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Home My WebLink AboutApplication and WC --� TOWN OF YARMOUTH B4ARA OF HEALTH �� AP'PLICATION F4R LTCENSE/PER�t'II"'�'-201 2�'� *Please�comelet�form and attach all necessary doca�ents:b}� ece er S 2�8�9.� � �E��D a�l u r o d o s o w�t l r e s u l t m t h e r e t u rn o f y p u r a p p l i c a t i o n p a c e t. H E q��h u t r,. NAME O�ESTABLISHMENT: -Zr�r� TEL. # 5c�-�Fs-S�3�7 LOCATION ADDRESS: Dr. � �. �2�(; MAILING ADDRESS: SaM�e �S a�rn,� OWNER NAME: � T D FE or S N ` CORPORA.TION NAME (IF PLICABLE): � ��s-;�QS Corp . MANAGER'S NAME: c� , lrR��•c� �r �---�EL. # g�3��-,5�13� . MAILING ADDRESS: �r= .5�-�-h o �-j POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Qperator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certificarion to this form. 1• 2. Pool operators must list a minimum o£two emp loyees currently certified in basic water safety,standard First Aid and Com�nunity Cazdiapulmonary Resuscitarion(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 capies and maintain a fde at yot�r place of business. 1- 2. 3• 4. FOOD PROTECTION�VLANAGERS - 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 applicatian. The Health Department will not use pRst years'records. � You must provide new copies and maintain a fde at your establishment. I 1. _ Q� �.-�'� t .� �� 2._ ��<z �s�e.�-�l, r�.�i,.,�, PERSON IN GHARGE: _ __ _ __ __�_—-------__-- . _ _ - __ _ _ --- -- - - �acl��ood establishment must have at least one Persoz�In Charge (PIC) on site during hours of operation. ; 1. . ��er� � � � �--�, �.__._._.�.��.a�`w1 �. �1�--� �, 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 rimes. Please list your employees trained in anti-chaking procedures below and attach copies of employee certifications to this form. The Health Department wil!not use past years' records. You mast provide new copies and maintain a file at yoar place of basiness. 1, 2. 3. 4. RESTAURANT SEAT'ING: TOTAL# ��ir �ir��w � OFF�CE USE UNLY LODGING: LIC�IVSE REQUIRED FEE PERMIT# LICENSE,REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&B $55 TCABIN $55 �MOTEL $55 � $5� ._,._CAMP $55 �SWIMMING POOL �80ea. _LODGE $55 ____TRAILERPA.RK $1p5 �WHIRLPOOL $80ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LTCENSE REQUIRBD F�E PERMIT# LICENSE REQUIRED FEE PERMIT# �0-100 SEATS $85 ( —(�J _GONTINENTAL �35 �NON-�'ROFIT $30 7ioos��rs $i6o I COMMONVIC. $60 lD�a 2 �WHOLESALE �so RETAII.SERVICE: —RESID.KITCHEN �80 LICENSE REQUIRED FEE PERMIT# LIC�NSE REQUIltED FEE PERMIT# LTC�NSE REQUIRED F�E PE12MI�# �<50 sq.R. $50 >25,000 sq.R. $225 _VENDING-FOOD $25 �<25,000 sq.f�. $80 .._FROZEN DESSERT $40 �TOBACCO $SS xa�cxaiv�E: $is AMOUNT DUE _ $ /5/�QO , "*""*�LEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM"�"** P ...,», .:.. .,.. .. ... ... . ♦ r :. ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yazmouth is now required to hold issuance or renewal _of'ariy iiCense or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WUR,KER'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 pemuts. 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 limit�d to the temporary and short term occupancy,ordinarily and customarily associaxed with motel and hotel use. Transient occupants must have and be able to demonstrate that they mairrtain a principal place ofresidence elsewh�re. Transient occupancy sha11 generally refer to continuous occupaney 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 sha11 not be considered transient. Occupancy that is subject to the collection of Room Occupancy Excise, as defined in M.G.L. c. 64C or 830 CMR 64G, as amended, sha11 generally be considered Transient. POOLS POUL OPENING: A11 swimming,wading