HomeMy WebLinkAboutApplication and WC �" ' c��E �L� c�.�+r��� y \
� TOWN OF YARMOUTH BOARD OF HEAI,T�
� � AP pLICATION FOR LICENSE/P� t§�y � il�1�9»
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* Please com lete form and attach all necess cuxne�n b De m e 13 2013.
:
• Fai lure to do so wi l l resu lt in t he r�h i r n of your application
ESTABLISHMENT NAME: � � c' ar T - � �
LOCATIONADDRESS: .5� ,2- TEL.#: S"7>5'-3 � ��/
MAILING ADDRESS: Sr..�� Vv�,�,+-.�,, �lit c� ri?(a(o�/
E-MAILADDRESS: �L�w� CJ�c'�"✓lw��.r.G✓a .Cn -.�
OWNERNAME: �t�/�-v�3
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
Operatar(s) and attach a copy of the certification to this form.
L 2.
Pool operatars 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 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 t"ile 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 Tile at your esta6lishment.
1. /1'I✓� �A-V1 S 2. I'1�1 e cz_.a /1-�, �r0 v�a�+l,. �
PERSON IN CHARGE:
Each food establishment must have at least one Person In Chazge (PIC) on site during hours of operation.
1. 2. '
ALLERGEN CERTIFICATIONS:
All food service establishments aze 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 Sle at your establishment.
1. !��✓J-+� �lf.�+� 2. � �-/�✓t-. �ti�l � _
HEIMLICH CERTIFICATIONS:
All food service establishments with 25 seats or more must have at least one em�loyee trained in the Heimlich
Maneuver on the premises at a11 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
�NN $55 CAMP $55 SWIMMINGPOOL $SOea
LODGE $55 TRAILERPARK $105 WHIRLPOOL $SOea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
�0-100 SEATS $85 #�P-1-04S- CON'I'[NENTAL $35 NON-PROFIT $30
>I00 SEATS $160 I COMMON VIC. $60 -lp lµ�-L'7 } —WHOLESALE $80
—RESID.KITCHEN $80
RETAIL SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
<50 sq.R $50 >25,000 sq.ft. $225 VENDING-FOOD $25
—<Z5,000 sq.ft. $80 L FROZEN DESSERT $40 � _TOBACCO $95
NAME CHANGE: $IS AMOUNT DUE _ $ 18�:U O
****•PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***•*
. -.
ADMINISTRATION • .
Under Chapter 152, Section 25C, Subsection 6,the Town of Yannouth is now required to hold i ssuance or renewal of
any license or permit to operate a business if a person or company does not have a Certificate of�`orke�'tiCompensation
Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVI'F MUST BE '
COMPLETED AND SIGNED,OR
CERT. OF INSURANCE ATTACHED
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth taaces and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES NO
MOTELS APID 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 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 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 OPEiVING: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 aze 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 Deparlment 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. I
_ _ _ __ _ _ ____ -- --
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 Yannouth 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 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 revocarion of your Frozen Dessert
Permit until the above terms have been met.
OUTSIDE CAFES:
Outside cafes (i.e., outdoor seating with waiter/waitress service), must have prior approval from the Board 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 annually from January I 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.),NNST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO
COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
DATE: /(L�I':�e/3 SIGNATURE: f.�� "�y, �c}-�,�'
PR1NT NAME&TITLE: �/✓M /iYl. ! ,/�v�S o�...,��,r-
. Rev. 10/08A3 �
r -
� The Commonwealth ofMassachusetts
Department of Industrial Accidents
O�ce oflnvestigations
l Congress Street,Suite I00
Boston, MA 02I14-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Leeiblv
Business/OrganizationName:G�� ��C Gv�,�-�,..,�
Address: � �F,�,e►./,,�e �.� A.,_ Q �
City/State/Zip: .s' �/� G a Phone#: S'Uy - 3�i �� S/y0U
Ar,_e..,�°u an employer? Check the appropriate box: Business Type(required):
1.LI I am a employer with�employees(full and/ 5. ❑ Retail
or part-rime).* 6. 0[�RestaurantBaz/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, §1(4), and we have 10.� Manufacturing
no employees. [No workers' comp. insurance required]*
4.❑ We are a non-profit organization,staffed by volunteers, I 1.❑ Health Caze
with no employees. [No workers' comp. insurance req.] 12•� Other
*Any appGcant that checks box#1 must also fill out the section below showing their workers'compensation policy informa[ioa.
