Loading...
HomeMy WebLinkAboutApplication and WC = � FD2InEaZt-YG��" d TOWN OF YARMOUTH BOARD OF HEALTH ' i� � �L'i , ��� APPLICATION FOR LICENSE/P,EI�I�I'F=�2 1 `�' � ��"� �;35 * Please complete form and attach all necessazy d��y' ee er 13"�2613. Failure to do so will result in the returneo�yout appli� ion pa et.HEqLTH DEPT. ', ESTABLISHMENTNAME: T ' LOCATIONADDRESS: /v�'a h,�-�J I� n j Zk TEL.#: SDP-39g -�S6U MAILING ADDRESS: �a�� _ E-MAIL ADDRESS: /3/(,- ,,�� �cTy�`Y4 f/�c� . �'�� OWNERNAME:_Q/Fn�� i4 Uo>�e.(�.4- CORPORATION NAME (IF APPLICABLE): ' MANAGER'S NAME: TEL.#: Svh- � -/F�d7 MAILING ADDRESS: .f.4n� -�— ' 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, standazd First Aid and Community Cardiopulmonary Resuscitation(CPR),having 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 fde at your place of bus�ness. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-rime employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishxnents, 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. �ir=n ��lJv z�«� a. PERSON IN CIIARGE: Each food establishxnent must have at least one Person In Chazge (PIC)on site during hours of operation. 1.Q/J�✓LLZ /�oZz��!�— 2. la4t_�� ���.r (�.!�- ALLERGEN CERTIFICATIONS: ' All food service establishments are required to have at least one full-time employee who has Allergen certification,as I 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.�%F/1�� /�G¢2z��4-- 2. c..��.�rt�� U z�,- G,4_ 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. 1.��/ �� f�(�J27�G� 2. L .Q[/n��,r �o �t 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 _SWIMMING POOL $80ea. LODGE $55 _TRAILERPARK $105 _WHIRLPOOL SSOea FOOD SERVICE: � LICENSE REQUIRED FEE P RMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 10-100 SEATS $85 �1�-aBN� CONTINENTAL $35 NON-PROFIT $30 >100 SEATS $160 �COMMON VIC. $60 lt1�4-O WHOLESALE $80 — =RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# � LICENSE REQUIRED FEE PERMIT# �50sq ft. S50 >25,000 sq.ft. $225 VENDING-FOOD $25 � =<25,000 sq.ft. $80 —FROZEN DESSERT $40 _TOBACCO $95 NAMECHANGE: $15 AMOiJNTDUE _ $ ITcr7� OO •****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*`**• � II _ .. _._. ' 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. TFIE 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 ar 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 mare 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. 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 Departsnent prior to opening. Contact the Health Departrnent to schedule the inspection three (3) days prior to opening.PLEASE NOTE:People are NOT allowed to sit in the pool area 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 outdoor in ground swimming pool must be drained or covered within seven (7) days of closing. FOOD SERVICE SEASONAL FOOD SERVICE OPEIVING: 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 Yannouth 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.yarmouth.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 ofyour Frozen Dessert ' Permit until the above terms have been met. ' OUTSIDE CAFES: Outside cafes (i.e., outdoar seating with waiter/waitress service), must have prior approval from the Board ofHealth. 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 RESPON5IBILITI'TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 13, 2013. i ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW I EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLA DATE: // 7� SIGNATiJRE: ����/"�G�,f���r-� PRINT NAME& TITLE: �//�-✓!e c� .� /�o z�/(� �ry n � I Rev. 10/OS/13 � . i The Commonwealth ofMassachusetts ' • , � Department of Industrial Accidents O�ce of Investigations � l Congress Street, Sudte I00 ' Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Le¢iblv Business/Organization Name:�Tj1(�,q��J'/�/',es,�/-it./=� uN U�- Address: /O�(o �r,ai,,, rr �.� ZY a 2 Phone#: , s—oY-3 58 -'S6o Ci /State/Zi : rndd No ( tY P 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 (�r� 2.[�'I am a sole proprietor or partnership and have no �, � 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, §1(4), and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]* 11.❑ Health Caze 4.❑ We aze a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.