The URL can be used to link to this page

Home My WebLink AboutApplication and WC I C-C- S�PeR-. B u��T , � ,�� TOWN OF YARMOUTH BOARD OF HEALTH APPLICATION FOR LICENSE/PERMIT-20 1 + �/� � ..., a.�`a� � * Please complete form and attach all necessary do �� '` s " e � r5 P � Failure to do so will result in the retum of y�app ack�t. `� � 6 Z O�O i ESTABLISHMENT NAME: d TAX ID: LOCATIONADDRESS: aa.R Main �h �i2t.a$ uu� Uclrmcyath MAc�26�3 TEL.#: S9g 1��-gttl� MAILINGADDRESS: aaR tYla(nst'P,t�R ��.rsl��r,+„hMF1 U�� OWNER NAME: Z� 2: ;axl CORPORATION NAME (IF APPLICABLE):� e��`�j_(��c. MANAGER'S NAME: - � TEL.#: - S� B 10 l� �c�^ 3l� 2Q�o MAILING ADDRESS: 8 m��n S� �ak Ilksf l�'dtCCG,� Mw C'�2��?. 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 o erators must list a minnnum of two em lo ees curr n 1 ifi p p y e t y cert ed m bas�c water safety,standard F�rst?udand Commuuity Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies ofemployee certifications to tlus form. The Health Department will not use past years' records. You must provide new copies and maintain a t"de at your piace of business. 1. 2, 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establistunents are required to have at least one full-time employee who is certified as a Food Protecrion Manager, as defined in the State Sanitary Code for Food Service Establislunents, 105 CMR 590.000. Please attach copies of certification to tlus application. The Heakh Department will not use past,years'records. You must provide new copies and maintain a file at your establishment. 1. �.l��M��dO�..� 2. PERSON IN CHARGE: ' Each iood establislunent must have at least one Person Iu �liarge (PIC) on sife durnig hours of operation. 1. ��TvY-�'�:� L� 2 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 Cle at your place of business. 1. ��7dr�ca �� l.i 2. � �� C1nQ\-�, 3. � 4. RESTAURANT SEATING: TOTAL # o�C�l7 LoncL�c: OFFICE USE ONLY LICENSE REQUIRED FEE PERMI7 r� LICENSE REQUIRED FEE � PER\4Ii= LICENSE REQL�IRED FEE PERb1IT r _B&B S55 _CABIN S55 _MOI'EL S55 _IIV1V S55 _CAbIP S�5 .__ _ __ _5��7:Y4�IINGPOOL S80ea. _LODGE S55 _IRAII,ERPARK 5105 _�L'HIRLPOOL SSOea. FOOD 5ER�7CE: LICENSE REQU[RED FEE PER'bU?t LICENSE REQUIRED FEE PE&bllT� LICENSE REQUIRED FEE PER�IR- _0-100 SEATS S85 _CONTINENrAL S35 NON-PROFII S30 I >100SEATS 5160 (�0 a- � C01�LMONVIC. S60 -�#ll,02� _\yT-IOLESALE S80 RETAIL SERVICE: —RESID.KII'CHEN S80 LICENSE�REQUIRED FEE PER'bII'I# LICENSE REQUIItED FEE PER�IIi# L[CENSE REQUIRED FEE PER'bIIT= _<SOsq.ti. S50 _>25,OOOsq.B. 5225 b'ENDING-FOOD S25 _<25,OOOsq.ft. S80 _FROZENDESSERi S40 TOBACCO S55 �.��7E ctiascE: sis AMOUNT DUE _ $ 220 .00 ***•*PLEASE TLR\OVER A\'D COVIPLE'IE O'IHER SIDE OF FORli*`"*" _ ;' 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 AFFIDAVTl'MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKfiR'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 AND l7THEIt LUL'GING ESTABLISHMENTS TRANSIENT OCCUPANCI': For purposes ofthe limitations of Motel or Hotel use,Transient cecupancy 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 ofresidence 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 OPENING:Ail swimming,wading and whirlpools which haue been closed for the sea son must be inspected by the Health Department prior to opening. Contact the Health Deparlment to schedule the inspection three(3)days pnor to opening. PLEASE NOTE: People are NOT allowed to sit m the pool area until the pool has been inspected and opened. POOL WA1'ER TESTING: The water must be tested for pseudomonas,total coliform and standard plate eount by a State certified lab, and submitted to the Health Department three (3) days prior to opening, and quarterly thereafter. �'OOL CLUSIIVG:Every outdoor in ground'swinuning 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 inspechon three (3) days prior to opemng. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Departmem 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 of your Frozen Dessert Pemvt 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 Boazd ofHeakh. _ _ _ _ _ . __ 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. TT IS YOUR RESPONSIBILdTl'TO RETIJRN THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 15, 2010. ALL RENOVATIONS TO ANY FOOD ESTABLISfIMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUII'MENT, ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: ��u, � � � SIGNATURE: C("�� -\ GZ PRINT NAME&TITLE:�� $j �,� ~Main� ;� 10'06'10 � i il �\ The Cominonwealth ofMassachuseKs DePartment ojlndustria!Accidents NAfna� 600 Wushington Sbeet, 7"Floor Boston,Mass. 02111 Worken'Compeeeatios In�oranee Aftidavih Bsildiop�Plembin�/Ekctriey�Contracto►s � narce: � a_dd�ess� - _�� L - /,� - ------'/�-- -- , � � � ��'t � s te: � i'� zi : d�C � — / ��/O work site locatioo(fvll address): ❑ I am a homeowner pert'ocm�ng ali work myself. Pro�ect Type: ❑New Construc[ion QRemodel ❑ I am a sole proprietor and have no one working in any capxity. �gw�d�g p��tion I ❑ I am an employer providing workers'compensation for my employees working on this job. . comw�v nme: � ddrees: �. cih• oYoee k , imnaKe es. oaLh p s� �/ l f-�'vCT� ❑ i am a sole � - . .. ... . ...... .... proprietor.Seaersl costractor,or homeawner(circle oRe)a�d have hired the conhactas listed below w!p have the following workers compen4ation polices: � como�ov aame- addraa: cih': ohose$ � ieemaeee eo. � e^m�..��_' � . . ad�ar cHv o�o�s M _ _ - _ __ _ -. __ .____. _ . _ . _ _._ i�l. . . . _ . . . .ppli'v M . _ . .. _ .. _ ... �.+rrrr,rrr..�T FaBve 0�accme ama`e a raqdred�adc Sectls�2SA at MCL t31 eu kad b 14 bq�dtlw�(afsWl pmMb d�ese�p b S1.3M.M uN�r °r Y�+�'�mpNwe�nl n weY aa dH pemqYa le[he fars eta 37'O�WORK ORDBR asd�eee dS190.M�day agalen mc. 1�deny�d tMl a �My a[Wh MaEeeeN dy he forwaMM b tAe Oelaa d loYestlptlw et 10e DIA far e�verase retlOnMw do hmrby cer6�under rhe Gs awd pewaMu oJperfrry fl�at Mr lafonw�lon proddtl above&Irre ad rrect / / ig�uture U`�t��'"� L'+. �7 /� / L / J � ��t� � �P,;�t� ' p � � �+7, �-7 PhoM k _ 1 U�� //�� /O atBel�l ax oaly do nW w�rNe d Ihh are�b be roapleled by dly or bwa oel�hl . .. .. city or towp: � PermN/Nceme q OBoidme Depar�ent ❑�hea H�mmeM.k rt�nme b.�yaRa . Ouneis�Rew �.eee:mtsl bl�ec rnslaef penoa: pho�e A: �NeMY D�ar�s! (n.4N SP Soml � . . � � �� NOTYCE � TO NOTICE EMPLOYEES T� EMPLOYEES The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston, Mass�chusetts 02211 617-'727-49011 As required by Massachusetts General Law,Chapter 152, Secdons 21, 22 & 30, this wil! give you nodce that I(we)have providec!for payment to our injured employees undec the above mentioned chapter by insuring with: A5SOCIATED INDUSTRIE3 OF MASSACHUSETI'S MUTUAL INSURANCE CAMPANY NAME OF INSURANCE COMPANY 54 THIRD AVENUE P.O. BOX 4070 BURLINGTON MA 018Q3-0870 ADDRE,4S OF INSURANCE COMPANY AWC7010845012010 �y�g�2010 _ �ypg/2017 POLICY NUMBER EFFECTIVE DATES 200 Lincoln Street, Unit#001 C T Financial Service Co Baston, MA 02111 (g1�282.0388 NAME OF INSURANCE AGENT ADDRESS PHONE Cape Cod Super Buffet Inc 228 Main Street W YermouM MA 02873 EMPLOYER ADDRESS 09/28l2010 EMPLOYER'B WORKERS COMPEAt$AT10N OFFICER(iF ANY) pp� lYI�DICA�. TRF.ATMFNT T6e abovc named ineunr ia rcqatred In cas�ot pereonel injurta arfeinQ out�md in the course ot emptoyment to fnrnish edequate and reaeooable hoepital aud medical�xvkea in�cordance witL the prnvisbne ot the Worlcen Compemallou Act A copy of Gu FSrst Report ot Iqiury must be given to the iqjnrad empioyree. T6e employee may sdect his or her own p6yekiau. The reasooaWe caet ot the aervices providcd by tLe treating p6ysieiau w81 be psid by tice i�am,if the treatment i�necessary and rmsoneWy connected to the work related iq�ury. In caees rcquiring hoepitel attendon,empioyces are hereby notiGed thet t6e i�urer has srranged for suc6 attenbtoa at the NEAREST AND BEST MEOICAL FACILITY NAME OF H03PITAL ADDRES.4 TO BE PUSTED BY EMP'�.OYER