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Home My WebLink AboutApplication and WC _ _ _ ~ � I � S TOWN OF YARMOUTH BOARD OF HEALTH , `� �� APPLICATION FOR LICENSE 24 N(�� Q� Z�f� :� � * Please complete form and attach all necess � c f` s �" e :yj Failure to do so will result in the ret y 1 i " ESTABLISHMENT NAME: R f -�2v Q�9 ('oY� T ID• �� LOCATION ADDRESS: � � „2-3i' �'7�'�1�`9'�'1 ha.sT��laix'1TEL.#: SD�' ��`"�' �. MAILING ADDRESS: OWNER NAME: �I'� ~F ' CORPORATION NAME(IF APPLICABLE): i2 i �S CoY MANAGER'S NAME: m,�P�/`�t�� 1 TEL.#: � � �� C o Z-�/ MAII.ING ADDRESS: C q�c�� ,1' � 'V ��-�cXa?Et ,.,�� POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated � Pool O�erat�r(s) and�ttach a copy of the certifi�ation to this forrr�. i 1. 3�l V 1'Tct 9�Qy1 �A-11''"S.Ls 2. _e �� 4' /3.c yt �0 �-� Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid � and Community Cardiopulmonary Resuscitation (CPR). Please list these employees 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. j i 1. 2. I 3. 4. � i 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 establishmen� 1. 2. i PERSON IN CHARGE: _ _ _- __ _-- _ _ _ __ - Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. i I L � 2. i 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-chokmg procedures below and i 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. L 2. ; 3. 4. RESTAURANT SEATING: TOTAL# � OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&B $55 _CABIN $55 �MOTEL $55 �2'�I _1�vN $53 _CAMP $SS � SWIMMING POOL $80ea.�,��( i _LODGE • $55 _TRAII.ER PARK $105 �WHIRLPOOL $80ea.�(Z-00� f FOOD SERVICE. , LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _0-100 SEATS $85 LCONTINENTAL $35 "66 l _NON-PROFIT $30 ' _>100 SEATS $160 _COMMON VIC. $60 _WHOLESALE $80 , I RETAIL SERVICE: —RESID.KITCHEN $80 I LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# ' i<50 sq.ft. $50 _>25,000 sq.ft. $225 _VENDING-FOOD $25 _<25,000 sq.ft. $80 _FROZEN DESSERT $40 _TOBACCO $95 NAME CHANGE: $�s aMourrT nuE _ � a 50•OO { *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** � � � � � -- � . , .. . . _ . .� _.. -- _ � -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 SIGNEID, OR CERT. OF INSURANCE ATTACHED . OR � j WORKER'S COMP. AFFIDF�VIT SIGIVI:D AND ATTACHED � j Town of Yarmouth taxes and liens must be paid pri r to renewal or issuance of y4ur permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO i0�I�1'ELS AND OTHER LODGING ESTABLIS��VIVIENTS 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 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 OPEIVING: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 OPEI�IING: 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 �ling 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.yannouth.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: _ �,,^•.-- ��€e�{�.e.y��es�sRat�.b vait�wa�ter/�r�itr�ss s��ir�),mi�st hav�priar agpraval from the BQ�d�f 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 RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15, 2011. ALL RENOVATIONS TO ANY FOOD ESTABLISHIVIENT, 1VIOTEL 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 E�'LAN. DATE: 1 �� '4" �� SIGNATURE: ��f / �'�� . �� PRINT NAME&TITLE: �4n �` R��.ioizsni I _ � ' �'\ The Commonwealth of Massachusetts Depart►nent of Ind�strial AcciJents M�riNir�sd�sflYl� . � � .�� . t � . 600 Washingron Street, �"'Floor , .. ; • , Itoston,Mas�.02111 _ : . .: _ , �Wor�ers'Compeasatioa I�oranee Al6da �• , �; . � � ��'i�hre�adn: Please P�TC k�ibl�► � ' �: �'�e�s c c�t�'l h ds✓ fY�oi r Z_ address_--�'-q� fl-of� !� 'Z�—_ _ � ci� W . �'f �/2.r+t1�3 �%� state: �q- � ,�o: 8�'�-S ohone# ��l(�-�'L� � work site lceation(full addtessl: , , ❑ I am a homeowner perForming all work myself. � ❑ I am a sole proprietor and have no one working in any capacity. ' � ❑ I am an employer providing workers'compensatioit for my employees wodcing on this job. . i � ' m�...��- �9 �.�": �'��9 �p 9_ t�r�`' - . -�P - - r � :�._ , � _ , A�.�� - , �aa�: 6 � /Z o+� F- 02� � � : ov. p 1�-n+o v�lf �''1� a: �� $�l.o —6 o z t.. �. � �Z: c ❑ I am a sole proprietor,ge�enl co■tractor,or bomeowuer(circle one)and have hirad the contractors listed below�who�have ' the following workers'compensation polices: oomoasv�ame: < _ � � addraa• i citv- ob��t• iesnaaer eo. �� , ��t�iame. ' ad�'as. citv- ��g• � � _ _ _ ___ _ _-- --— -- -- ---- f ��ee ao. oeiiev!f _ .