and whirl ools which have been closed for the season must be inspecteci NN p by the Health.Department�prior to opening. Contact the Health Department to schedule the inspectian three(3)days pnor to operung.PLEASE NOTE:People are NOT allowed to sit m the pool azea until the pool has been�inspected . and opened. POOL WATER 1'ES1`ING: 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�round swimming pool must be drained or covered within seven(7)d�ys of : closing. '. FOOD SERVICE CATERING FOLICY: ' 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 abtained at the Health Depariment. FRUZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Per�mit untit the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e., outdoor seating with waiter/waitz�ess service),must have prior approval from the Board ofHealth. OUTDOOR COOKING: Outdoor cooking,prepa.ration,or display of any food product by a retail or faod service establishment is prolubited. NUTICE:Pertnits run annually from�anuary 1 to December 31. IT IS YOUR RESPONSIBILI'I'Y TO RETURN TI�COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 1 S, 2009. � ; ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOI. (i.e., PAINTING, NEW ; EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR ; TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: //�//V SIGNATURE: ' �.�'' PRINT NAME&TITLE: ��P � ��t�c.v �r . �(,�c�e� ; 09l25/09 , Apr 0� 10 11:22a p,� . : . _ . - . .. • . . . •. Q� '• �RAI�ITE STATE INSURANCE GQMPANY �— 0097954-oc wc oo7-b3-6t25 13 i 0 2 --------------------------�------ 0�3-66-o2ro-oo . . � p � , . - � ' . .- . • . LATSWAW ENTERPRISES CORP L F-t A R T � 5 831 LA1CfFI.Ela ROA� S YARMOU'�W, M.A 02£64-0000 A Chartis company EXECUTIVE OFFlCES: SEE EXTEf3SI0I�f OF ITEM 1. OF THE INFORMATION PAGE - WC99U6'10 ��' W�� S�� New York, NV 10038 1-D# A lJ • �.. • . • •r.- WUB INTERNATlONAL NEW E�iGLAND LLC WORKERS COMi'ENSATION AND EMPLQYERS �65 ORLEANS i2D LLABILITY POLICY INFORMATION PAG� NORTH GHATHAM, MA 02650-0000 INSLJRED IS PREVIOUS POLfCY NUM6ER CORPQRATION NEW OTHER WaRKPLAGES WOT SHQWf�i ABOVE: SEE EXTENSION OP ITEM 7. OF THE INFORMATION PAGE - WC9906EO �ITE7N 2 POUCY PERI00 t2_Ot A.M,standard time 8t tl�e Insured�s �aa�ngaadress Fao� 02/04/10 To 02J04/11 �'�� A, V1fo�ke►s Gompensation Insurance: PaR On'e of the palicy appGes to the Wnrkers C�mpensatio� Law of tF� states listed here: MA 8. Empkoyers Liability Insurance: Pare Two of the poliCy applie5 to tho wofk in 6ach Stdte {isted 9n item 3.A. The limits of vu� tiabilit�t under Part Two are: godil In'u 6 Acciden# $ )00. y � ry y 000 eech acciderrt 8odily Injwy by Qisease � 500.000 policy limit Bodily Iniury by Disease $ 100.000 eqch empinyee C. Qther 5tates Insuranse: Part Three of the poliry applies tn the stabes, it any, listed hare: SEE ENDORSEMENT - WC2003U6A D. 7h'es poli�y includes these SEE EXTENSION OF ITEM 3.D. OF THE 1NFORMATION PAGE - WC990612 •r i ��+ The prcmium for this policy wiif be determined by our Manuals of Rules. Qassificetions, Rates and Rating Plans. � qll iniormaticn required below is subject to verificatton and change by seidit Eslimated Total Rate Per Estimatad Remuneration Premium Qassi�iwtions Code Num6er S70D OF Re- � Mncral ❑3 Year ^��^��110^ �kri,�uai ❑3 Yoar SEE EXTENSION OF ITEM 4. OF THE 1NFORMATION PAGE - WCT754 TAXES/ASSESSMENTS/SURCHARGES S99 E7fPENSECONSTANf(E7ICBT'YVHEREAPPLK`.ASLEBYSTpT� 5 � MA tMNU1W�t PRE7u�UM $Z�Ej MA 70TA1 F_S�IMA7ID PRE2AIUM S� 73� li intl�utatl balow,mterim ad�ustmen�s o[premlum s�all be maCe- � SQmi-Annuallq � QuaAetly � MonthlY DEPOSITPAB111UM i 03/O1/10 ASSIGNEO RISK 66 f—� � '^�' IssUe Date luuing Offics quthwk[ed Representative wC 00 00 01 39957 {Rev'd O�/OD)