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Home My WebLink AboutApplication and WCr `� r . � � TOWN OF YARMOUTH BO O�E T� � � APPLICATION FOR LICEN��' T� 17 � � , �C� •.�i I �f'1� ``°` * Please com lete form and attach all nec�sa t� ` '� e��1�ce be � �� Fail e to do so will result in the return of your application p �P� ESTABLISHMENT NAME: �' � �0 4 D S A M 'S TAX ID•04;�j�'l.� 3 Z� '' ' LOCATION ADDRESS: � Q Q lP�` ?,�j TEL.#: �"'d 6-� 9�f -�3tj"Q„�' � ; MAILING ADDRESS: � d U G T" 2�� ,�". �Iq l2 � /�'3A p �6 G� �U - , i ' E-MAIL ADDRESS: OWNER NAME: ��L �a�o N�""Ro CORPORATION NAME (IF APPLICABLE): ! MANAGER'S NAME: 1�141'��L x � r/1�S`p dtij TEL.#: �Q$_ ��_��,�,�, ,. MAILING ADDRESS: ; � ' POOL CERTIFICATIONS: The pool supervisor must be 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. I - - -_--�"��-� -- -- � . _ �--- _ �. - - _ _ _ 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 employees below and attach copies of their 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. C � ;� r�Ason 2. N a��a �� r- MAs6� 3. 4. 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 far 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 file at your establishment. � 1. �-�Nat� �N C uRR y 2. 'tRA�'y V�voAMD �� . PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. i I 1• � � ' � 1`'��S� e� N _ 2. ALLERGEN CERTIFICATIONS: 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 Establishments, 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 maintain a file at your establishment. �._ N�T�� ►�. M r�� r� 2. UrA � R� ��%�� I� A S a �v 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 iattach 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. C l�l�1' M qSG N 2. 1VA-t,q L i ��' ,r"'� A�'�1V 3. 4.�'-r RESTAURANT SEATING: TOTAL# _ _ �.s��s: - -- OFFICE USE ONLY - -- - - - LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $110 INN $55 CAMP $55 SWIMMING POOL$I l0ea. _LODGE $55 _TRAILER PARK $105 WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �0-100 SEATS $125 �.1�^b�� CONTINENTAL $35 NON-PROFIT $30 >100 SEATS $200 �COMMON VIC. $60 � =WHOLESALE $80 ' —RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 <25,000 sq.ft. $150 _FROZEN DESSERT $40 _TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE _ $_�Q�'j�QQ *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** ��5-l007-02 � � � 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 OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid priar 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 limitations of Motel or Hotel use,Transient occupancy sha11 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 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 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 Temporary Food Service Application form 72 hours prior to the catered event. These fortns 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),must have prior approval from the Board of Health. 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 RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 16, 2016. 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 COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: SIGNATURE: PR1NT NAME & TITLE: ' Rev. 10/12/16 , INFORMATION PAGE RENEWAL AGREEMENT Insurer• PRODUCER: Agent�� 542 MA Retail Merchants WC Group Inc. Rogers & Gray Insurance Agency, In PO Box 859222-9222 434 Route 134 Braintree, MA 02185 South Dennis, MA 026bQ (Carrier Code: 34355) Carrier Policy ��: 014005032775116 Carrier Prior Policy �k: 014005032775115 l. The Insured: Seafood Sams South Yarmouth, Inc. Seafood Sam's Mailing Address: 1006 Rte 28 South Yarmouth, MA 02664 Fein: 043181324 Other workplaces not shown above: 'I�pe of Business: Corporation NO 0'1�-iER WORKPLACES FOR THIS POLICY Risk ID: Z. The policy period is from 12:01 a.m. on 1_/O1[2016 _ to 12:01 a.m. on _ 1j0_1J2017 at the insured's mailing address. 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers Liability Insurance: Part 'I�ao of the policy applies to work in each state listed in Item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident $__ ____500,_000 _ each accident Bodily Injury by Disease $_ . 500�_000 •__ policy limit Bodily Injury by Disease $_ __ 500�0 each employee C. Other States Insurance: D. This policy includes these endorsements and schedules: WC000422B Ol 15 WC200301 04184 WC000310 04 84 WC000414 07J90) ( 1 ) t ) 000c oi l� 1 ) ( wc000 ( / ) t WC200302(OS/86) WC200303B(07/99) WC20030bB(06/13) WC200405(06/O1) WC200601A(07/08) 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Classifications Code Premium Basis Rate Per Estimated No. Total Estimated $100 of Annual Annual Remuneration Remuneration Premium SEE SCHEDULE OF OPERATI�NS Total Estimated Annual Premium $ 4,189.00 Minimum Premium $ 269.00 Expense Constant .00 Deposit Premium .