HomeMy WebLinkAboutApplication and WC I ' TOWN O�'YARMOUTFF BOARD OF HEALTH i
APPLICATION FOR LICENSElPERMIT-2017 I
*Please complete form attd attach all necessary documents by en r 1 2 16. �
Feilure to do so will result in the return of your applicahon pac ei.
ESTA$LISHMENT NAIvI�: ' C S �
LOCATION ADDRESS: TEL.#: ' 6 `
MAILING ADDRESS: `- 4
E-MAIL ADDRESS: <'� '�1C+� a� -' � `
� OWNER NAME: . (
CORPORATION NAME(IF APPLICABL�• �
MANAGER'S NAME: ��c� �� � 'yC.4 TEL.#: �O z �v K� - �
MAILING ADDRESS: �'7�`�_
POOL CERTIFICATIONS:
'I'he pool supervisor mast be cerlified as a Pool Uperator,as required hy State law. Plesse list the designated C
Pool Oper�tor(s)and attach a copy of the certification to this form. �
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Pool operators must list a minimum of two empbyees currcndy certified in standard First Aid and Community
Cardioputmonary Resnscitation(CPR),having one certified employee on premises at all rimes. Please list the
emgloyees below and attach copies of thsir cer*afications to this f�nn.T6e Health Departmeui,wil!not use past '
yeans'rccords. Yoe mnst pr�vfde new c�rpies xnd maiabin i fltc'�t yanr pl�e of bueineeis. E
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FOOD PROTECTTON MANACERS-CERTIFICATIONS: S 'p � ,
All foad service establistiments ane c�uired to have at least ane full-time employee who is certifed as a Food � n �
Prot�tion Manager,as defined in the State Sanitary Code for Food Serviee Establishmen#s, 105 CMR 59Q.00(?. r ('�
Please attach copies of certification to this application. T6e HeAlth Departmegt will not use past years'records. � � ;�
You muat provide aew copies and maintain x�le�t your establishmen� p � �
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PERSUN IN CHARGE: ��
Each food estabiishment must have at least one Person In Charge(PTC)on site during hours af operation.
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ALLERGEN CERTIFICATIONS:
All food service establishmeuts are required to have at least one futl-time employee who has Allergen certification, `'
as defined in the StaGe Sanitary Code far Food Service Establishments,105 CMR 590.0(}9(Gx3xs). Please attach �;
copies of certification to this applicatioa. The Health Department will not use past y�rs'records. You mast
provide new copies aad maintaiu a fite at yaar establishment. ,
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HEIMLICH CERTTFICATIONS: ����
Ali food service establishments with 25 sests ar more rnvsr,have at least one emgloyee trained ia*he Heimlich
Maneuver an the precnises�f ail timcs. Pi�list y�remp loye��es treincd in anti-chokiag gtvaccdures below and
attach copies of employee certificaticros ta this form. Tha Health Deg�rtment will uot use past pears'recorda.
You must provide ntw oopies and maintain a file at your place of business.
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RESTATJRANT SBATING: TO.TAL#,,.,_�_
O�FICE USE ONLY �
LDDGIIVG:
� LICENSE REQU[RED FEE PSRMIT�l LICENSE REQUIRED FEE PERMIT 11 LICENSE REQtJIRED FEE FE1tMIT�l
B&B S55 CABIN S55 MOT"EL St10
—1]+!N S55 GAMP SSS SWIMMtNG POOL S116ca.
! =T,ODG6 SSS =TRAILERPARK SI03 _WHIR1aPO4L $IIOea.�
FOOD SERVTCE• '
LICENSE REQUII2ED FEE RMIT LICENSE REQUIRED FEE PERMIT i� LICENSE RE UIREU FF� PERMIT k
�Q-100SEA�'S 5125 ��J # _C4NTiNEIVTAL S3S NON-PRQ�iT S30
>t00 SEATS ST00 COMMQDt V]C. 56U �WHOLESAL& SBi1
— — .�RE3ID.KtTCHEN S80
RETAYY,SERVICE:
LICEiJSE TtEQUIRED FSE PERMIT# LICENSE REQUIRED FEE PBitlt'IIT# LICENSE REQt7IRED fF.� PERMi?"#
� <SOsq R� S50 >25.0� ft. S2$S YFIVUING-FOOD S25
_<25,OOOsq.R $156 =�ROZEN�ESSERT S40 �I'UBACGf.� SI1Q
NAME CHAIVGE: S15 AMUUI�TT DUE = ,-� ��.�,
� "•'**PLEASE TURN OVER A1VD CQMPLETE OTHER S[DE OF FQRM****�" �jQ��`y.►I�SI^O`Z-'
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AI3lVfIP+TI$TRA`TIUN
Under Chapter I S2,Section 25C,Subsection 6,the Town of Yarmouth is now required to hold issuance ar renewat
of any license or permit to nperate a business if a person or company cloes n�t have a Certificate of Worker's
Campensation insurance. THE AT�"ACHED 5TATE W4ItKEB'S CUMP�YSATIUN INSURAAICE ;
; AFFIPAVIT MUST BE COMPLETED AND SIGNED,�R
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CERT.4F INSIJRANCE ATTA�HEI�
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WQRKER'S CC3AqP.AFF'IDAVTT SI'Gl*IED AND ATTACHED
' Town of Yarmouth ta�ces and liens must 1�paid prior ta renewat or issuanca ofyovr pernlits. PLEASE CHECK
j APPR�PRtATE�.Y EF PAID:
YES NO
MQTELS AND OTHER LODGING ESTABLISHMENTS
T1tANSiENT OCC[7l'ANCY: Par purposes of the lunitatioas ofMotel or Hatel u�,Traasiern occup�ncy shaU be
limited to the temporazy and shart term occupancy,oxdinarily and custamariiy ass�iated with mate!and hc�tel use,
Transient oceupants mast have and be able to demonstrate thai they maint�in a princigal place of resi.der�ce
efscwhere.Tr�sient occu�ncy shali B�tl�'refer ka continntotxs oc.etiipencycsf�mors�ti��rtY{3�j days,aad
an aggnegate of not more thsu�ztinety{90}da.ys wi;hin any six{6�mouth pesiod. Use of a guest unit as areside�e or
dwelling unit shall not be eonsidered ttansient. Qccugancy that is subj�t to the colleetion af R,oam Occupancy
Excise,as defined in M.G.L.a.64�G or 83fl CMR 6�G,as amended,shafl genexa.11y be cansider�i Transien#.
POOLS
PUUL OPENING:Ail swimrning,wading end whicl Is whic�have been closed fortbe seasan must be inspeete<i
n
� by the Health Departmeat ior to o ening. Contact e Health De ent ta seheduk the ins au thr�{3)
� days prior to ape�ing.P�,,����,.I�QT�:Peop[e are N4T atlow�t in the pool area,until�pooi has been
inspected�nd opened. ,
� Pf34L W ATER T�STING: �The water must be test«i for pseudomanas,tota!coiifomi and standard glate count
by a StaYe certified l�b,and submitted to We Health Department three(3}days prior to opening,and quarterly
i ther�atter. • ` ,
PUOL CLOSINGs Every outdoor in�round swimming p�t must he drained or covered within seven(?)days af
� �losing. � � �
FOi3D SERVIGE
SEAS�UNAL FQ4D SERYICE OPE2ITIP+TG:
All food service establishments must be in,spected by t4e Health Department prtor to opening. Please oo�t the
Health Deparbnent to sch�ul+e th�ins�on fhree(3)days pr%or ta opening.
CATERIl#iG FOLICY:
Anyone wha caters within the Town of�aanouth must norify th�Yarmouth Health Department by�iling ihe
r�uired Tempc� Food Scrvice Apptication form 72 hnurs priar to tlre cxitecsed evc�nt. These fom�s can be
obtained at the He�fih I�partment,or from the Town's website at us underHeatthDepartment,
I)owrilvadable Fozxns,
'�II I�RUZEN D�ESSERT3;
Frozen desserts must be te,ct�by�State certified 1ab prior ta o �nnd mcmtfily the�+rafter,vv�th sarnpie nesults
submitted to the Health Dep�rkment. Failure to do so.will result in e suspensic�n or revocation of your Fmzea
Dessert Permit until the abave terms have been mei.
OUTSIDE CAF�S:
Quxside cafes(i.e.,c�ntdoor seatiag witta w�iter/waitr�:s s�rvice),must have prior spprovat firom the Ba�erd of Heatth.
QUTDUUR COOKING:
Outdoor cooking,Irreparation,or display of any fa�d product by a retai!oc food�rvicc establishment is proLibited, ;
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NUTICE:Pernuts nm annually from January 1 ta L�e+eember 31.1T IS YUUR RESPOI�TSIBII.ITY TO RETURN
THE COMPLETEll REN]'�WAL APPLICATION{S}AI�TD REQUIRED FEE(S)BY DECEMBER i6,�416.
ALL RENQVATIONS TO ANY �OOD ESTABLISHMEN`F, M �?R FOU (i, FAl2�1Tt?�iG, NEW
�QUIPMENT,ETC.),MUST BE REP4RTED T �'PRO D BY THE B F HEALTH PRIOR
T'O COMIVIENCEMENT. RENOVATI�}AIS MAY IRE STTE PLAN.
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Rav�tMl2tib � � �
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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
INFORMATION PAGE
AGENT NO 3020 OFFICE NO 3020 ;
MARK SYLVIA INSURANCE AGENCY LLC '
404 MAIN ST
CENTERVILLE MA 02632-2976
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FARM FAMILY CASUALTY INSURANCE COMPANY 508-428-04�t0
NCCI COMPANY NO. 16721
POLICY NO 2007 W6070
,.:::...............::_:..:...... ._........ -
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I��;:;;:1w;:;;Il��U��; INSURED AND MAILING ADDRESS: ` a��usT ReN�nra� '
:::::::::......:::::::::::.::....:::...:...
EFFECTIVE ���4/76
TRS ENTERPRISES INC
DBA TIMMY'S ROAST BEEF I
198 ROUTE 28 �
W YARMOUTH, MA 02673-4660
i
TI� INSURED IS CORPORATION
Workplaces covered by this policy: k
ST WP N0. ADDRESS OF WORKPLACE RTG.BUR NO. INTRASTATE NO.
MA 01 798 MAIN ST 345867
WEST YARMOUTH MA
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The policy period is from �/2a/�s to �/2a/�� 12:01 A.M. Standard Time at the insured's mailing address.
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.:::::::::.::::::::::::::::::::::::::::::::::::::::::::::.::::::.;::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::..................................._............................:...............:......................................___.......
A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of
the state listed her� MA
B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A. C
ur liabilit under Part Two are:
The hm�ts of o y
Bodily Injury By Accident Bodily Injury By Disease Bodily Injury By Disease ;
$ 100,000 each accident S 500,000 policy limit $ 100,000 each employee �
C. Other States Insurance: Part Three of the policy applies to the states, if any, listed her� All states
except the states designated in item 3.A. of the information page and ND, OH, WA, and WY
D. This policy includes these endorsements and schedules: '
WC 00 00 OOC WC 00 00 01B WC 00 03 15 WC 00 04 74 WC 00 04 22B WC 20 03 01 ',
WC 20 03 02A WC 20 93 03D WC 20 04 05 WC 20 06 01A '
� Copyright 1987 National Council INSURED COPY PROCESSED 09/28/16
� c�►��t�on r�,�ce
wc o0 00 oi s Issuing Office - PO Box 656 • ALBANY, NEW YORK 12201-0656