**If the cotporete o�ce�s have exempted themselves,but the wrporation has other employees,a workers'compensation policy is requiced and such an
organizafion should check box#I. � � �
I am an employer that is providing workers'compensation insutance for my employees. Below is the policy information.
Insurance Company Name:
Insurer's Address:
City/State/Zip:
Policy#or Self-ins. Lic. # Expiration Date:
Attach a copy of the workers' compensafion policy declaration page(showing the policy number and eapiraHon date).
Failure to secure coverage as required under Section 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
Investigations of the DIA for insurance coverage verification.
I do hereby certify, nder the pains and penalties ofperjury that the information provided above is true and correcG
Si¢nature: ��/(�� �i}�� Date• / - � • ��/J
Phone#: � �f �i � - 7Go � � G3
Ojficial use only. Do not write in this area,to be completed by city or town officiaL
City or Town: yA�Mntt�a Permit/License#
ng u circle one):
.Board of Health . Building Department 3. City/Town Clerk 4.Licensing Board 5. Selectmen's Office
6.
Coutact Person: P6one#: ,�-�qR-,�33! x I ZN�
www.mass.gov/dia
' , � � WORKERS COMPENSATION AfVD EMPLOYERS LIABILITY INSURANCE POLICY
INFORMATION PAGE
� , � Associated Employers Insurance Company
54 Third Avenue, Burlington, Massachusetts 01803-0970
(800)876-2765 NCCI NO 40959
POLICY NO. WCC-500-5011995-2013A
PRIOR NO. NEW
ITEM
1. The Insured: Cape Cod Creamery LLC
DBA:
Mailing address: 1199 Route 28 FEIN: "-"'
South Yarmouth, MA 02664
Legaf Entity Type: Limited Liability Corporation
Uther workplaces not shown above:
2. The policy period is from 05/01/26t3 to OS/Otl2014 12:01 a.m.standard time at the insured's mailing address.
3. A. Workers Compensation Insurance:Part One of the policy applies to the Workers Compensation Law of the
states listed here: MA
8. Employers'Liability Insurance:Part Two of the policy applies to work in each state listed in item 3.A.
The limits of Iiability under Part Two are: Bodily Injury by Accident $ 500,000 each accident
Bodily Injury by Disease $ 500,000 policy limit
Bodily Injury by Disease $ SOQ,000 each employee
C. Other States Insurance:
D. This Policy includes these Endorsements and Schedules: SEE SCHEDULE
4. The premium for this policy will be detertnined by our Manuals of Rules,Classiflcations, Rates and Rating Plans.
All information required below is subject to verification and change by audit.
Classifications Premium Basis Rates
� Code Estimatetl Per$100 Estlmated
No. Total Mnual Of Annual �
Remuneration RemuneraGon Premium .
II INTRA
�I INTER OOU481863 SE CLASS CADE SCHEDU E
Minimum Premium $520 Total Estimated Annual Premium $2,099
' GOV GQV Deposit Premium
ISTATE CLASS
MA 8017 MA Assessment Chg.
$70
This policy, including all endorsements,is hereby countersigned by ���� 05/02/2013
Authorizatl Signature Date .
Service Office: Miller McCartin
973 lyannough Road
Hyannis,MA 02601
WC 00 00 01 A(7-11)
Inclutlea eopyrightetl material Oi tlfB Natbnai Council on Compensetlon Insurence,
usetl with its permission.
� \
� Client#�65428 2CCCR7
'ACORDM CERTIFICATE OF LIABILITY INSURANCE °""„"""'°""'",
� 10/2812013
7-HIS CERTIFICATE IS ISSUE�ASA MATiER OF INFORMATION ONLY ANO CQNFEftS NO RIGHTS UPON THE CERTIFICATE HOL�ER.THIS
CERTIFICAxE�OES NOTAFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER iHE COVER4GE AFFOROED BY THE POLICIES
BELOW.T�S�CERTIFIGATE OF INSURANGE DOES NOTCONST1TUiE A GONTRAGT BEfWEEN THE ISSUING INSURER�S).AUTHORIZED
REPRESENTATNE OR PRODUCER,AND THE CERTIFICATE HOLOER.
