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Home My WebLink AboutApplication and WCi � , � �^' TOWN OF YARMOUTH BOARD OF HEALTH �� APPLICATION FOR LICENSE/PERMIT-2017 *Please complete form and attach all necessary documents by December I6 2016. Failure to do so will result in the return of your application pac cet. ' , ESTABLISHMENT NAME: G LOCATION ADDRESS: 2$ TEL.#: D$ 7? S(pCo� MAILING ADDRESS: '7 E-MAIL ADDRESS: — . C �G( OWNER NAME: CORPORATION NAME(IF APPLICABLE): "� f.� fi r/V L MANAGER'SNAME: �Ut� C'/�C',(7�i�US�J TEL#• =J`7.J��(oCtnj MAILING ADDRESS: S�Wi� POOL CERTIFICATIONS: The pool supervisor must 6e certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s)and attach a copy of the certification to this form. 1.__�l /�2l tJ��Z i'�q-C�'K- 2. Pool operators must list a minimum of two employees currently certified in standard First Aid and Community = � � Cardiopulmonary Resuscitation(CPR),having one certified employee on premises at all times. Please list the � _.�_a � employees below and attach copies of their certifications to this form.TLe Healt6 Department will not use past r' (7 years'records. You must provide new copies and maintain a file at your place of business. _ � � 1._ (A�.S I� (��E�k,�vj l.s�-) 2. Cd 2.f�;� 1 G1�Ft LC a�9 S � � � 3. 4. � -t'_5� S"� FOOD PROTECTION MANAGERS-CERTIFICATIONS: All food service establishments are required to have at least one fWl-time employee who is certified as a Food •- - � Protection Manager,as defined in the State Sanitary Code for Food Service Establishments, ]OS CMR 590.000. Please attach copies of certification to this applicarion. The Healt6 Department will not ase past years'records. ` � You must provide new copies and maintain a file at your establishment. �-,., "' �� _� � . 1. J�rQ ,�i��l 0✓1 e�� 1 � 2. � PERSON IN CHARGE: -•� Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. � � =�3 1. �I"�l4 �''� !�L � C� 2. ( f.i!7�' �t C Ll c]�Sc��., `v � ALLERGEN CERTIFICATIONS: = I�¢' All food service establishments are required to have at least one full-time employee who has Allergen certification, as defined in the State Sanitary Code for Food Service Fstablishments,105 CMR 590.009(G)(3)(a). Please attach copies of certification to this application. The Health Department will not use past years'records. You must provide new copies and maintaia a file at your establishment. . i.�.�-a S�� a�.e�I� z. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trtined 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 copiea and maintain a file at your place of business. t. M A2�J�Z I�R-c��c 2. 3. 4 ad�d �1.� RESTAURANT SEATING: TOTAL# ' i,oucnvc: OFFICE USE ONLY LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# ' �B S55 CABIN S55 MOTEL 5110 17-06( �SWIMMING POOL Si l0ea 1�–mJ��'Z�OQZ. O�E S35 _TRAILERPARK Ss05 ,LWHIRLPOOL $110ea.�� FOOD SERVICE: LICENSE RE�UIRED FEE PE T LICENSE REQUIRED FEE PERMIT# LICENSE REQUiRED FEE PERMIT# � 0-100 SEA S 5125 �� 1CONTINENTAL S35 00 NON-PROFIT S30 >!00 SEATS $200 1,COMMON VIC. $60 .�pZ —WHOLESALE S80 RETAIL SERVICE: —RESID.KITCHEN S80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQLJiRED FEE PERMIT li _<50sq ft. S50 >25,000 sG.R. 5285 VENDING-FOOD $25 _<25,000 sq.ft. 5150 =FROZEN DESSERT S40 ='TOBACCO S I 10 NAME CHANGE: S15 AMOUNT DUE _ $ �o�o . "'*•'PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM**+"" 1 � ADMINISTRATION iUnder Chapter 152,Section 2SC,Subsection 6,the Town of Yazmouth 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 � 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 MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitarions 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 by the Health Department prior to opening. Contact the Health Department to sc6edule the ipspection three(3) days prior to opening.PLEASE NOT'E:People are NOT allowed to sit in the poot 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 cerrified 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 Yartnouth must notify the Yazmouth Health Department by filing the requtred 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 wwv✓.yarmouth.ma.us under Health Department, Downloadabte Forms. FROZEN DESSERTS: Frozen desserts must be tested by a Stata certified lab prior to opening and monthly thereafter,with sample results submitted to the Health Department. Failure to do so will result m the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAF�S: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. i OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. i � NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILiTY TO RETURN ; THE COMPLETED RENEWAL APPLICATTON(S)AND REQUIRED FEE(S)BY DECEMBER 16,2016. � , ' ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAIN'TING, NEW I i EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR I TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ' DATE: ld. �S• �(p SIGNATURE: PRINT NAME&TITLE: '�"�`b C�Z_�?�UV�L�j Rev.t0/12/16 � WORKERS COMPENSATION AND EMPLOYERS LIABIL.ITY INSURANCE POLICY INFORMATION PAGE A.I.M. Mutual Insurance Company 54 Third Avenue, Burlington, Massachusetts 01803-0970 (800)876-2765 NCCI NO 26158 POLICY NO. WMZ-800-8003721-2016A PRIOR NO. WMZ-800-8003721-2015A � ITEM � 1. The Insured: Travis Hospitality Inc DBA: Bayside Resort Hotal � � Mailing address: Rt 28 FEIN:""-"** 225 Main Street West Yarmouth,MA 02673 Legal Entity Type: Corporation Other workplaces not shown above: See Location 2. The olic eriod is from 04/01/2016 to 04/01/2017 12:01 a.m s ' P Y P . tandard time at the insured s mailin address. 9 3, A. Workers Compensatfon Insurance: Part One of the policy applfes to the Workers Compensation Law of the states listed here: MA 5. �mployers'Liability Insurance: Part Two of�tFie'policy applles to work in each state fis#ed in item 3,A. The Iimits of liability under Part Two are: Bod(ly Injury by Accident $ 500,000 each sccident Bod(ly Injury by Disease $ 500,000 policy limit Bodily Injury by Disease $ 500,000 each empfoyee . C. Other States Insurance: Coverage Repfaced by Endorsement WC 20 03 08 B D. This Policy inciudes these Endorsements and Schedules: SEE SCHEDULE 4. The premlum for this policy will be determined by our Manuals ot Rules, Classifications,Rates and Rating Plans. All information required below is subject to verification and change by audit. Classifications Premium Basis Rates Code Estimated Per$100 Estimated No. Total Annual Of Annual Remuneration Remuneration Premium INTRA 362922 INTER SE CLASS CODE SCHEDU E Minimum Premium $284 Total Estimated Annual Premfum $13,517 GOV GOV Deposit Premium $3,587 STATE CLASS . MA 9052 State Assessments/Surcharges $14,465.00 x 5.7500% $$32 • This policy, including all endorsements, is hereby countersigned by `^^�""�� 03/01/2016 Authorized Signature Dete Service Office: � Rogers&Gray Insurance Agency One Lakeshore Center 434 Route 134 Bridgewater MA 02324 South Dennis, MA 02660 WC 00 00 01 A(7-11) Includea copyrighted material oi the National Councii on Compensatfo�Insurance, used with its permission.