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Home My WebLink AboutApplication and WC � � C .c. sA�r lil��n Ja� '' ' � ' TOWN OF YARMOUTH BOARD OF HEALTH ' � APPLICATION FUR LTCENSE��.VIIT-ZO10 ' - �� i ?��1� `� � * Please complete form and attach all neces c�ocum�Deceanb�1 S,20�'19. ' ; � Fas�ure to do so will result in the retu�t�of your application p c�. :� f . _ �� ! NAME OF ESTABLISHMENT: ' CQG��C��" �`� C�: C�- �,�#'tl, TEL. # �D�'3�'�( �S.� 7 LOCATION ADDRESS: � ' � MAILING ADDRESS: i'�-- i OWNER NAME: ' 1 U� � U.� X D FE or ��' � � '; CORPORATION NAME (IF APPLICABLE): ' 'T� ''� � �-- ' MANAGER'S NAME: LO`f1 f.�i�"t� TEL. # 1 N MAILING ADDRESS: °l��'( IZ�-- � C� �t-�1'1ti- POOL CERTIFICATTONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(sl and attach�s�gy of ihe certific�tion to this form. ; 1. 2. Pool operators must list a minimwm o£two employees currently certified in basic water safety,standard First Aid and Community Cardiopulmonary Resuscitarion(CPR). Please list these employees below and attach copies of employee certificarions to this form. The Health Department will not use past years' records. Yoa must provide new copies and maintain a file at yonr place of business. �. a� 3. 4. w�� wnn�■r�� . FOOD PROTECTION�v1ANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food � Protecrion Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification ta 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• PERSON TN CHARGE: -- -__- - _ --- -- -- ; - - -- _ Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. l. 2• HEIMLICH CERTIFICATTONS: Ali foqd service establishments with 2S seats or more must ha�e at least one employee trained in the Hei.mlich Maneuver on the premises at all times. Please list your erYployees trained in anti-choking procedures below and attach copies of employee certifications to tlus 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• RESTALTRANT SEAT'ING: TOTAL# OFFICE US� UNLY LODGING: LIC�TTSE REQUIRED �'EE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENS�REQUIRED FEE PERMIT# I� ,�,B$cB $55 �CABIN $55 �MOTEL $55 � �INN $55 �CAMP $55 �SWI�VIMING POOL �80ea. j _,,,_LODGE $55 �TRAILBRPA.RK $105 __,_._,�___ �WHIRLPOOL $80ea. � � FOOD SERVICE: LICENS�REQUIItED FEE PERMIT# LIC£NSE R£QUIRED �'$E PERMIT# I.ICENSE REQUIRED FEE PEItMIT# �0-100 SEATS $85 � _GONTINENTAI, �35 NON-PROFIT �30 >l00 SEATS $160 �COMMON VIC. $60 ____WHOLESALE �80 I R�TAII.SERVICE: —..–RESID.KITCHEN �80 ' LIC�NSE RE(2UIRED FEE PERMTf# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMTT# � y<50 sq.ft. �50 >25,000 sq.8. $225 VENDING-FOOD �25 � ,�,_a25,000sq.ft. $80 �� ._FROZENDESSERT $40 TOBACCO �55 j NAME GHANGE: $is AMOUNT DUE = S 80.OO , � ***"*PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM**"** , f. ,- . ADMINISTRATION � � Under Chapter 152, Section 25C, Subsection 6,the Tawn 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 Certifica.te of Worker's Compensation Irisurance. THE ATTACHED STATE WORKER'S COMPENSATION INSU1tANCE AFFIDAVIT MUST BE COMPLETED.AND SIGNED, OR � CERT. pF INSURANCE ATTACHED� OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED ; Town of Yannouth taxes and liens must be paid prior to renewal or issuance of your pemuts. PLEASE CHECK � APPROPRIATELY IF PAID: ; YES NO I ; MOTELS AND OTHER LUDGING ESTA.BLISHMENTS , ; ' I i ; TRANSIENT OCCUPANCY: For purposes af 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 mairrtain a principal place ofresidence�lsewhere. Transient occupancy shall generally refer to continuous occupancy of nat more than thirty (30) days, and an ` aggregate of not more than ninety(90) days within any six(6)manth 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. 