The URL can be used to link to this page

Home My WebLink AboutApplication and WC '�`.`.�`_. .�.. 7`u6.8oA`T5'i � TOWN OF YARMOUTH BOARD OF HEALTH � " � � APPLICATION FOR LICENSE/PE , . 1a�6 ;: �:?7 OCT 3 O ZO1� � ti..,, � � �;� * Please complete form and attach all necessary d i�rer�s�� ecembe 15 TE_a ��nT ' Failure to do so will result in the return of ` r a l�ation paeke "- ESTABLISHMENT NAME: � TAX ID: LOCATION ADDRESS: �� G/m _ �.�1. TEL.#: �d- ��S '" ��3�J MAILING ADDRESS: 31� C��-�r�-- -2e- �.�vv�vu't�'�, h��. �ZS�.O E-MAIL ADDRESS: OWNER NAME: '� 1��a vY., 2-a-�`�^-�r" CORPORATION NAME (IF APPLICABLE): �� MANAGER'S NAME: -� C, ��.t TEL.#: ��--1�S' l.l.��-!3 3 MAILING ADDRESS:�`�ll C�-�-�J�G1 4 ��1MCti..� � �� f�Z S�l,� 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 __._ _ . _ . _ 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. L 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: �� d �Sr �� 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. 2• PERSON 1N CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. l, _ _ _ _ --- -� 2._��._� -- �.______�...�..,__�,.—__._T..� ALLERGEN CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who has Allergen certification, � as c�efined 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. 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. 2. 3. 4. RESTAURANT SEATING: TOTAL# ------- _-- �FI�I�v��-�iv�.sx, ___ _ _ -- - __ _ LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $110 INN $55 CAMP $55 SWIMMING POOL$I l0ea. _LODGE $55 TRAILER PARK $105 WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERM[T# 0-100 SEATS $125 CONTINENTAL $35 NON-PROFIT $30 =>100 SEATS $200 �� ZCOMMON VIC. $60 ��7 =WHOLESALE $80 —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 =<25,000 sq.ft. $I50 _FROZEN DESSERT $40 TOBACCO $110 NAMECHANGE: $is AMOUNTDUE _ $ 2�,0 .00 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** e ! I 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 / I WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED v ' E 6 � Town of Yarmouth taxes and liens must be paid p ior 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 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 G 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 liave 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: I 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: i 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 COOKING: 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. IT IS YOUR RESPONSIBILITY TO RETI.JRN 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 REQU RE SITE PLAN. DATE: ��` �� '�s� SIGNATURE: c� PR1NT NAME & TITLE: z� �t'/1�, Rev.10l01/15 1 l � The Commonwealth of Massachusetts � • _ Department of Indacstrial Accidents Office of Investigations ' ' ' 1 Congress Street, Suite 100 Boston,MA 02114-2017. www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legiblv Business/Organization Name: ��.(_ Ot.t,—�6�e.� C��rGt�' Address:��-P'c��,l ��n�. �� .' ' City/State/Zip: C,�vvw�.l,'I� '1�C--� Phone#: �� ' ��S — ��'l 33 ' ' Ar,�e y,�o an employer? Check the appropriate boz: Business Type(required): 1.L�" I am a employer with�O_employees (full and/ 5. ❑ Re ' or part-time).* 6. estaurantlBaz/Eating Esta.blishment - - - -__ __ - ---- -- 2.� I am a sole proprietor or partners�p a.ricThave no - -- "— - ' -- - -- - ._—._ ._ 7. ❑ Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers' comp.insurance required] 8• ❑Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4),and we have 10.� Manufacturing no employees. [No workers' comp. insurance required]* 11.� Health Care 4.❑ We aze a non-profit organization,staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.� Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#1. