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Home My WebLink AboutApplication and WC ,,.� -�n�cstr�- �qzT TOWN OF YARMOUTH BOARD OF HEALTH � APPLICATION FOR LICE E I'{:�2� O�T Z 6 ZO15 �0� * Please complete form and attach all ne�eS : ��ts by DNece ber IS 2015. Failure to do so will result in the te4urn�f�o}u,app�eatron p ketF;�^,�, .t, DrPT. � .. , ESTABLISHMENTNAME: �4�5 cI2 �Su TAXID• LOCATION ADDRESS: Zz-S (�s7� 2rt TEL.#: 3'Z�� -- 7�S-Scac�q MAILING ADDRESS: W `�A2✓v�crsT�l+ v'v�Jk C�c�'73 E-MAILADDRESS: (LS � �ySid�ere�c,� . co�n,. OWNER NAME: S �4't� C CORPORATION NAME (IF APPLICABLE): `t'lz��.lS s I� 1vc. MANAGER'S NAME: f�D 51��✓�lcl TEL#• 57�X-?7S-Sta49 MAILINGADDRESS: S�twi.Q_ POOL CERTIFICATIONS: The pool supervisor must be certi£ed 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. �. __M ar�i�� c�� _ z, -- _- - - - Pool operators must list a minimum of two employees currently certified in standazd First Aid and Community Cardiopulmonary Resuscitation (CPR), having one certified employee on premises at all 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. S�e- �}� �d l,�s� a. 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 file at your establishment. 1. ��GrG �Iv1n0�2.�� 1 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. �. �d Sra ezQ�c l�, _ _ �. _ /� t��, ►M�r��_ _ 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 wi11 not use past years' records. You must provide new copies and maintain a file at your establishment. �. ��,��, s��,, d.��f� � 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 file at your place of business. 1. b � iP D n"� 2. 1�✓�Q Q►v 3 z �Ik�,�1,c_ 3.��tlsaa�t l�r v v 4. RESTAURANT SEATING: TOTAL# � --� -- f3�F1�-�a��iVI��`-- - LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQU[RED FEE P RMIT# B&B $55 _CABIN $55 l MOTEL $1f0 I � I tNN $55 CAMP $55 �SWIMMINGPOOL$ll0ea. _00 dOZ _LODGE $55 _TRAILERPARK $105 �WHIRLPOOL $710ea. FOOD SERVICE: LICENSE REQUIRED FEE P �tMIT# LICENSE REQUIRED FEE P RMIT# LICENSE REQUIRED FEE PERMIT# I 0-100SEATS $125 - ((��OdZ �CONTINENTAL $35 (6-603 NON-PROFIT $30 >I00 SEATS $200 �COMMON VIC. $60 y _WHOLESALE $SO — —RESID.KITCHEN $80 RETAIL SERVICE: LICENSB REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq.ft. $50 >25,000 sq.ft. $285 _VENDING-FOOD $25 _QS,OOOsq.ft. $150 —FROZENDESSERT $40 _TOBACCO $I10 NAMECfiANGE: $15 AMOUNTDUE _ $ 660. 00 *'***pLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** "Z„�,--. 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 AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED � OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taYes 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 ofthe limitations ofMotel 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 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 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. 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 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.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 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,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. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 15, 2015. 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 RE UIRE A SITE PLAN. DATE: ��I l� SIGNATURE: PRINT NAME & TITLE: �b SI�OC2'�N Slc-� Cr Vl/i Rev. 10/01/IS WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE A.I.M. Mutual Insurance Company 54 Third Avenue, Buriington, Massachusetts 01803-0970 (800) 876-2765 NCCI NO 26158 POLICY NO. WMZ-800-8003721-2015A PRIOR�NO. WMZ-800-8003721-2014A ITEM 1. The Insured: Travis Hospitality Inc DBA: Bayside Resort Hotel Mailing address: Rt 28 FEIN:""* 225 Main Street West Yarmouth, MA 02673 Legal Entity Type: Corporation Other workplaces not shown above: See Location 2. The policy period is from 04/01/2015 to 04/01/2016 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 ihe states listed here: MA B. Employers' Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A. The limits of liability under Part Two are: Bodily Injury by Accident $ 500,000 each accident Bodily Injury by Disease $ 500,000 policy limit Bodily Injury by Disease $ 500,000 each employee C. Other States Insurance: Coverage Replaced by Endorsement WC 20 03 06 B D. This Policy includes these EndorsemenTs and Schedules: SEE SCHEDULE 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Classifications Premium Basis Rates Code Estimated Per$100 Estimated No. Total Annual OF Annual Remuneretion Remuneration Premium , INTRA 362922 INTER SE CLASS CODE SCHEDU E Minimum Premium $284 Total Estimated Annual Premium $14,203 GOV GOV Deposit Premium $3,773 STATE CLASS MA 9052 State Assessments/Surcharges $15,269.00 x 5.8000% $886 This policy, including all endorsements, is hereby countersigned by `--�-� 02/11/2015 Authonzed Signature Date Service Office: Rogers&Gray Insurance Agency One Lakeshore Center 434 Route 134 Bridgewater MA 02324 South Dennis, MA 02660 W C 00 00 01 A(7-11) Includes copyrighted matarlal of the Netional Council on Compensetlon Insurance, used wifh its permission.