The URL can be used to link to this page

Home My WebLink AboutApplication and WC . G3C�C�C��C��N � TOWN OF YARMOUTH BOARD OF HEALTH �� APPLICATION FOR LICENSE/PER�VIIT . ��t� Ukl: . 4 ZO1� '"" * Please complete form and attach all necessary documen# y eem 'r S.DEPT. Failure to do so will result in the return o�your�pplieation•p'a e . E5TABLISHMENT NAME:ri+�e CaPe Pa t� t- TAX ID:� LOCATION ADDRESS: y�6 M/)/ N S'f ne 2l� TEL.#: Co8- ��f-ls�� MAILING ADDRESS: w es r �/a rr_..� o c�fi G. I✓1 a- 6 y6� Z E-MAIL ADDRESS: OWNERNAME: �ocKs�de Alat� ( G2oc�P � CORPORATION NAME (IF APPLICABLE): t>a i ra r h� � MANAGER'S NAME: Z?�vL Sw e 2t 2- TEL.#: S o�'' 3 E 2-F'r 1�� MAILINGADDRESS: to� ��ec.� SauY �^'�S J4uc L'e�v6eevabl� ,�-(,C� p��3Z— 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. l.�e��/ ��c//1✓ ,� __ _ 2. Pool operators must list a minimum of two employees currently certified in standard 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. �OU/� �mP�F/� a. s�i�5liox,A /yN2 3.�Sow� ��••a 4. !/.6/o,+�iF G�.l ip�✓JS _ FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service estab(ishments 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.J,4,��7 /�i ss�� 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. � 1. �t�C 3� �isSl / . 2. ALLERGEN CERTIFICATIONS: All food service estabiishments are 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. 1. �U�� /1/SSf� 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. � ✓rv,✓ 2. �ll7�.S d'"�rn�.S ,-, 3. T NN �'�� 0 4. T ,. _ RRf Z RESTAURANT SEATING: TOTAL# `7 �' ; __ _ --- -- --- - --^�.��F,ISE 9PI�3'- __ _— LODGING: � LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 �MOTEL $I10 -�(b-Ooe INN $55 CAMP $55 �SWIMMINGPOOL$110ea. 6-6�3o��d�5 _LODGE $55 _TRAILERPARK $105 �WHIRLPOOL $110ea.�q FOOD SERVICE: LICENSE REQUIRED FEE P RMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 1 0-100 SEATS $125 �j�-b�1j CON'I�INENTAL $35 NON-PROFIT $30 >100 SEATS $200 �COMMON VIC. $60 ��0 WHOLESALE $80 — —RESID.KITCHEN $80 � RETA[L SERV►CE: WCENSE REQU[RED 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. $150 _FROZEN DESSERT $40 _TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE _ $ 13 S.Oo *•***PLEASE TURN OVER AND COMPLETE OTNER SIDE OF FORM***** .-. . 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 taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: \, YES X NO MOTELS AND 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 ofnot 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 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 Tocvn 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 thereafrer,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 Boazd 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 RETL7RN 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 REQUIRE A SITE PLAN. DATE: �Z- �`a ` /5 SIGNATURE: '� „��W1, � � PRINT NAME&TITLE: i''�t2,or r��Vl/� Rev. 10/O1/IS INFORMATION PAGE ��' A��`� PRODUCER: Agent� 137 isurer: Boynton Insuarance Agency Inc. � Retail Mexchants WC Group Inc. �y givet rark St � Box 859222-9222 . Needham. MA 02194 � ._ caintree, MA 02185 Carrier Policy 9F: 014005033479115 �arrier Code: 34355) Garrier Prior Policy 9f: 014005033479114 The Insured: Dockside Hotel Group Inc Mailing Addzess: 476 Main Street West Yarmouth. MA 02673 Fein: Type oP Business: Corporation � Other vrorkplaces not shown above: Risk ID- SEE SCHEDiJLTs OF OP$RATIONS � . The policp period is from 12:01 a.m. on 1/O1/2015 to 12:01 a.m. on 1/0l/2016 ' at the insuted's mailing address. ;. A. Workers Compensation Insutance: Part One of the policy applies to the Workers Compensation Law oY the atates liated here: MA B. Employers Liability Insurance: Part Two of the policy appliea to work in each state listed in Item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident $ 1 000 000 each accident Bodily Injury by Disease $ 1 000 000 policy limit Bodily Injury by Disease $ � 000 000 each employee C. Other States Insurance: D. This policy includes these endoraements and schedules: WC20030�1(04/$4), WC200302(OS/86) WC200303B(07/99) WC200405(06/0�1) WC2Q0601(06/92)> 4. The premium for tbis policy will be determined by our Manuals of Rules. Classifications, Rates and Rating Plans. All information required below is sub�ect to verificatian and change by audit. Classifications Code Premium Basis Rate Per Eg�uald pa, Total Estimated $100 of Annual Remuneration Remuueration Premium SEE SCFIEDULE OF OPERATIONS Total Estimated Annual Premium $ 12,895.00 ,p0 De osit Premium • �nim� premium $ 309.00 Expense Co�stant P � � I 5CHEDULE OF OPERATIONS FOR: PAGE: 1 Dockside Hotel Group Inc Carrier Policy #: 014005033479115 476 Main Street Fein: West Yarmouth, MA 02673 DIV #: 00000 E/L Number: 0000000001 OTHER WORKPLACES: The Point LLC Fein: 043418497 Cape Point Hotel 476 Main Street, Route 28 NJ Ta�cpayer ID#: 0466659 West Yarmouth, MA 02673 Eff date: 01/O1/15 NAICS:721110 DIV #: 00001 E/L Number: 0000000001 The Mariner Motor Lodge LLC Fein: 043418500 Mariner Motor Lodge 573 Main Street, Route 28 NJ Taxpayer ID#: 0466659 West Yarmouth, MA 02673 Eff date: O1/01/15 Mailing: NAIC5:721110 573 Main StreEt DIV #: 00002 West Yarmouth, Mp, p26�3 E/L Number: 0000000001 Cape Town & Country Motor Lodge LLC Fein: 043418499 Town 'N Country Motor Lodge 452 Main Street, Route 28 NJ Taxpayer ID#: 0466fi59 West Yarmouth, MA 02673 Eff date: O1/O1/15 NAICS: 721110 Mailing: DIV #: 00003 476 Main Street, Route 28 E/L Number: 0000000001 West Yarmouth, MA 02673 WC 00 00 O1 A