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Home My WebLink AboutApplication and WC� ` � TOWN OF YARMOUTH BOARD OF HEALTH �� APPLICATION FOR LICENSE/PEIt�VIiT s�1��j�S�� NUV L 3 2015 ; .-� `� * Please complete form and attach a11 necessary;�cur�ehts byt e "r 5 2015. Failure to do so will result in the return o your appTication packet. HEALTH DEPT. ESTABLISHMENT NAME: M AA �.1�. OD C C.,�S J IJ TAX ID: // LOCATION ADDRESS: /��O�� Tn4k%t/O��SE �0 TEL.#: MAILING ADDRESS: �fIn1F E-MAILADDRESS: .TK f�J55C � H�7MA�L:�qM1� OWNER NAME: �'aNiJ 1< r�JSSC CORPORATION NAME (IF APPLICABLE): AH'1 . �C. MANAGER'S NAME: J�A/�C 1 h'I Q /A1E�2,�E Y TEL.#: �SO ^ fI�/-�iG,3 MaiLnvGaDD�ss: pea c��N,� w-�/AQ�nvu�/ POOL CERTIFICATIONS: The pool supervisor must be certiCed 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. -- � _— _ _ . _ _ 2. __ . Pool operators must list a minimum of two employees currently certified in standard First Aid and Community Cazdiopulmonary 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 t►le 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 file at your establishment. i. �Hn�cT' n�cl�c,��-k�y 2. �cfcty m ��eP�y PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. ' �. .7'A+�cT m��E2��` � z. .S o�lw l� �i�=�0 ALLERGEN CERTIFICATIONS: �J� mCLL y �� y 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 file at your establishment. �. moc.c� m�2P��y 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. �. SL��IiJ I� �2�SSv a. fnaccy mJ,P/��y 3. 4. RESTAURANT SEATING: TOTAL# l0�c OFFICE USE ONLY — —�;ese.�;�:—___—__ _ _ _ _ --- ---- ---- _ — __ _ LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PEAMIT N LICENSE REQUIRED FEE PERMIT# � '� _B&B $55 CABIN $55 MOTEL $I10 �' _INN $55 CAMP $55 SWIMMINGPOOL$110ea. ' _LODGE $55 =TRAILER PARK $105 _WHIRLPOOL $110ea �� FOOD SERVICE: WCENSE REQUIRED FEE � P RMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT k �0-100 SEATS $125 �02?� CONTINENTAL $35 NON-PROFIT $30 i _>I00 SEATS $200 �COMMON VIC. $60 L,-6 _WHOLESALE $80 RETAIL SERVICE: —�SI0.KITCHEN $80 LICENSE REQUIRED FEE� PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# � _<50 sq.ft. $50 _>25,000 sq.ft. $285 VENDING-FOOD $25 �� _<25,000 sq.ft. $I50 _FROZEN DESSERT $40 _TOBACCO $110 ' NAMECHANGE: $15 � AMOUNT DUE _ $_ I$5.00 �� I *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FO��s�* ~�F�� I — __. I i � ADMINISTRATION Under Chapter 152,Section 25C,Subsection 6,the Town of Yannouth 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 I Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE I AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR /� I 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 or 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 I 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 Deparhnent 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 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 standard 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 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 Deparhnent. 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 Boazd ofHealth. 