— _ ___ _ _ _� AII�vt�lwlfi�rtiffra�� .. FaY�re 0�xeere aweR�e as reqdr�eA�adv Seetls�2SA�t MGL 132 eai Ind b tie��tQislad pe�aNtn�f a�e�p b i1,SN�N aadl�r � eee yean'ImprYo�aeet af wy as dvi pnaltle�h t6e t�ot a STOr WORK ORDEA ud��e e[S1M.N a d�y apimt u�e. 1 ndenta�d t6�a cepy o[thb�faoemeot�y be[�rwarded 1s tYe Omce�[IareNiptl�m�[tlu DIA far awerase reriAeatlw /lo Are►+tby cerfffy reder NYe polws�pe �hies ofPM+�'!'tAi�t NYe iwforw�fo�proddel eboae is lrre awd co II� S,� � � �� -- �n /��`,1 > � /� q ; Print nanx %/�-V¢n9 J ��1�= 7 , P6one# �_2��-�/O r-(o O Z 1 j I i . � efHciai ex aoty do oet wrke�thh area b be covPicted bY eHY or�wa o�cW ' • � . I city or tewo: P�� f �Lk+es�Bdard ' t ' ❑e4eek if i�a�ale rsapeme is reqoir+ed + �Selcet�ees s Ofsce . � QHeakY Depati�eat mntact P�� phwe M; �� c�� i i � � ,• , _ � �� Workers' Com ensation and Em lo er's Liabili po�� c NorGUARD Insurance Company- q Stock Company �� Po��cy Number PQWC229030 ��'� Renewal of PAWC122735 NCCI No.[25844] _._ _...._. Policy information Page _.._.._ _..._.._ Named Insured and Mailing Address _.._ . _._.... _ __._.._ _._ _ .....___ _..._.. --, PARI DEVANG CORP. gency 69 Main Street DOWLING & O'NEIL INS AGY West Yarmouth, MA 02673 9�3 IYannough Road P•O. Box 1990 Hyannis, MA 02601 Agency Code: MADOWLIO Federal Empioyer's ID Risk ID Number Insured is Corporation 48617 Additional Names of Insured (N2) AMERICAN HOST MOTEL [2] Policy Period ----______ From August 11, 2011 to August 11, 2012, 12:01 AM, standard time at the insured's mailing address. [3] Coverage i A. Workers' Compensation Insurance - Part One of this policy applies to the Workers' Compensation Law of the fol�owing states: Massachusetts B. Employer's �iability Insurance - Part Two of this policy applies to work in each of the states listed in item [3]A. The limits of our liability under Part Two are: Bodily Injury by Accident - each accident $500,000 Bodily Injury by Disease - each employee $500,000 Bodily Injury by Disease - policy limit $500,000 C. Other States Insurance - Part Three of this policy applies to all states, except any state fisted in item [3]A. and the states of North Dakota, Ohio, Washington, and Wyoming. D. This policy includes these endorsements and schedules: See Extension of Information Page - Schedule of Forms �—.— --_.....-----------....._.___.._.__------....._...----...___._..._...._..---...__......_..__._—.._____—_.._........_.-----� --- ------..._.._._._. ---------- ---.._._._..._....—.--.._.._..._.._...___-....._..._._.._._....------------..._..------:...---_______...---._.....-----___-----------------_------.. ; [4] Premium The Premium Basis and, therefore, the premium will be determined by our Manual of Rules, Classifications, Rates, and Rating Plans. All required information is subject to verification and change by audit. (Continued on another page) Total Estimated Policy Premium Total Surcharges/Assessments � 8O9 Total Estimated Cost $ 30 � 839 INTERNALUSE XX MGa : PAWC229030 Page - 1 - �ace : o�/zl/zoii Information Page MANOTE WC OOOOOlA 16 South River Street•P.O. Box A-H.Wilkes-Barre, PA 18703-0020.www,guard.com � , 1 �� Workers Com ensation and Em lo er's Liabili po�� i ��,t�� NorGUARD Insurance Company- A Stock Company � �y �' �! � I'o�icy Number PAWC229030 � ��L,,�� Renewal of PAWC122735 ' NCCI No.[25844] Po�icy Information Page Extension of Information Page Schedule of Forms * WC 000403 - EXPERIENCE RATING MODIFICATION FACTOR * WC 000414 - NOTIFICATION OF CHANGE IN OWNERSHIP ENDT * WC 200601A - MA CANCELLATION ENDORSEMENT * WC 200301 - MA LIMITS OF LIqBILITY ENDORSEMENT � * WC 200302A - MA ASSESSMENT CHARGE � * WC 200401 - MA PENDING PREMIUM CHANGE ENDORSEMENT * WC 200405 - MA PREMIUM DUE DATE ENDORSEMENT * WC 200101 - MA TERR. RISK INS. PROG REAUTHORIZATION WC OOOOOlA - INFORMATION PAGE WC OQ00006 - STANDARD POLICY * As part of GUARD's ongoing commitment to environmental responsibility throughout our o erati ; we have chosen not to reprint those forms (marked with an asterisk) that have not changed and were previously sent to you. You can obtain a new co information at GUARD's Po/icyho/der Service Center (a selectionea�ai ab e viaCour�website at y g your account www.Quard com). Please be aware that you will be asked to enter your policy number, policy inception date, and federal ID number in order to log on to this secure portion of our site. Alternatively, you can contact us via phone at i-800-673-2465; our Customer Service Representatives will either be able to help you locate a document yourself or can send a copy to you. As always, we thank you for selecting GUARD as your insurer. We look forward to serving you! INTERNALUSE XX MGA : PAWC229030 Page - 2 - Date : 07/21/2011 Information Page MANOTE WC OOOOOlA 16 South River Street•P.O. Box A-H.Wilkes-Barre, PA 18703-0020.www,quard.com