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Home My WebLink AboutApplication and WC ` F_z ,R F:�� . TOWN OF YARMOUTH BOARD OF HEALTH �.c. �� APPLICATION FOR LICENSE/PERMIT'-�0 �, �� I�OV O � ZO11 �, . ,r� ��_ ,� ;, , * Please complete form and attach all necessary doc�en ` ` e ir'' 2 LTH DEPT. '' Failure to do so will result in the return of your application pac et. 'I i ESTABLISHMENT NAME: . C�.--T �- ID• � I LOCATION ADDRESS: ��'( G�l,: TEL.#: f MAILING ADDRESS: C OWNERNAME: �llinl 1 � l.lff"Y1 � � ; CORPORATION NAME(IF AP�LICABLE): � MANAGER'S NAME: �Q�Ci �(Yl TEL.#: ` MAILING ADDRESS: , S(�.�'Yt.�. i � POOL CERTIFICATIONS: ' The pool supervisor must be certified as a Pool Operator,as required by State taw. Please list the designated � Pool Operator(s) and attach a copy of the certification to this form. � 1. 2. 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 certi�cations 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. 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. i You must provide new copies and maintain a file at your establishment. i � 1. 2. � PERSON IN CHARGE: _ _ Each�ood esta'b�ishinent must fiave at�east one�ersan I�-��harge(PIC) on site during hours of operation. 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. � I RESTAURANT SEATING: TOTAL# i i OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# '' _B&B $55 _CABIN $55 _MOTEL $55 _INI� $55 _Ct1,11�F $55 _S�,'VIlN_lyllld'`G DC?�JL $8�ea. _LODGE $55 _TRAII.ER PARK $105 � _WHIRLPOOL $80ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIIZED 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 REQUIItED FEE PERMTT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �<50 sq.ft. $50 _>25,000 sq.ft. $225 _VENDING-FOOD $25 �<25,000 sq.ft. $80 �� ,FROZEN DESSERT $40 _TOBACCO $95 ' � NAME CHANGE: $15 AMOUNT DLJE _ $ 80•b0 ' *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** : _ -, ADMINISTRATION LTnder 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 Certi�cate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDA�VIT MUST$E COMPLETED AND SIGN�D, 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 -P�IIE�TEI.S ANY� OT�;It I.��iIit��'1"A�3LI�I��NT� 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 OPElvING: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 OPEIVING: 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: 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),rriust haye prior approval from the Board of_Health. OUTDOOR COOKING: i Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. NOTI E: � C 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, MOTEL OR POOL (i.e., PAINTING, NEW � EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR � TO GOMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. , �DAT�: I� 3 I� SIGNATURE: PRINT NAME&TITLE: �i ��1 .L'�'l,t.�'1`�P �'�Lt �-�" I Rev.10/25/11 ! � � f � 4 . �� WORKERS COMPENSATION TRAVE�ER5 ANa � EMPLOYERS LIABIUTY POLICY QUOTE PROFILE i POLICY NUMBER: (7PJUB-0323N10-4-1 i ) ' INSURER: TRAVE�ERS PROPERTY CASUALTY COMPANY OF AMERICA � � 13579-MQ INSURED'S NAME : CAPE COD TAFFY CO. , INC. RATE BUREAU ID: 000157421 . PREMIUM BASIS -- ESTIMATEd RATES ESTIMQTED TOTAL ANNUAL PER $100 OF ANNUAL CLASSIFICATION GODE REMUNERATION REMHJNERATIQN PREMIUM LOCATION 001 01 FEIN ENTITY CD 001 CAPE COD TAFFY CO. , INC. � 984 ROUTE 28 ' SQUTH YARMOUTH, MA 02664 CUNFECTION MFG. 2041 44466 2.62 1165 _ _ - - - ___ __ ___ ----- -_ _— _ _ - - --- -- -- _ _ , STORE-RE TAI L NOC 8017 36134 1 .15 416 CLERICAL OFFI�E-.,EN�'l.0YEE5 P�C. 8810 �4289 .09 4� ---------------------------------------------------------- .950 MERIT RATING MODIFICATIOiJ (9885) $ �1 TOTAI. ESTIMATED ANMUAL STANDARD PREMIUM 1540 .00% ARAP MODIFICATIQN PROGRAM (0277) NONE � EXPENSE CONSTANT(0900) 338 '0.0300 TERRORISM (9740} 37 6.80°/a MA WC SP,��IAI FUND Att1D TRUST FUND 105 � : '. ` TOTAL �STIMATED PREMIUM 2024 D�POSIT AMOUNT DUE 2020 i I ; i i i DATE O� ISSUE: 02-04-11 WC ST ASSIGN: MA SCHEDULE NO: 1 OF LAST � , i r voAc . � �� THIS IS A QUOTE, NOT A POLICY TRAVELERS J WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY QUOTE PR�FILE — VERSION 01 POLICY NUMBER: (7PJUB-0323Ni 0-4-11 ) RENEWAL OF (7PJUB-0323M10-4-10) INSURED'S NAME AND ADDRESS WORKERS COMPENSATION ' CAPE COD TAFFY CO. , INC. INSURANCE PLAN 50 LONG POND DRIVE A/R (WCIP) # MA ' SOUTH YARMOUTH MA 02664 - POLICY PERIOD FROM: 04-01-1 1 TO 04-01 -12 TOTAL ESTIMATEQ ANNUAL STANDARD PREMIUM $ 1540 FREMIUM DISCOUNT NONE 0900-20 EXPENSE CONSTkM' 338 TERRORISM 37 TOTAI ESTIMATED PREMIUM 1915 TAXES AND SURCHARGES id5 DEPOSIT AMOUNT DUE 2020 Employer's Liabitity BI Limit: $ 100000 Each Accident 500000 Policy Limit i 00000 Each Empioyee INSURER: TRAVfLERS PROPERTY CASUALTY COh�ANY OF AtdIERICA Adjustments of Premiums shall be made ANNUALLY ********,r************,r**,t*****,r Deposit Amount Due: � 2020 *,�**********,�*******,t�******** . POLICY NUAABER: �7PJUB-0323N10-4-11 ) DATE OF ISSUE:02-04-�� wc ST ASSIGN: Ma OFFICE: DIRECT ASSIGNMENT701 PRODUCER: �oHN F MARTIN INS AGCY 28LFB