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 QUIRE A SIT PLAN. DATE: J��' �� SIGNATURE: PRINT NAME& TITLE: J�C�N/L! K R��' �KLS�l��/ Rev. 10/01/IS � 55 �po��y p��; wC o0 00 0o a) 96 � INFORMATION PAGE �� WORKERS COMPENSATION AND EMPLOYERS LIABILITY POIICY INSURER: TWIN CITY PIRS IN3DRANCS COMPAN7t ONS HARTPORD PLA7.A, HARTPORD, CONNSCTICtlT 06155 NCCI Compa�yr Number. 1a97a 1 HE com�,ycoa.: � HARTFORD sw� wis a�Ewa. POLICY NUMBER: oa WSC CB9655 18 Pl�evi0Y6 POIiCy Nlqllber: 08 iVSC CB9655 . � HOIISII�G CODS: 38 1. Namad Insursd and Mailiny Addrass: M�� IxC. nsa zoxGasi,i,ow�s rUB (No..Street,Town.State,Z�Code) 530 OLD TOWA1Fi0USS ROAD FEIN NU111be►: SOUTH YARMOUTH, MA 02664 State IdeMNicatia�Number(s): The Named Insured is: ro��Tlox B�Ine�of Named I�ured: �STAURxe�T Otlrer worl�laeas not shorm�ove: � SODTA YARMOUTfi MA 02664 2. PolicyPeriod: Fram oa/a3/i5 To oz/as/ie 12.�01 a.m.,Standard time at the insured's maBing addr�s. Produ�xr's N�ne: CFmGrrop ixsoxaNCs ac�rCY itaC PO BOX 355 W YARMOUTFi, MA 02673 Pp�uQprg Cq�� 084400 � IBSuYI�OIflC6: Tfi& HARTFORD � 301 WOODS PARIC DRIVS CI+INTON NY 13323 (800) 962-6170 Total Estimated Mnual Pramium: Sa,059 Daposit Premlum: Polky Mlnimum Pramium: $216 ru Audit Period: �� InstsllmeM Term: The policy is not binding urdess aountersigned by our author¢ed representative. Countersigned by !1'�a'ro� C�`i' oi/ii/i5 Authorized Representative Date Form WC 00 00 01 A (1) Printed in U.SA Page 1 (Cordinued on ne�d page) p�ot�spate; o1/1i/is pdwyEzplr�ionpate: o2/a3/i5 INFORMATION PAGE (Corrtinued) Poiiry Number: oa wsc CB9655 3.A. Workers CompensaHon Inwranee: Part one of the pdicy appNes to the Workers Compensatla�Law of the states Iisted here:� B. Employers LiaMIHy Insurance: Part Two of the pdicy applies to waic� each state listed fn Item 3A. The limits of our Ilabilfty under Part Two are: Bodly Injury by Aecldent $100,o0o each auident Bodily Injury by Disesse Ssoo,o0o polky Iimit Bodib M1urY by Disease Sloo,o0o each employes C. Olher Sfates Insurance: Part Three of the pdicy appiies to Uie states,if�y,listed here: � ALL STATSS 87CCSPT ND, OEi, WA, iiY, VS TSRRITORIBS, AND . STATBS DESIGNATSD IN ITfiM 3.A. OF TFffi INPORMATION PAGE. D. This policy ineludes these endorsements and seheduls: � WC 00 04 21C WC 00 04 22A WC 20 Ol Ol WC 20 Ol 02 WC 20 03 03D SS& ffi417f 4. The premlum for fhis pollq will be determir�by our Man�is of Rules,Classtflcatlons, Rates and Rating Plans. All inTormatlon requlred l�low is wbject to verlflcatlon and change by a�it Premium Basls Classific�ions Total Eslimated Rabes Per Estlmated Code Number and Mnual f100 of Mnual Desc�iption Remuneration Remuneration Premium 9079 145,000 1.15 1,868 � RESTAURANT NOC � TOTAL PRSMIi1M SUBJSCT TO B7LPffi2ISNC8 MODIFICATION 1,668 � MA -.MSRIT RATING CRBDIT (9885) .950 PRSMIUM ADNSTSD BY APPLICATION OF SRPSRISNCE MODIFICATION 1,585 TOTAL SSTIMATSD ANN[JAL STANDARD PRSMIUM 1,595 B7CP8NSS CON6TPN!' (0900) 338 MASSACHfJSSM'S DIA AS585SIdS[IT 5.800 PBRCffiiT 92 TBRRORISM (9740) 145,000 .030 44 � TOTAL ESTIMAT� ANN[TAI, PR�fIi1M 2.059 Total Estlmated Mnual Premium: $2,O59 DaposR Premlum: Poliq Minimum Premium: 5215 MA 1nExsqte/lntrastats Identlficayon Number: / o001ase9e rm.iCs: Labor Cw�tractors Policy Number. g�C; sei2 Form WC 00 00 01 A (1) Printed in U.SA Page 2 Process Dete: oi/ii/is Polley Expirotlon Deb: o2/a3/ie