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Home My WebLink AboutApplications and WC TOWN OF YARMOUTH BOARD OF HEALT�, ° �: '�'��D APPLICATIONFORLICENSE/PERM#4`'=�$0�!D', t. � � 2�NOV Z 3 7009 *Please complete form and attach all necessary docuiheqts ` l�i�qi ti DEr� . F a i lure to do so w i l l resu lt in t he retum o f youts�p licataon pac . NAME OF ESTABLISHMENT: Q S �P„/ u " TEL. # 0 '7�—��/�o LOCATION ADDRESS: 2 i MAII.ING ADDRESS: z a� l"�" fy!- vy 3 OWNER NAME: F o CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: u 1✓C TEL. # - — //D MAILING ADDRESS:____ _�7�'��k�E 2 naL ffi - Oy6�3 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 certificarion to this form. 1. 2. Pool operators must list a minimum of two employees currently certified'm basic water safety,standazd First Aid and Community Cardiopulmonary Resuscitarion(CPR). Please list these employees below and attach copies of employee certificarions 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 IviANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-tune employee who is certified as a Food Protecrion 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 Heahh Department will not use past years'records. Yoa mnst provide new copies and maintain a t'ile at your establishment. �.�u�'C gi'� , �,' z. PERSON IN CHARGE: — _ _ - - - Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. 2. HEIMLICH CER1'IFICATIONS: 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 mained in anti-chokwg procedures below and attach copies of employee certificarions 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. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FE$ PERMIT# LICENSE REQU[ItED FEE PERMIT# _B&B $55 _CABIN $55 _MOTEL S55 �INN $55 _CAMP $55 �SWID�IIvIINGPOOL �80es. _LODGE S55 _TRAILERPARK $105 _WfI1RLPOOL $SOea. FOOD SERVICE: LICENSE REQIJIItED FEE PbBMIT# LICENSE REQUIItED F£E PERMIT# UCENSE REQUIItED FEE PERMIT N _0-100 S£ATS $85 _CONTINENTAL $35 NON-PROFIT $30 �>1005EATS 5160 �I�-o3`�( �COMMONVIC. $60 �{ jb�O!-�'j _WHOLESAL£ S80 RETAII,SERVICE: —RESID.KTfCHEN 380 LICENSE REQUIItED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LIC6IVSE REQUIRED FEE PERMI I# _<SOsq.R $50 >25,OOOsq.R. 5225 _VENDING-FOOD S25 ,QS,OOOsq.ft. $80 _FROZENDESSERT $40 TOBACCO S55 NaME cAnNGE: $is AMOUNT DUE _ $ 220.00 •»•""PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*"*�• . . _._,._ .. t � . ADMINISTRATION IJsuler..Chap#er: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 INSIIRANCE . AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth ta�tes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LODGING ESTABLISHM�NTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transiem occupancy shall be limited to the temporary and short term occupancy, ordinazily and customarily associated with motel and hotel use. Transient occupants must have and be able to demonstrate that they maimain a principal place ofresid�ce eLgewhere. Transient occupancy shall generally refer to continuous occupancy of not more thau 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 Faccise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transieut. 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 Departmem to schedule the inspection ti�e(3)days pnor to opening.PLEASE NOTE:People aze NOT allowed to sit m the pool area un1i1 the pool has b�n inspacted and opened. POOL WATER TESTING: The water must be tested for pseudomonas,total wliform and standard plate count by a State certified lab, and submitted to the Heakh Department three (3) days prior to opening, and quartetly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered witlun seven('n days of closing. FOOD SERVICE CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Depaitm�rt byfihn�the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be o6tained at the Health Departmern. