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Home My WebLink AboutApplication and WC� .c.�. Sa�z- W�-r�.'t��Y � � � � � �� TOWN OF YARMOUTH BOARD OF HFAL�'�' � �L��',i i z� ' � = APPLICATION FOR LICENSE/�'E, 'F�2 1= r ` � _�� ' u�v �Jn !� �..� �! * Please complete form and attach all necessa - cu ' s by D em�'er 1 S 2��0. Fa.ilure to do so will result in the return�your applicatio pa�LTH DEPT. , ESTABLISHMENT NAME: 0 : � �Q`�' ��Q � `f" TAX ID. LOCATION ADDRESS: �i-( u,.�rv1 b . TEL.#: � $ � ��- � MAILING ADDRESS: �- OWNER NAME: f�P�{ rYl " CORPORATION NAME (IF APPLICA$LE):��(, �(_ '�d-�. ��, G MANAGER'S NAME: 1�, �,(Y)(�Y1� TEL.#: �Z� I�( MAILING ADDRESS: + /')'i vt.L_. �-�- POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool O�erator�s)a�a�t�a co�y_�f�� c�r�ific�tion to_this f�rnL_: __ ___ _—___ �� ---_—_ l. 2, Pool operators must list a minimum of two employees cun ently cei�tified in basic water safety,staudard First Aid and Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies ofemployee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at y�our place of business. 1. 2. 3- 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establislunents a1e 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 Setvice Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past 3�ears'records. You must provide new copies and maintain a file at your establishment. 1. 2, PERSON IN CHARGE: - . _ _ . . _� _ _ . �� acn oa estab st�unent inust Iiave at Ieast one Persoii In Ci�arge �YIC) on srte durnig hours of operation. l. 2. HEIMLICH CERTIFICATIONS: All food seivice establishments with 25 seats or more must have at least one employee trained in the Heunlich Maneuver on the premises at all times. Please list your em loyees trained in anti-choking procedures below and attach copies of employee certifications to this foim. The�ealth Department witl not use past years' records. You must provide new copies and maintain a �le at ti�our place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LODGI\G: LICENSE REQUIRED FEE PERIVIII'# LICENSE REQUIRED FEE PERVIIT# LICENSE REQUIItED FEE PER'�IIT� _B&B S�5 _CABIN S55 _i�IOTEL S» _INN S55 _CA�NIP S55 _S�V`L'�LviING POOL 580ea. _LODGE S55 `TRAII.ERPARK S105 =��IIRLpOOL S80ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERVIIT� LICENSE REQUIRED FEE PERNIIT� _0-100 SEATS S85 _CONTINENTAL S35 NON-PROFIT S30 _>100 SEATS S160 _COMMON VIC. S60 `T��HOLESALE S80 RE?AII.SERVICE: —RESID.KITCHEN S80 LICENSE REQUIRED FEE PER'�III'� LICENSE REQUIRED FEE PERi�1IT.~ LICENSE REQUIRED FEE PER'41IT*� _<50 sq.ft. S50 _>25,000 sq.ft. S225 VENDING-FOOD S25 �Q5,000 sq.ft. S80 ��jl..o�� _FROZEN DESSERT S40 _TOBACCO S» \AVIE CHt1�GE: S15 AMOUlV'T DUE _ $ $O. 00 **'��'*PLEASE Tti'R\OVER A\D COviPLETE OTHER SIDE OF FOR`Z***** � ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal ; af any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. 1'HE ATTACHED STATE WORKER'S COMPENSATION INSUItANCE : -AFFIDAVIT MU5T BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED ✓ � OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Ya,rmouth t�es and liens must be paid prior to renevaal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES ✓ NO iC�1�'�'1:1.5�1VU UTHEI�LUDGING ESTAY3LISHMEr1TS 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 sha11 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 � by the Health Department prior to opening. Contact the Health Department to schedule the inspection three(3)days pnor to opening.PLEASE NOTE: People are NOT allowed to srt 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. Pt)�T.