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Home My WebLink AboutApplication and WC a TOWN OF YARMOUTH BOARD OF HEALTH APPLICATION FOR LICENSE/PERMIT-2017 , *Please complete form and attach all necessary documents by December 16 2016. ' Failure to do so will result in the return of your applicatton pac e�t�— ' ESTABLISHMENTNAME: N N E Go - �- LOCATION ADDRESS: b SU MM ER ST. , �RMo UT1-� ORj TEL.#: .�D$ 3'7S o 5 9 O ' MAILING ADDRESS: B o� 3�� yR l�c�n o v�TH ('0 2'r O��S E-MAIL ADDRESS: �� o��c �cd-Co cY► OWNERNAME: �1�HA�� -1- 1-1 E :v Cf�Ss�t,..S CORPORATION NAME(IF APPLICABLE): `7}�I� 1 NN AT CF►PE G�o D, LLC MANAGER'SNAM�; qS qlooJ2. TEL#• o►S o�bvv ' MAII,ING ADDRESS: '` �� ' POOL CER'T�ICATIONS: The pooi supervisor must be certiffed as a Pool Operator,as reqaired by Sta w. Please list the designated : Pool Operator(s)and attach a copy of the certification to this form. ^ ' � l. �� Pool operators must list a minimum of two emplo currently certified in standard First Aid and Community Cardiopulmonary Resuscitation(CPR),havin e certified emp loyee on premises at all times. Ple,ase list the employees below and attach copies of the' rtifications to this form.The Health Department will not use past years'records. Yon must provide copies and maintain a file at your place of bnsiness. L 2. , _ _ __ �_� _ . 3. 4. FOOD PROTECT'ION MANAGF.Y25-CERTIFICATIONS: -- � All food service establishments are required to have at least one full-time emplayee who is certified as a Food � n °ti ' Pmtection Manager,as defined in the State Sanitary Code far Food Service Establishments, 105 CMR 590.000. --- P'lease attach copies of certification to this application. The Health Department wiq not nsepast years'recards. �--� —' 6 r You must provide new copies and maintain a file at your establishment. `7 v' 3 t � `� o � ' 1. t'1 E�..E�1 �SSC LS 2, -�� _. . —�+ � �n�.� PERSON IN CHARGE: Each faad establishment must have at least one Person In Charge(PIC)on site during hours of operation. ! i. I-1 E��n� CP►s s E�--s 2. w :�� c :� �� 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(Gx3xa). Please attach x� � copies of certification to this application. The Heaith Department will not use past yeara'records. You must � provide new copies and maintaia a file at your establishment. � �(+� � 1. ��L'�I� �'�-SS�L� 2. �:r�•=� i � HEIMLICH CERTIFICATIONS: (�f� � � , All food service establishments with 25 seats or more must have one em oyee trained in the Heimlich Maneuver on the premises at all times. Please list your e s trained in anti-choking procedures below and attach copies of employee certifications to this fo e ea h De artment will not use past years'records. m You must provide aew copies and maint ' e at your place o bnsiness. 1. 2. 3. 4, RESTAU SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B S53 CABIN S55 MOTEL 5110 ��`wtG,?Z��L LODGE ��' C'+� SSS �SWIMMINGPOOLS110ea. r` — S55 T AILERPARK 5105 _WHIRLPOOL S110ea. F�OOD SERREVQICE: ' �/ 0-�100SEAi'S� 5125 ��S LIC�S��D S35 PERMIT# L[C ONPRO I�'f� S30 PERMIT# �1��'��?�'�Z ''i >l00 SEATS 5200 �COMMON VIC. S60 � _WFiOLESALE s80 RETAIL SERVICE: —RESID.KITCHEN S80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERM[T# <50sq ft. S50 >25,000 R S285 VENDING-FOOD S25 =<25,000 sq.R S I50 =FROZEN�ESSERT S40 �I'OBACCO SI 10 , NAME CHANGE: SIS AMOUNT DUE = S `a�}-O '' 0 O *"«*•pLEASE TURN OVER AND COMPLETE OTHER S[DE OF FORM*•*•* r ' ADMINISTRATION Under Chapter 152,5ection 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 Wot�ker's Corapensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR CERT.OF INSURANCE ATTACHED V OR WORKER'S COMP.AFFIDAVIT SIGNED AND ATTACHED Town of Yaimouth 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 purpases of the limita6ons of Motel or Hotel use,Transient occupancy shati be limited to the temporary and short term occupancy,ordinarity and customarily associated with motel and hatel use. Transient occupants must have and be able to demonstrate that they maintain a principal place of zesidence elsewhere.Transient occupancy shall generally refer to continuous occupancy of not more than thiriy(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,sha11 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 o Contact the Health Department to schedule the inspection three(3) days prior to opening.PLEASE NOTEgPeople 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 ttu�ee(3)days prior tb opening,and quartezly cherea#ter. POOL CLOSING:Every outdoor in ground swimming pool must be drained or cavered within seven(7)d$ys of closing. FOOD SERVICE SEASONAL�OOD SERVICE OPEMNG: All food service establishments must be inspected by the Hcalth Deparhnem pnior to apening. 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 I�eatth Departmerzt by filing the required 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 www.yarmouth.n�a,y�under Health Department, Downloadab(e Forms. — — _ FRQZEN DES��RTS: '' Frozen desserts must be fesfeT6y a S`tate certi ie�ta�6r ' ' _ ___ _ __ ; submitted to the Health Department. Failure to do so w�ll result in the suspension or revocarion of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAF�S: Outside cafes(i.e.,outdoor seating with waiterlwaitress service),must have prior approval from the Board of Health. � OUTDOOR COOKING: Outdoor cooking,preparation,or dispiay of any food product by a retail or food service establishment is prohibited, NOTICE:Pernrits run annually from January 1 to Ilecember 31. IT IS YOUR RESPONSIBILITY TO RETtJRN ' ' THE COMPLETED RENEWAL APFLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 16,2016. � ' ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW � i EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TQ COMMENCEMENT. RENOVATIONS MA.Y REQUIRE A S1TE PLAN. ' DATE: I�' �3 I � b SIGNATURE: � � �—�� ' PRINT NAME&TITLE: H E l.�f�! CFl S S�t-5 Cp —�l.J�)�(t � Rev.10l12/l6 � � WORKERS COMPENSATION AND EMPLOYERS' LIABILTY I INSURANCE PO�ICY----INFORMATION PAGE ' lNSURER: POLICY NO: �Q84924A NORFOLK & DEDHAM MUTUAL FIRE INSUFtANCE COMPANY ' 222 AMES STREET RENEWAL ' DEDHAM, MA 02026 NCCI Company No: 21Q59 ' � Account No: g62009099 ' FEIN: r ITEM 1. NAMED INSURED AND MAILING ADDRESS: AGENT NAME AND ADDRESS: THE INN AT CAPE CC?D, I�LC ROGERS & GRAY INS. Pt� BOX 371 AGENCY, ING SOUTH DENNIS YARMOUTHPORT, MA f?2675 OFFICE 434 ROUTE 134 S�UTH DENNZS, MA 0266U AGENT NO.: 2p5�7 LEGAL ENTITY: y=MITED LIASZLITY. C4A�ANY {LLC) OTHER W��tKPLACES NOT SHOWN ABOV�: (See Workers Compensation�tassification Scfieauie) ITEM 2. POI.ICY PERIOD: From: 12j01j2016 To: �.2/osl2oz� Effective 12:01 A.M. Standard Time at the Insured's mailing address. lTEM 3. COVERAGE: 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 Two of the policy applies to work in each state listed in Item 3.A. The limits of liability under Part Two are: Badily Injury by Accident: $ 5p�}r pQp each accident ; Bodily Injury by Disease: $ �Op, pp0 policy limit , Bodily Injury by Disease: $ �pp r pqp each employee C. Other States Insurance: Part Three of the policy applies ta the states, if any, listed here: ' SEE ENDORSEMENT WC 20 03 06 8 D. This Policy inciudes these Endorsements and Schedules: ; See Schedule of Forms and Endorsements. ' ITEM 4. PREMIUM:The premium for this Policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required on the Workers Compensation Classification Schedule is subject to verification and change by audit. Total Estimated Minimum Premium: $ Z,�� Annual Premium: $ 1 623 , Audit Period: �U�, Additional/Return Premium: Comments : Issued At: i Date: Zp��4 jgpl� Countersigned by � ; WC 00 00 01 A Copyrlght 1987 National Council on Compensation Insurance INSURED COPY i N CJTI CE N QTI CE � TO TO i EM PLDYEES � FJUI PLOYEES The Commonwealth of l�/�assa�husetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston, Massachusetts 02111 617-727-4900 - http://www.mass.govldia As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this will give you notice that I(we)have provided for payment to our injured employees under the above-menrioned chapter by insuring with: N4RFOLK & DEDHAM MUTUAL FIRE INSURANCE COMPANY ' NAME OF INSURANCE COMPANY � 222 AME3 STREET, DEDHAM, MA 02026 , ADDRESS OF INSURANCE COMPANY wEos��z�A �afa�.f�o�� POLICY NUMBER EFFECTIVE DATES ROGERS & GRAF INS. AGENCY, INC 434 ROUTE 134 SOUTH DENNIS OFFTCE SOUTFi DENNIS MA 02660 ' NAME OF INSURANCE AGENT ADDRESS PHONE# 4 StTMMER ST. 508-790-0590 ' ._THE___INN _AT_CAI�E._CCJD�---LLC.,,_......�..._...._.—....._............_YARMOUTHPORT MA 02 675 ' .__..,..,..�..�___._....._...._..............�............_.____.._.._---._......��..� _ ___...._____........,��__ EMPLOYER �ADDRESS �.ol2a12��.� EMPLOYER'S WORKERS'COMPENSATTON OFFICER(IF ANY) DATE M EDlCAL TREATM ENT The above named insurer is required in cases of personal injuries arising out of and in the course of ' employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers' Compensatian Act. A copy of the First Report of Injury must be given to the ; injured employee. The empioyee may select his or her own physician. The reasonable cost of the ser- vices provided by the treating physician will be paid by the insurer,if the treatment is necessary and reasonably connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the � NAME OF HOSPITAL ADDRESS � TO BE POSTED BY EMPLOYER Form WC 88 20 01 C Printed in U.S.A. IfdSi1RED COPY