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sant to the FIealth Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit untitl the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval fromthe Board ofHealth. OUTDOOR COOHING: __ Outdoor co_o_kin�preparatioq Qr display of any food prod�ct by a retail or food service est�blishc�nent is_�ro6ibi�. NOTICE:Permits run annually from 7anuary 1 to December 31. TT IS YOUR RESPONSIBII.ITY TO RET[JRN TF�COMPLETED RENEWAL APPLICATION(S)AND REQUIltED FEE(S)BY DECEMBER 15, 2009. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQiJIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY TE�BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: �� ZU � SIGNATURE: �-T�t `:�'" � t`` � / l"f � PRINT NAME&TITLE: C�� K/�JD - G i �2� 09/25/09 � � The Commonwealtk of Massachusdts Department of Indusdia!Accidents N�ie�N� 600 N'ashington Streey JR"'Floor Bostou,Mass. 02111 � worlcers'CompeasaHoa I�araace Affidavir Baiidiog/Plombiag/Eledricat coetractors � t �: � � � G � �s: z� > � ct C state: zi : 3 ace �U — �� work site lacati�(fn1(addassY. �� ❑ I am a 6o�wcer pecformiog all work myself. Project Type: ❑New ConshucUon❑Remodel ❑ I�a sole{vopcidor and have no one wocking in�y�capecity. ❑Building Addition � � I am�employer psovidiog wock 'compensation for mY�P Y �g��s job. wo �: p : .e�.. ��u� • G� 3 �: ��77�- �r� � �. �'sULI 1�s i u U�' WG � o�� zoo .: .;., �. ...r, .. :: T , e . . �:,: .. ...�,:; .��s..x�r,.,�:��.... ❑ I am a sole praprietor,gwcral eoatraetor,or hom� crrefe oee)aod have hirod the co�actas listed below who have We following'woike.�rs'compeasatiou poGcey; � � � eanm�v�.mr . � � . � . . . : . . . ad�[u•. � . � . � . dA• . . . - . . _ , � . e►ae Ae. � .. . . . . . � . . . i�sea�eeco.- -. �. . . g .. . . . . . 'M.��y.:T'..^'J�� „ . . ... ., ... .. n.. v'ir a �?.e:.?i'ss`.X��`tsP'.;.' O9S�YMol: . � . �tl!' :�Y:. ,. � . . . . . . . . . � �pMee�-. . .. . . . � . , . . . _.__ _ _. . . ____ ___ . _ -.- __ .___ . . _ _ .. . —_._ _.. _ _.__-__'_ — A . .. . . . -.- , : . . �:. . :. ::u i�t...z 53�.��".�.�r•:;`��..� '��.,,,�,'?`�4'...._ . . Faila�e r+eeee wvea6e o Rqe4eA dv9aYw?SA dMGL�Iffi m kad M 1Ye iynWr de�W peml6e da ie�is t1,3MM aWru ••�m�+'�...�n.Re..a.��wu.ur..r,slor wo�cososem.a.�.tsiea.N.ay�.�.i�wu.�, npytuhmaaatrryre6rwwdrueomoe�l�ndueuukrs.en6e�eN�. - : � � - .-. �loeorayce�ify,a�le.NiepBu..agewe(daelveN�'rAmMelefaw�lew�r.rlAd.sevenave Ac.rmx� � � � � b � G-� hzw� �z � Ir� z �/ z�� u�tN�r k� �/� n 1 �� S°b�-77 —�/�o .�.�.�, �..«,��,.�.��..� aryKb�.: _ .. ��pa.Wiemes ns -- ne�o.nt ❑eYak N�'apne b�eq�ised .. .. �� . � � . � .. �� . . �tl�s�n40mae . .. . . ❑HdM D� �� p�e: f'IO�re NOTICE � NOTICE TO TO EMPLOYEES EMPLUYEES The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston, Massachusetts 02111 617-727-4900 As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, tk►is will give you notice that I(we) have provided for payment to out injured employees under the above mendoned chapter by insuring with: ASSOCIATED INDUSTRIES OF MASSACHUSETfS MUTUAL INSURANCE COMPANY " NAME OF INSURANCE COMPANY 54 THIRD AVENUE P.O. BOX 4070 BURLINGTON MA 01803-0970 ADDRESS OF INSURANCE COMPANY AWC 7010845012008 12J06/2009 - 12/O6/2010 POLICY NUMBER EFFECCIVE DATES 200 Lincoln Street, Unit#007 C T Financlal Service Co Boston, MA 02111 (617) 292-0388 NAME OF INSURANCE AGENT ADDRESS PHONE Cape Cod Super Buflet Inc 228 Main Street W Yarmouth, MA 02673 EMPLOYER ADDRES5 10/OS/2009 EMPLOYER'S WORKERS COMPENSATION OFFICER(IF ANY) DATE MEDICAL TREATMENT The above named iosurer is required in cases of peraousl injuriea arising oat of and in the course of employment to tumish adequate and reaa�onable h�pital and medical sercices in acsordance with the pioovisions of thc Workers Campensatan Act A twpy of the Firat Report of Iqjury must be giveu to the iqjnred employee. The employee may select his or her own physic+en. The reseooable cost of We services provided by the treating physician tvill be paid by the insurer,iP the treatment�necessary and reasonably connectad to the work releted injury. In cases requiriug 6ospital atteotion,employees are hereby not'ffied that the insurer has arranged for such attention at the NEAREST AND BEST MEDICAL FACILITY 1VAA�*�F.OF I30SPTfAL ADDRESS TO BE POSTED BY EMPLOYER