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Home My WebLink AboutApplication and WC a TOWN OF YARMOUTH BOARD OF HEALTH �� APPLICATION FOR LICENSE/PE T f-�{Ol�"�; �"�° Ut� , 4 2015 �"'' * Please complete form and attach all necessary d��nt�y�ecem~ r I S 2015. Failure to do so will result in the return of you�ap�l�catforl�a et. DEPT. ESTABLISHMENT NAME: T�✓� TAX ID: � LOCATION ADDRESS:�(�i�1 �-I-e- 2'£� � •cqA.lw�h M� TEL.#: �Ug .�`�Jy 71e� MAILING ADDRESS: E-MAILADDRESS: ci. C� o . C'l�W1 OWNER NAME: v CORPORATION NAME (IF APPLICABLE): rM 2- MANAGER'S NAME: ��Ov TEL.#: , D � / MAILINGADDRESS: .�. 0 D C7 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. r: N��,�. i.�C; (r�`� � :,.( �: �i �c 1 -��t�`c�� 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 tile at your place of business. 1. � o v ��. I'"b'b�l�� 2. Ml�C'.,� �Gc.l Q�'-F �� 3. �„/a I !R n�2 4.`�'6 H 1 � e 6��. 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 tile at your esta6lishment. 1. �(i,/l�� S (1�.P�2� 2• PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. f',G/l�i s V�wZ�c� 2.___ 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 will not use past years' records. You must provide new copies and maintain a file at your establishment. 1. C�/ C� � tl-�-l�Q. 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. loPn�'r o tT� IOd�J 2. �au �.Q1,v�2d�l. 3. �r,w c (�t1�v� 4. RESTAURANT SEATING: TOTAL# • - -- _ _ _ - _—.�1FEiCEUSE.-1lNI,X -------- --- _ _----- LODGING: UCENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT k LICENSE REQUTAED FEE P6RMIT# _B&B $55 CABIN $55 LMOTEL $1(0 dk 6-06 _INN $55 CAMP $55 �SWIMMING POOL$I l0ea�p�7 _LODGE $55 =TRAILERPARK $105 �WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT N LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# I 0-100SEATS �$125 ��_�—Q�{cj CONTINENTAL $35 NON-PROFIT $30 _>l00 SEATS $200 �COMMON VIC. $60 (T— O �L =RESOID KITCHEN $80 RETAILSERVICE: LICENSE REQUIRED FEE PERMIT k LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT k <50 sq.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 <25,000 sq.ft. $150 =FROZEN DESSERT $40 TOBACCO $110 NAMECHANGE: $15 AMOUNTDUE _ $ (oZ-S.00 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM****' • 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 Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MU5T 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 NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes ofthe limitations ofMotel 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 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 Transiznt. 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: Peop(e 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 Departrnent 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 Departrnent. 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,preparation,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 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 REQUIRE A SITE PLAN. DATE: SIGNATURE: PRINT NAME & TITLE: Rev. 10/O UI S 03 (policy Provisions: WC 00 00 00 s) , 40 , �•• INFORMATION PAGE �G WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLIC'Y INSURER: TNTIN CITY FIRE INSURANCE COMPANY ONE HARTFORD PLAZA, HARTFORD, CONNECTICUT 06155 NCCI Company Number: 14974 THE comPanycode: � HARTFORD � � N O� O $U(fIX 'i LARS RENEWAL ,�-i POLICY NUMBER: 