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Home My WebLink AboutApplication and WC F �.- _ � E-'"30t�K�.� � ; - � � TOWN OF YARMOUTH BOARD OF HEALTH v �AN 10 Z 011 $ � � ' =� � � � APPLICATION FOR LICEN5E/PERMIT-_�011 , �' ° , •-�< �� , ;�;�.. * Please complete form and attach all necessary docu�e .� ` ece ��'� � "�' �' Failure to do so will result in the return o£your��t�3r1 packet. ESTABLISHMENT NAME: �� 9t-z. P� ?�c�� TAX ID� LOCATION ADDRESS: '-41 �oc,o, � '�;v� 5=�rn� ,IJ11��66�1 TEL.#: SC'.Fs-3QF�-S�f�-7 i MAILING ADDRESS: �ar-, OVVNER NAME: �'eoc�P 12 �.o.�sb�� 'r. — ; CORPORATION NAME (IF APPLICABLE): Lt�,�s�cs,� �rr„�e�r�es Cr�c�a � MANAGER'S NAME: I.,�z Lo.�s�cecv TEL.#: SDFs-32&�SY3� MAILING ADDRESS:��p ', POOL CERTIFICATIONS: The pool supervisor must be certi�ed as a Pool Operator,as required by State law. Please list the desisnated Pool Operator{s)__and ait�ch a co�y of the certification to this form. 1. � 2. Pool o�erators must list a mulimum of two employees cun ently certified'ui basic water safety,standard First Aid aud Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies ofemployee certificatians to this form. The Health Department witl not use past years' records. You must provide new copies and maintain a file 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 ��ho is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Seivice Establislunents, 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. r l. ��..{� �.ae��r�ec.J 2. i PERSON IN CHARGE: ' Each food establislunent must have at least one Person Iii Cfiarge (PIC) on site duruig hours of operation. 1. ��i�hb2� LQaC�1cKe�.c.� 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 tinies. Please list your em�loyees tranied in anti-chokui�procedures below and attach copies of einployee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at vour place of business. 1. �.�z�e� L��`c�Ge,c..�-� 2- 3. 4. RESTAURANT SEATING: TOTAL # �/I� OFFICE USE ONLY LODGI\G: LICENSE REQUIRED FEE PER11�fIT�? LICENSE REQUIRED FEE PERNIIT� LICENSE REQUIRED FEE PERMIT# BRB S�5 CABIN S» _MOTEL S» INN S55 CAMP S55 __ �SZVLVI:v1INGPOOL S80ea. LODGE S�5 �TRAII.ERPARK S105 ��V'HIRLPOOL S80ea. FOOD SERVICE: LICENSE REQL�IRED FEE PERMIT� LICENSE REQUIRED FEE PERVIIT� LICENSE REQUIRED FEE PERiViIT� I 0-100 SEATS S85 �l� _CONTINENTAL. S35 NON-PROFIT S30 >100 SEATS 5160 �CO'_VIIvION VIC. S60 �lf-6�� '�`HOLESALE S80 RETAII.SER�'ICE: —RESID.KITCHEN S80 LICENSE REQUIRED FEE PER'�1IT� LICENSE REQUIRED FEE PER�'�IIT Y LICENSE REQUIRED FEE PER'�IIT# _<50 sq.ft. S50 _>25,000 sq.ft. S?25 _VENDING-FOOD S2� Q�,000 sq.ft. S80 _FROZEN DESSERT S40 _TOBACCO S» �A��E CHA�GE: sis AMOUNT DUE _ $ l�5.Oo *****PLEASE TL�R\O�'ER A�D CO3�PLETE OTHER SIDE OF FOR�i***** ,, • � ADMINISTRATION F � �� 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 1NSURANCE 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: �S_� NO MOTELS AND OTHEla LODGING ESTABLISHMEN'TS 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 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, sha11 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 De�artment to schedule the inspection three(3)days pnor to opening.PLEASE NOTE:People are NOT allowed to sit m the pool area until the pool has been mspected 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 ins�ected by the Health Department prior to opening. Please contact the Health Department to schedule the inspection three (3) days prior to operung. 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.varmouth 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: ; Outside cafes(i.e., outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth. ; - _- -- _ _ _ _ - _ _ __ OUTDOOR COOHING: Outdaor 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 RESPONSIBII,TTY TO RETtJRN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15, 2010. ALL RENOVATIONS TO ANY FOOD ESTABLIS�-IMENT, 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 S TE PLAN. DATE: 'Z�v /U SIGNATURE: PRINT NAME&TITLE: �� p La,�� _�� -- u 10�06 10 E"-'•-" • • � 6 tTE STATf INSURANCE COMPANY 0097954-00 WC 00]-43-6125 r3��2 -------------------------------------------- o�3-b6-oz�o-oa . . � l.ATSHAId ENTERPR(S E S CORP ••• �+ �/'"1 R T I � 831 tAKEFiELD ROAD S Y�Rt40UTH, Mk o2664-0000 A Chartis comparry EI�Ct)TIVE OF�ICES: SEE EXTENSiQN QF ITEM 1. OF THE INFORMATION PAGE - WC99061U 175 Wat�ar Street New York, NY 10038 !D� .,�. ��r � •.�- HUB INTERNATIONAI NEW EN6LAND LLC WORKERS COMPENSATION AND EMPLOYERS 265 ORLEANS RD LIABtltTY POL{CY INFORMATION PAGE NORTH CHATHAM, MA 02650-OOOQ tNSURED IS PREv1oUS POUG1t NUMBER CORPQRATfON NEW ER WORKPLACES NOT SHOWN ABOVE: SEE EXTENSION OF ITEM L OF THf fNFORMATiON PAGE - WC990610 ITEk12 POLICY PERIOD 12�81 Ait standard t4ne at the insured's �+�ng�� FROM OZ�OlFJ�O TO UZ�OIF�� 3 A. WoHc�s Compensation insur�ce: Part One of ffie poficy applies to the Warkers Compensation i.aw of the states iisted her� MA B. Employ�s Liability insurar� Pert Twa ot tffe palicy applies to the work in esch statie listed in rtern 3.A. The iimits of our liability ander Part Two ar� 8o�iy Injury by Acadent S 100,000 �ch accident Bodiiy injury by Disease $ 500.000 poiicy fimit Bo�ly Injury by Disease S 100.000 e�ch employee C. Other Stabes Insurance: Part Three of the policy apPlies m the States, ff any, listed her� SEE ENDQRSEMENT - WC200306A D. This policy incfudes these SEE EXTENSION OF ITfM 3.D. OF THE INFORMATION PAGE - WG990612 r�� The pr�nium for this policy wiff be determir�eci by aar Manuais of Rufes, qassifitxtions. Rates and Rating Plans. a Ail iMormation required below is subject to v�ification snd change by audit Estimated Totai �e p� Estimated passifications Code Number �mwreration s�pp pp�, Premium M�ual 3 Year ��t� x Annual 3 Year SEE EXTENSION OF fTEM 4. OF THE INFORMATION PAGE - WC7754 TAXES/ASSESSMENTSISURCHARGES $]0 �E co�sr�wr�occ�r wr�e ara�.icae�.e sr srA�► 2 0 MA M��+��+ $246 MA �a-�u►�� 51,24b N indicsted 6Now.interim adjustments of premium&hatl be made: � Semi-MnwiH ❑ �arteM ❑ Monthty D@�StT PR�IIUM 04/O1j10 ASSIGNED RISK 66 " '�''' Issue Date issul�OHics Aufhoriaed BepreseMatNre vVC 00 00 Ot �67(Rev'd 04/OB)