(:I.OSING: 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 opening. CATERING POLICY• Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required ' Temporary Food Service Applica.tion 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,Downtoadable 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. � , - --- - _ _ _ _ i OUTDOOR COOHING: 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 RESPONSIBILTI'Y TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15,2010. ; ! ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW � EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR ' TO COMMEN�EMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: i� I�'I � I � SIGNATURE: �.��;bl�;/�� PRINT NAME&TITLE: �Vl '�" C� i✓ �o-o6fio . . V VJ►�►i.r . TRAVELERSJ� WORKERS COMPENSATION AND EMPIOYERS LIABIUTY POLICY TYPE AR INFORMATtON PAGE WC�00 01 ( A} POLICY NUMBER: (7PJUB-0323N10-4-10) REAtEWAt OF (7PJUB-0�23N10-4-09) lNSURER: TRAVELERS PROPERTY CASUALTY CON�ANY OF AI�RICA �. NCC1 CC1 CODE: 13579 INSURED: PRODUCER: CAPE COD SALT WATER TAFFY CO. , _ _ _ �lQt�(_E MQRTIN _INS A�CY -. INC. 1023 ROUTE 28 50 I.ONG POt� DRIVE BOX 350 SOUTH YARt�UTH MQ 02664 5 YARb10UTH MA 02664 Insured is A CORPORATiON tJther work{�aces and ider�tification numt�rs ara shown in the schedule(s) attached. 2. The policy period is from 04-01-1 o to pq.-01-1� 12:01 A.M: at the insured's mailing address. 3: 1X. W�RKERS e�MR�NSQTtON tNSURANCE: Part One of the poticy applies to the Workers Compen�ation Law of the state(s) listed here: � � R�� m- �� 1q� �� B. EMPLOYER� LIABILITY IN�URANCE: Fart Twa of the�licy appites to_u�rork in each state tistecl in — item 3.A. The limits of our Ifabilrty under Part Two are: N- a-- Bodily Injury by Accider�t: $ 100000 Each Accident � Bodily Injury by�isease: $ 500000 Poticy Lim� � Bodfly Injury by Disease: $ t o0000 Each Em�oyee m= C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, list�i here: � _ _ �— _ _ _ COVERAGE REPLACED BY EI�ORSEMENT WC 20 03 06A a� �� _ D. This p�icy includes these endorsemeMs and schedules: �— a.� SEE LISTING OF ENDORSEI�NT$ - EXTENSION QF INFO PA�E o� � i 4. The premium for this policy wili be determined by our Manuals of Rules, Classifications, Rates and Rating i Pians. All required i�ormation is subject to verffication and change by audit to be made ANNUA��v. ..._ �_ . flQTE OF ISSUE: 04-01-10 WC ' ST A�SI6W: MA OFFICE: DiRECT ASSIC�dMENT 701 PRODUCER: JOHN F MARTIN INS AGCY 28LF6 002358 �. + �� R�V�LERS� WORKERS COMPENSATtON � z ' AND EMPLOYERS LIABILITY POLICY � ` . . EXTENSION OF INF� PAGE—SCHEDULE WC 00 00 01 E A) POLtCY NUMBER: '("7PJUB-0323N10-4-10) TNSURER: TRAVELERS PROPERTY CASUAITY COMPANY OF AMERICA 13579—MA INSURED'S NAME : CAPE �OD SALT WATER TAFFY CO. , IP1G_ RATE BUREAU ID: 000157421 _ _ _ _ E IUM BASIS __ _ ESTiMATED RATES ESTIMATED 70TA� APNVUAL PER $100 OF At+�HJAL CLASSiFICATIQN CODE REN�lI�RATION REN�JNERATION PREMIUM LOCATiQN OU1 01 FEIN ENTITY CD 001 CAPE COD SALT WATER TAFFY CO. , INC. 984 ROUTE 28 SOUTH YARN�UTH. MA 02664 CONFECTTON MFG. 2041 44466 2.33 1036 •i STORE—RETAIL NOC 8017 36134 1 .09 394 �� ,— �" CLERICAL OFFICE EN�LOYEES t�C 8810 44289 .12 53 ,�—� s �,� ..� �� o� o.� m= .� m'=� � o� o� �� .� ------•-------^---------------------------------------------------------�------------- �.■� o� .950 N�RIT RATING MODIFICATION (9885) $ 74 a� TOTAL ESTIMATED AI�JAL STA(�ARD PREMIUM 1409 � .00q ARAP MQDIFICATION PROGRAM (0277) NOP� � EXPENSE CONSTANT(0900) 33$ a'�` Q.0300 TERRORISM (974p) 37 �� 7.20% MA WC SPECIAL FU1� A1� TRUST FUND 101 TOTAL E5TIMATED PREMIUM 1885 DEPOSIT AN�UNT DUE i885 DATE OF ISSUE: 04-01-10 WC ST ASSIGN: MA SCHEDULE NO: 1 OF LAS7 ooa�se