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Home My WebLink AboutApplication and WC1 i . C��[�10 • � r � � TOWN OF YARMOUTH BOARD OF HEALTH � � � APPLICATION FOR LICENS _2��3 P rf;9, �h �� b' � �... ��,� :� �°� �:,. t' � ,� �� - * Please complete form and attach all neces� °' c�o�:ilme ts..l�y�e�► e��-�b�1��R7'. , Failure to do so will result in the retu�of y�ur application pac et. ESTABLISHMENT NAME: CC� GL CD . TAX ID: LOCATION ADDRESS: I,t,�C. S• �f-h TEL.#: SS 7 MAILING ADDRESS: SA.rY�� OWNER NAME: �Q.h 1� DU�lY��T('' CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: 1�0Y i �VrY1Ur�fi TEL.#: �p k c3q� � t t-Q� MAILING ADDRESS: �12� J� �� n n 1S 2�ad. ya,rmt,u--�►r�r�-�- f�'1� o"Ll�'].� POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated - ?'ool Operutnr(s) and attach a w��►y��th� cex-ti_ficatir�n t�thi3 form. _ ,.--- � l. 2. _ Pool opera�ors 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. 1. 2. 3. 4• - . 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 590.0��. 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. Y� v 1 l, . � _.--_ —___ __ Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. l. 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# OFFICE USE ONLY ; LODGING: ' LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $55 _INN $55 _CA1�iP $55 _SWIMNIING POOL $80ea. ''' _LODGE $55 _TRAILER PE1RK $105 _WHIRLPOOL $80ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# ; _0-100 SEATS $85 _CONTINENTAL $35 NON-PROFIT $30 >100 SEATS $160 _COMMON VIC. $60 _WHOLESALE $80 ' RETAIL SERVICE: —RESID.KiTCHEN $80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq.ft. $50 >25,000 sq.ft. $225 _vENDING-FUOD $25 ' �<25,000 sq.ft. $80 I��( —FROZEN DESSERT $40 _TOBACCO $95 _ :vaiwE c�rrcE: $is AMOUNT DUE _ $_gp,pp *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** � . . � 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 5TATE WORKER'S COMPENSATION INSURANCE � AFFIDAVIT MUST SE 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 N�(3`�`�LS AND OTHER i;OBCING'E��'AB�..]�SH19��NTS I 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 OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected i by the Health Department prior to opening. Contact the Health De�artment 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: 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 obtamed 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: i Outside cafes(i.e.,outdoor seating vvith vv�it�r/waitre�s serYic�),mus�have-�ri�rapproyal frQm the Boa��ef H�,� - -- OUTDOOR COOKING: II 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, 2012. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MtiST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY UT A SITE PLAN. , DATE: 11 I S �!1— SIGNATURE: � PRINT NAME &TITLE: Cv h �(�f'Y► / xe�. ioro9iia , � ¢__ � � � �= �' , �� VDAC . �� ., . .w, _ TRAVEi�ERS� WORKERS CON(PENSATIflN` : AND EMPLOYERS LIABILITY POLICY TYPE AR INFORMATION PAGE WC 00 00 Oi ( A} � POLICY NUMBER: (7PJUB-0323N10-4-12) i RENEWAL OF (7PVUB-0323N10-4-11 ) � � _ i NSURER: TRAVELERS PROPERTY CASUALTY COMPANY OF AMERICA � NCCI CO CODE: 13579 1 1� j INSURED: PRODUCER: i CAPE COD TAFFY CO. ,. INC. • �OHN F MARTIN INS AGCY ! �0 LONG POI� DRIVE 1023 ROUTE 28 ; SOUTH YARMOUTH MA 02664 SOX 350 S YARMQUTH MA 02664 Insured is A GORPORATION Other work places and iderrtification numbers are shown in the schedule{s) attached. 2. The policy period is from 04-01-12 to 04-Oi-13 12:01 A.M. at the insured's mailing address. 3. A. WORKERS COMPENSATI__ON INSURANCE: Part Qne of the poficy applies to the Workers _ _ _ __ _ _ _ Compensation Law of the state(s) listed here: .� MA �,� � �� B. EMPLOYERS LIABIIITY INSURANCE: Part Two of the poticy applies to work in each state listed in = item 3.A. The limits of our tiability under Part Two are: a� � Bodily Injury by Accident: $ t o000o Each Accident fl= Bodily InJury by Disease: � 500000 Policy Limit o_ Bodily lnjury by Disease: $ t o0000 Each Employee �� C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here: m-- ��- COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06A ��— . � � o� _ D. This poiicy includes these endorsements and schedules: o� SEE LISTING OF EMDORSEME(dTS - EXTENSION OF INFO PAGE o� _ - 4. The premium far this policy will be determined by our Manuals of Rules, Ciassifications, Rates and Rating _ Pians. Ali required ir�formation is subject to verification and change by audit to be made A►vNUA��v. — ..— DATE OF ISSUE: 03-23-12 WC ST ASSIGN: MA OFFlCE: DIRECT ASSIGNMENT 701 PRQDUCER: JOHN F MARTIN INS AGCY 28LFB 004873 ` TRAVf LFRS J� WORKERS COMPENSATION AND EMPLOYERS LlABILITY POLICY EXTENSION OF INFO PAGE-SCHEDULE WC 00 00 01 ( A) POLICY NUMBER: (7PJUB-0323N10-4-12} INSURER: TRAVELERS PROPERTY CASUALTY CON�ANY OF AA�RICA � INSURED'S NAME : CAPE COD TAFFY CO. , INC. t3579-MA RATE BUREAU ID: 00015742i � • PREMIUM BASIS ESTIMATED RATES ESTIMATED CLASSIFICATION TOTAL ANNUAL PER $100 OF ANNUdL CODE REMUNERATION REMUNERATION PREMIUM LOCATION 001 01 FEIN ENTITY CD OOi CAPE COD TAFFY CO. , INC. 984 ROUTE 28 SOUTH YARMOUTH, MA 02664 ' CONFECTION MFG. 2041 44466 2,62 1165 ' _ ��'{�E�RETA� �IOC __ _ ._- $��g- _ -- ___ � _--__ �613� _ -- -� .-i�---- _ 4f 6 � •�= CLERICAL OFFICE EMPl.OYEES NOC 8810 44289 .09 i -a� 40 �� i �� .�. � � �� , o� o� �� _� -� - , �� — � � o� �� ,.�, ------------------------------------------ � ------------------------------------------ o? .950 MERIT RATING MODIFICATION (9885) $ gi �� TOTAL ESTIMATED ANNUAL STQNDARD PREMIUM 1540 �� EXPENSE CONSTANT(0900) 338 .�� 5 .90% MA WC SPECOA030U�D ANDRTRUST9FUP� 37 TOTAL ESTIMATED PREMIUM 91 2006 DEPOSIT AMOUNT DUE 2006 DATE OF ISSUE: 03-23-12 wC ST ASSIGN: MA SCHEDULE NO: i OF�AST aoas�a