76 WEG DR4003 —1 03 m Previous Policy Number: 76 VTEG DR4003 � 0 o HOUSING CODE: 76 � 1. Named Insured and Mailing Address: HEMEON ABBOTT MANAGE64IIVT CORP DBP. Q (No., Street, Town, State, Zip Code) Ci,ARION INN � N 0 1199 ROUTE 28 � FEIN Number: SOUTH YARMOUTH, MA 02664 � State Identification Number�s): - UIN: = The Named Insu�ed is: CORPORATION � Busi�1C55 Of Nall�ed ifISUfCd: HOTELS AND MOTELS - W POOLS OR = Other workplaces not shown above; 1199 ROUmE 28 � SOUTH YARMOUTH MA 02664 — 2. Policy Period: From 02/Ol/15 To 02/Ol/16 = 12:01 a.m., Standard time at the insured's mailing address. Producer's Name: COMPLETE BENEFIT SOLUTIONS/PAC = PO BOX 33015 = SAN ANTONIO, TX 78265 = Producer's Code: 250837 � ISSuing OffiCe: THE HARTFORD 3600 WISEMAN BLVD. � SAN ANTON20 TX 78251 = (877) 287-1316 - Total Estimated Annual Premium: $10,490 = Deposk Premium: = Policy Minimum Premium: $281 MA (INCLUDES INCREASED LIMIT MI:V. PREM. J - Audit Penod: �AL Installment Term: = The policy is not binding unless countersigned by our authorized representative. Countersignedby �"`g""'� C��"`�"`L' 01/27/15 Authorized Representative Date Form WC 00 00 01 A (1) Printed in U.S.A. Page 1 (Continw�d on next page) Process Date: Ol/27/15 Policy Expiratio�i Date: 02/01/16 ORIGINAL _ INFORMATION PAGE (Continued) Policy Number: 76 wsc DR4003 3. A. Workers Compensation Insurance: Part one of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers Liability Insurance: Part Two of the policy applies to work in each st:�t�� listed in Item 3.A. The limits of our liability under Part Two are: Bodily injury by Accident $500, 000 each accident Bodily injury by Disease $500, 000 policy liniil: Bodily injury by Disease $500, 000 each em��loyee C. Other States Insurance: Part Three of the policy applies to the states, if any , listecl here: ALL STATES EXCEPT ND, OH, WA, WY, US TERRITORIES, AND STATES DESIGNATED IN ITEM 3 .A. OF THE INFORMATION PAGE. D. This policy includes these endorsements and schedule: wC 20 O1 O1 WC 20 O1 02 WC 20 03 03D WC 99 03 OOD WC 00 04 14 WC 20 03 O1 WC 20 03 02A WC 20 04 O1 WC 20 04 OS WC 20 06 OlA 4. The premium for this policy will be detertnined by our Manuals of Rules, Classifiw:ations, Rates and Rating Plans. All information required below is subject to verification and change by audit. Premium Basis Classifications Total Estimated Rates Per Estimated Code Number and Annual $100 of Annual Description Remuneration Remuneratic�n Premium 8810 159, 500 . OB 128 CLERICAL OFFICE EMPLOYEES NOC 9052 402, 700 1.56 6, 363 HOTEL: ALL OTHEA EMPLOYEES & SALESPERSONS, DRIVERS INCREASED LIMITS PART TWO (9807) 1.00 PERCE[VT 65 TOTAL PREMIUM SUBJECT TO EXPERIINCE MODIFICATION 6, 556 MA - INTRA EXPERIENCE MODIFICATION 000014437 1.440 PREMZUM ADJUSTED BY APPLICATION OF EXPERIENCE MODIFICATION 9, 441 TOTAL ESTIMATED ANN[JAL STANDARD PREMIUM 9, 441 EXPENSE CONSTANT (0900) 338 MASSACHUSETTS DIA ASSESSMIIVT 5.800 PII2CENT 542 TERRORISM (9740) 562,200 . 030 169 TOTAL ESTIMATED ANNtJAL PREMIUM 10, 490 Total Estfmated Annual Premium: $10, 490 Deposit Premium: Policy Minimum Premium: $281 MA (INCLUDES INCREASED LIMIT MIN. PREM. ) Interstate/Intrastate Identification Number: / 000014437 Labor Contractors Policy Number: �ICS: SIC: 6512 UIN: NO. OF EMP: 30 Form WC 00 00 01 A (1) Printed in U.S.A. Page 2 Process Date: 01/27/15 Policy Expiration Date: 02/01/16