IMPORTANT: H the cett'rficate hoidet is an AD�ITONAL INSURE�,the policy(ies)must 6e endorsed.If SUBROGATION IS WAIVE�,su6ject fo
the temis and conditions of the policy,certain policies may require an endorseme�rt.A statemerrt on this certificate does not confer righis to ihe
� rertiTicate holder in lieu of such endoraement�s).
veuuoCte CONTACT
xaxe
Dowling 8,O'Neil vnawe
� InsuranceAgenCy w�a�,e.n:508775-1620 ja�,�„�, 5087781218
noonF`ss: �
9is lyannough Rd., PO Box 1990 IrygUREWSI�FOR01qGCDVERACE eucn
N;annis, MA 02601 .
msuxcxn:S3fESylndemnity �
"`iQ"`O insunerss:Associated Employere Insurence
Cape Cad Creamery, LLC
msuxcK C:
5 Theatre Colony Roatl
SouthYa�mouth,MA 02664 insuneno:
INSYMkN k:
� INSVRER F:
C�?VER4GE5 CERTIFICATE NUMBER: REVISION NUMBER:
-'-il� I^a TC CEftTIFV THAT THE POLICIES OF INSURANCE LISTE� 6ELOW HAVEBEENISSUE�TOTHE INSUftEO NAMEDABOVE FORTHE FOLICYPERIO�
�:]ICAT3D. NOPNRHSTANUING AM/ RE(1111REMEM, TERM OR CONGITIONOF ANV CONTRACTOR OTHER GOCl1MENT WITH RESPECT TO WHICH THIS .
.=�TIFlc';.vTE IdtiY 5E ISSt1E� OR MAV PERTAIN, THE INSl1RANCE AFFOR[lEG BV THE POLIGES fiESCRIBEfi HEREIN IS Sl7BJECT TO ALL THE 7ERMS,
�..rL15iCPl5 ?ND CONDITIONS OF SUCH POLIQES. LINIiS SHfJN7V MAV HAVE BEEN REDUCE� 6Y PAID CL41M5.
L+���>� T�PEOFINSUFAHCE A�� �tlN VOUCYkFF VOIICYlXM
IN9R WYO POLILYflOMBER (MMIOIIIYTYT) (MMNWYYYY� V�� I�I�
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� ���GED x RETEflTInN ��000 §
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(Mantla�orylnNH) F.I.IIIAFAtiF.F4FMYIlIYYY $.r100000
f rs., ra1Le unJei
ur'=:CF�ivii)rvOFOVFHnnqN;ine:irnv E.LDIP,EA�E�PO4CYLIMIT $500,000
�lStHIV i IUN OF OVlMA I ION6/IALR I ION6/VlNICLk&(R�4 c�ACOMO 101�ACOtllwal Nunaikz Se�etluls�I(men sp CP IS fnqWieO)
Insurance coverage is limitetl to the terms, conditions,exclusions,other IimiWtions and endorsements.
Nothing cantained in tha cartificate of insuranca shall 6e deemed to hava altared,waivetl,ar extenAed tha
coverage providad 6ythe policy provisians.
C��RTIFICATE HOL�ER CANCELLATION
Town Of Yatmauth SHWL�ANV OF TiE ABOVE�ESCRIBED POLICIES BE CANCELLEO BEFM2E
THE EXPIRAiION DATE THEREOF, NOTIGE WILL BE OELNEREU IN
�146 ROutB Y$ ACCORDANCE Wlhl TkiE POLICY PROVISIONS.
South Yarmouth, MA 02664
RII I HOI[ILkU NkVNlSlN I F IIV!
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�91988-7A10 ACORD CORPORATION.All rights reserved.
A�;GRD 25(2070/05) 7 oT 1 The ACORD nama antl logo are registered marks of ACORO
#S119789/M119788 KKM