64G or 830 CMR 64G, as amended, shaU generally be considered Transiart. � ; POULS POOL OPENIl�TG:All swimming,wading and whirlpools which ha.ve been closed for the season must be ins by the Health Department�priar to opening. Contact the Health Departme�t to schedule the inspectiott thrce(� pnor ta opening.PLEASE NOTE:People aze NOT allowed to sit m the pool area until the pool has baen ins�ected and opened. ; POOL WATER TESTiNG: The water must be tested for pseudomanas,total cnliform and standazd plate count by a State certified lab, and submitted to the Health Department three (3) days prior to opening, and quarterly _ thereafter. POOL CLOSYNG:Every outdoor in ground swimming pool must be drained or cove�red within seven(7)d�ys of r closin�. � f FOOD SERVICE ' CATERING FOLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Depaztmeirt by Sling the r wred Tempora.�Food Service Applicarion form 72 hours prior to the catered event. These forms can be obtained�at the � Health Department. .., FROZEN 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 ar revocation of your Frazen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e., outdoor seating with waiter/waitress servi.ce),must have prior approval from the Board ofHealth. OUTDOOR COOHING: ___ Outdo�r cnoking,_pr�paratiQn,Qr di�lay o��fQQ�g�o�uc�b��retaal Qr food_service establishmern is�rohibited. ••, NOTICE:Permits run annually&om 7anuary 1 to December 31. IT IS YOUR RESPONSIBILT�'Y TO RETURN ; THE COMPLETED RENEWAL AppLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15, 2009. ALL RENOVATXONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOI. (i.e., PAINTING, NEW ' EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY'THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUtRE A SITE PLAN. � ; DATE: ��- �p�_ SIGNATURE: � � �,�/�� PRINT NAME&TITLE: �.�-�r�► �U-/1�1�r1-`�` t'YIGt..d2%--��✓ 09125/09 , 4 � TRAVELERS��` WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY QUOTE PROFI�E j POLICY NUMBER: (7PJUB-0323N10-4-09) INSURER: TRAVELERS PROPERTY CASUALTY COMPANY OF AMERICA 13579-MA INSURED'S NAME : CAPE COD SA�T WATER TAFFY CO INC RATE BUREAU ID: 000157421 _ _ _ _ , - _: , PREMIUM BASIS - , ; ESTIMATED RQTES ESTIMATED TOTAL ANNUAL PER $100 OF ANNUAL C�ASSIFICATION CODE REMUNERATION REMt1NERATION PREMIUM LOCATION 001 01 FEIN ENTITY CD 001 CAPE COD SALT WATER TAFFY CD INC 984 ROUTE 28 SOUTH YARMQUTH, MA 02664 CONFECTION MFG. 2041 44466 2.33 1036 STORE : RETAII. NOC 8017 36134 1 .09 394 CLERICAL OfFICE EMPLOYEES NOC 8810 44289 .12 53 .950 MERIT RATING MODIFICATIQN (9885) $ 74 TOTAI ESTfMATED AI�IUAL STAI�ARD PREMIUM 1409 EXPENSE CONSTANT(0900) 338 0.0300 TERRORISM (9740) 37 6.30% MA WC SPECIAL FUND AND TRUST FUND 89 TOTAL ESTIMATED PREMIUM 1873 DEPOSIT AMOUNT DUE 1873 DATE OF ISSUE: 02-04-09 WC ST ASSIGN: MA SCHEDULE NO: 1 OF�AST a , . . V DAC , . �� THTS IS A QUOTE , NOT A POLICY 7RAVELERS J WORKERS COMPENSATION � ar�o EMPLOYERS LIABIIITY POLICY QUOTE PROFILE — VERSiON 01 POLICY NUMBER: (7PJU6-0323N1O-4-09) RENEWAL OF (7PJUB-7431A07-4-08) � INSURED'S NAME AND ADDRESS I WORKERS COMPENSATION � CAPE COD SALT WATER TAFFY CO INSURANCE PLAN ING A/R (WCIP) # MA 50 LON6 POND DRIVE I _ -- SDl1TH IEARMOLtTH MA 026€4 i � POLICY PERIOD FROM: 04-01-09 TO 04-01-10 TOTAL ESTIMATED AIWNIAL STANDARD PREMIUM $ 1409 PREMIUM DISCOUNT NONE � 0900-20 EXPENSE CONSTANT 338 � TERRORISM 37 ' TOTAL ESTIMATED PREMIUM 1784 iTAXES At� SURCNARGES 89 i DEPOSI7 AMOUNT DUE 1873 � I � I i Employer's Liability BI Limit: � 100000 Each Accident ' 500000 Policy Limit 10000o Each Empfoyee INSURER: TRAVELERS PROPERTY CASUALTY COMPANY 0� AMERICA Adjustments of Premiums shali be made ANNUALLY **************�r�**************,r Deposit Amount Due: � 1873 *********�******************** POLICY NUMBER: �7PJUB-0323N10-4-09} DATE OF ISSUE:02-04-09 wC ST ASSIGN: MA OFFICE: DIRECT ASSIGNMENT701 PRODUCER: �OHN F MARTIN INS A6CY 28LFB �