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Home My WebLink AboutApplication and WC I . "� � �`� � � TOWN OF YARMUUTH BOARD OF HEALTH = ' � �C`U i APPLICATION FOR LICENSE/PERMIT -2013 . `� I � � _ . .; ,, � D�C 17 2Q1Z ;' i � �� * Please complete form and attach all necessa�'':i�c � ��ts��1�ec�� be _PT I Failure to do so will result in the returi��f yo��plicahon p j � ESTABLISHMENT NAME: Csa,p� l�'d I n)f TAX ID: �� LOCATION ADDRESS: y 7�' M�, ,� Srn�.� TEL.#: SQ8- 7�c�'^fS�� MAILING ADDRESS: OWNER NAME: �oC k:Sr d� V ort�� ed c>� CORPORATION NAME (IF APPLICABLE): �a N � MANAGER'S NAME: i�n�� Sc,c)�R�`Z TEL.#: ff� 6� � MAILING ADDRESS: 10� /�/,,ecx_��,•�� (�r�eS AvC ��NZs2�.ut.�( �° �"t,�... �� rZ POOL CERTIFICATIONS: cj , The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated � I Pool Operatar(s)and attach a cony of the certification xo khis form. _ - _ - - � 1. .��"��r��',�� 2. p� 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 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. �ry � � � �� 1. :.;�'J '/�� ,�1�� e 2.,�Loti�,��,��.o Z G' 3. �i ti sT fl�O 5c-Gr�ou��r� s,� 4. o� � � 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. You must provide new copies and maintain a �le at your establishment. �� _--- ,�, / ` � 1. J�� l5�ss,�/ 2. � -----�v�ii'�-L�i� v . — -- - - ----- -- -�-� Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. ��5�� sC��s�� 2. HEIMLICH CERTIFICATIONS: � All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich 2 Maneuver on the premises at a11 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. �ti�J JCISSd`/ J��4c��K '' � )��✓ 2.�a��/1� �lti�� h�✓�'��I 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 L MOTEL $55 �I 3—d25 _ _ ��13�5 _INN $55 _CAMP $55 3 SWIMMING POOL $80ea. I — 5 LODGE $55 TRAILER PARK $105 I WHIRLPOOL $80ea. ��OZl FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# I 0-100 SEATS $85 �l3-�{I� _CONTINENTAL $35 NON-PROFIT $30 >100 SEATS $160 �COMMON VIC. $60 I�S^07�'I _WHOLESALE $80 RETAIL SERVICE: —RESID.KITCNEN $80 LICENSE REQUIRED FEE PERMIT# 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 DUE _ $ 520 �OO *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** i i l :; _ � y '; � 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 STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED 1/ i OR ; WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED I � Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: / YES �/ NO I MOTELS AND OTHElt LODGING ESTABLISI�M�AT��. - - -�=--=-�-'�---° •-=- 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 thirly(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 Departmerit prior to opening. Contact the Health De�artment to schedule the inspection three(3)days ; prior to opening.PLE�SE NOTE:People are NOT allowed to srt m the pool area until the pool has been inspected � and.opened: � � � � j POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count �by apStat$ eerki�'ied lab, and submitted to the Health Department three (3) days prior to opening, and quarterly - -_ thereafter. � . .�_.,_ , _ ----__ _ , . ____ _ _ �,_ b_ _ _ ' 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 Tempora`r'y. Food Service Application form 72 hours prior to the catered event. These forms can be 'j obtamed at the Health Department,or from the Town's website at www.varmouth.ma.us under Health Department, I Downloadable Eorins. i 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: � �l�lE��pe�.S . �__ � 1.�?1tTPc�YcP��r}��.1Y1USt�v�-��'�A��X$Vc1� nmtl�PRnarrinf�Te�J�y� OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. j 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.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR i TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ! DATE: SIGNATURE: , ��x7�� PRINT NAME & TITLE:�,��a��- Rev.10/09/12 I � . (Ed. 7-1-87) � � Atlantic Charter Insurance Company VDAC � � POLICY INFORMATION PAGE ENDORSEMENT Endorsement No. 1 NCCI Co. No 29211 Endorsement Effective 04/01/2012 Atlantic Charter Insurance Company VDA� Policy Number WCV01006600 Location Number 1 insured Dockside Hotel Group, Inc. Policy Period 4/1/2012 To 4/1/2013 Policy Rating Period 4/1/2012 To 4/1/2013 item 4. •Class, Rate, Other is changed to read: Classifications Code Premium Basis Total Rate Per$100 of Estimated Annual No. Estimated Annual Remuneration Premium Remuneration . " Clerical Office Employees Noc 8810 810,284 0.09 729 Hote1-A/O 9052 700,112 1.49 10,432 Hotel-restaurant Employees 9058 151,184 1.49 2,253 , � All other terms and conditions of' Issue Date 05/21/2012 Page 1 of Last (c)1987 Nadonal Council on Compensation Insurance. ��:�09