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: �Gl �,.Q�'G�l � �.21C�'�.Lw� � �- [�lld�� I 1(1 C�� '. Insurer's Address: City/State/Zip: - �(�,�ha1'.C11,, �•,_ O �.-\ � ' Policy#or Self-ins. Lic. # �� "�J�o� � � � l � 'Jr Expiration Date: Attach a copy of the workers' compensation policy declaration page(showing the policy number n ezpiration date). _______Failure to secure coverage_as required under Section 25A of MGL a 152 can lead to the imposition of criminal penalties of a —— --- —_—_ - -- __ -� fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOPi��K��7�,�an3 a�rie of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of ' Investigations of the DIA for insurance coverage verification. I do hereby certify,under the pains and penalties ofperjury that the information provided above is true and correct. Si ature: ``-'� �-- �W`r^ Date: I� �� a�I� Phone#: ��- ��' a 3� Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2. Building Department 3. City/Town Clerk 4.Licensing Board 5.Selectmen's Office 6.Other ii'! Contact Person: Phone#: www.mass.gov/dia T , � INFORMATION PAGE .RENEWAL AGREEMENT Insurer: PRODUCER: Agent�� 644 MA__.:Retail Merchants WC Group Inc. Lawrence-Carlin Insurance Agency, F '.�x 859222-9222 230 Jones Road Suite 3 �-.- Bidintree, MA 02185 Falmouth, MA 02540 (Carrier Code: 34355) Carrier Policy ��: 014000502147115 Carrier Prior Policy ��: 014000502147114 1. The Insured: CINN Corp Coonamessett Inn Mailing Address: 311 Gifford Street Falmouth, MA 02540 Fein: Other workplaces not shown above: Type of Business: Corporation SEE SCI�DULE OF OPERATIONS Risk ID: ; 2. The policy period is from 12:01 a.m. on __1./O1_/2015 _ to 12:01 a.m. on ___101 2016 _ at the insured's mailing address. 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 �ao of the policy applies to work in each ; state listed in Item 3.A. The limits of our liability under Part �ao are: ,'' Bodily Injury by Accident $__,__ __. 500,.000 _ each accident Bodily Injury by Disease $_ _____5__00�000 _.._._ _ policy limit Bodily Injury by Disease $_ __500 000 __ ____ each employee' C. Other States Insurance: I I i D. This policy includes these endorsements and schedules: WCOOOOOOB(07/11) WC000308 WC000310(04/84) WC000406A(08/95) WC000414(07/90) WC000422A(09/08) WC200301(04/84) WC200302(05/86) WC200303B(07/99) WC200405(Ob/O1) WC200b01(06/92) � 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 Code Premium Basis Rate Per Estimated No. Total Estimated $1d0 of Annual Annual Remuneration Remuneration Premium SEE SCHEDULE OF OPERATIONS Total Estimated Annual Premium $ 27,699.00 Minimum Premium $ 53b.00 F�pense Constant .00 Deposit Premium • � f , , ._ SCHEDULE OF OPERATIONS FOR: PAGE: �-�� 1 I Coonamessett Inn Carrier Policy #: 014000502147115 CINN Corp Fein: 311 Gifford Street Falmouth, MA 02540 DIV #: 00000 E/L Number: 0000000001 OTHER WORKPLACES: { Swan River LLC Fein: 8 Upper County Road NJ Taxpayer ID#:4189593 Dennis, MA 02638 Eff date: 01/01/15 SIC:5812 Mailing: DIV #: 00008 311 Gifford Street E/L Number: 0000000001 Falmouth, MA 02540 Sailor' s, Inc. Fein: The Flying Bridge Restaurant 220 Scranton Avenue NJ Taxpayer ID#: 0189593 ; Falmouth, MA 02540 Eff date: 01/01/15 ! SIC:5812 � Mailing: DIV #: 00002 311 Gifford Street E/L Number: 0000000001 Falmouth, MA 02540 " RH Inn LLC Fein: ;� Red Horse Inn 28 Falrnouth Heights Road NJ Taxpayer ID#: 0189593 ; Falmouth, MA 02540 Eff date: 01/01/15 � SIC:5812 Mailing: DIV #: 00007 311 Gifford Street E/L Number: 0000000001 Falmouth, MA 02540 QAS Fein• Tugboats 21 Arlington Street NJ Taxpayer ID#: 0189593 Hyannis, MA 02601 Eff date: 01/O1/15 SIC: 5812 Mailing: DIV #: 00005 311 Gifford Street E/L Number: 0000000041 Falmouth, MA 02540 