 208 . 00 Section II —Liability $ 678 . 00 Inland Marine NOT APPLICABLE Total Policy Premium: $ 1, 8 8 6 . 0 0 ' For Coverages subject to premium audit: Annual Audit Applies j Item 5. Form(s) and Endorsement(s) made a part of this policy at time of issue: See:Schedule of Forms and Endorsements� . ' Countersigned: , Date: By: Authorized Representative THIS BUSINESSOWNERS COMMON DECLARATIONS AND SUPPLEMENTAL DECLARATION(S), TOGEfHER WITH SECTION III —COMMON POLICY CONDITIONS, COVERAGE PARTS, COVERAGE FORMS AND ENDORSEMENTS, IF ANY, COMPLETE THE ABOVE NUMBERED POLICY. BPM D 1 1207 . n��r coar ��.