❑ Other •My applicant that checks box#1 must also fill out the sec[ion below showing the'v workers'compensation policy information. **If the corporate officeis have exempted themselves,but the corporadon has other employees,a workers'compensation policy is requimd and such an organization should check box#1. I am an employer that is providirsg workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: �.L�a ,��oz� -T�JS�nR��� ��. Insurer'sAddress: /�d �Ou 3SS� Y/� /Lf � CiTy/State/Zip: (✓�� �ArlmO�t�� /�✓J- lJ Ll���3 Policy#or Self-ins.Lic. # D /nc�77r.h —d gw'��PG 867 Expirafion Date: �� �(�/Y Attach a copy of the workers' compensaHon policy declaration page(showing the policy number and eapirafion date). Failure to secure coverage as required under Section 25A of MGL a 152 can lead to the imposition of criminal penalUes of a fine up to$1,500.00 and/or one-yeaz imprisonment,as well as civil penal6es 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 fonvazded to the Office of Investigations of the DIA for insurance coverage verification. I I do hereby certify,unde the pains andpenaUies ofperjury that the injormation provided above is true and correct. � Si ature: Date: �/ .l� i IPhone#: IOfficial use only. Do not write in this area,to be completed by city or town officiad City or Town: YAQn��]U7tF Permit/License# ' Iss ' ' c�rcle one): .Board of HeaU 2.Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's O�ce 6. e� � ContactPerson: Phone#: �B-3g8—�3/ X2y� www.mus.gov/dia AC�o' CERTIFICATE OF LIABILITY INSURANCE ��'�i�e�13 �� THS CERTIFICAiE IS ISSUED AS A MATTER OF IPFORMATION OI�IY AND CONFERS NO RIGHTS UPON iHE CERTIFlCATE HOLDER THS ; CERTIFICA7E DOES NOT AFFIRMATVELY OR NEGATIVELY AMEW, EXTEND OR AL7ER TFE COVERAGE AFFORDED 8Y THE POLJqES � i BELOW. THS CERfIFlCATE OF INSURANCE DOES NOT CONST1TUlE A CONTRACT BETWEEN THE ISSUING INSURER�S), AIJ�FIOPoZED s REPRESENTA7IVE OR PRODUCER,AND 7HE CER�IRCATE HOLDER. ; IMPORTANT: M the certificats hdder is an ADDIiIONAL INSURED,tlie polic�es) must be endased. If SUBROGATON IS WNVED,subject to j the temu and conditio�ofthe policy,certain policies may require an endoisement A atalemerk on this cerfifipte does not eonter ri�ffi to Ihe S certificate holder in lieu of such erdasemenl(�. '.Rowcve NAME�T Chevonne A Pratt ' Chagnon Insurance Agency, Inc. P�+oNE F`X . (508) ��s-iiss �� � (508) 771-1660 a . � � PO Box 355 noo�Ess: chevonnepratt@ciainsurance.net . ;�� Q�.1 ROUtB �LB INSUFE SAFFORqNGCOVERAGE NAICp I West Yarmouth, MA 02673 ��Rmp:The Hart£ord Inaurance Com aa � � . . . . ... _---_ ..___ ._._ ....__..... . ' .� HS'il�� INSIIREfiB: � Alfred Vozzella c�a i�R��, �� ' Big A1's Breakfast 6 Lunch i�R�no: i � � 1076 Route 28 ± INSURF3l E: _ � South Yarmouth, MA 02664 i�R�F: , .COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: j� THIS IS TO CERTIFY TW1T THE POLICES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSU2ED NAMm ABOVE FOR THE POLICY P6210D � INDICATm. NOTWITHSTANDWG ANY REQUIREMENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMFM WRH RESPECT TO WHICH THIS i CERTIFICATE MAY BE ISSUm OR MAY PERTAM,THE INSURANCE AFFOF�ED BY TFE POLICIES DESCRIBED HEREMI IS SUBJECT TO ALL THE TERMS, . ; EXCLUSIONS ANDCONqT10NS OF SUqi POLICIES.LNAfTS SHOWN MAY HAVE BEEN RFAUCED BY PAID GAIMS. •!NSR�.. - .___ _. .. . . . . ._ADDLSUBR ____ ..... . . __..____- POLICYEFF POUCYF7� _...__. . ._. _- __ .____.. .. �%_TR iYPEOFINSURANCE Pd1CIM1116EIt MIODIY WNdYWY UMTS i��A ��A��&� QB$$M4977FM 11/6/13 11/6/16 �HOCCURRENCE $ 1 000 000 _ � X CObfAERCIALGEIERALLIHBILITV DAM4GETORENtED S 1.000,000 � cue.uanaoe ❑X occua r.EoowWMorepesm� a 10 000_ . � � PERSON4L8PDVINJURV $ S OOO OOO � � r GENERALAGtliEG47E $ 'L OOO OOO I �GEN'LAGGREGATELMITAPPLIESPER PROWCfS-CO�ProPAGG $ '1 OOO OOO � f � POLICV P� lOC t AUTOMO&LEIIABNT/ aeccitlert ` � 3 ��. �� IWYAUlO BODILVINJURV(Perperson) $ a ILLIOWPED SCHEDULE�' BODILY INJURV(Per amJtlent) $ I I __ AUTOS NON-0NMED PR�a��PM4+� s r_ HIREDAUTOS _ q�J70S $ , � ' ������� OCCUR EACHOCCUPRENCE f .. EXC�SLIAB CWMS-M40E AGGPEGATE $ -- + —_ � DED RETENTIONS s � p NORKH6CONPENBATION 08FlECCP0867 ii/�/i3 ii/�/ia wcsrnru- arN- �wo anv�ov�t+s une�u�v - ����E�������� v� NIA EL.EACHACq�EM $ SOO�OOO OFFK£MAEMEER EXCLIAEU7 i (FlanilabryinNH) E.L.DISEASE-EAH.QLOVEE $ 5��,�0� HYes desaibeun0er I DESCRIPTIONOFOPEAATIONSbebw E.L.DISEASE-POLICYLMR $ SOO OOO � . �I'�ESCRIPIIdlOFOPERA710NSILOCA710NSIVEFIClE51�hACORD1b1.AtriEonelRa,re�1nSG�etluk,ifmorespecein9Jred) � Certificate holder has been added as an Additional Insured on the CGL policy. i.. CERTIPICATE HOLDER CANCELLATION � SHOULD ANV OF 7HE ABOVE DESCPoBED POLICES BE CANCELLED BEFORE � T!ff E%PIRATION DAIE THEfffOF, NOTICE WILL BE DELIVERED N TOOPil Of Yarmouth ACCORDANCE WI7H 1HE PO pNB. y ; Health Department j A RE � �__ �198 0 ACORD CORPORATION. All righis reserved. . ACORD 25(2010/05) The ACORD reme and logo a ' �� red marks of ACORD !�hone: Pax: (508) 760-3640 E-Mail: