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Home My WebLink AboutApplication and WCi MAILING ADDRESS: 31 l 04ou��. .�Z� /1/�.a•�:� S� a�rr�.��-EL. 0�6 7� E-MAIL ADDRESS: r . ,� - 6 ►.,.. � OWNER NAME: -' I�� A.� CORPORATION NAME(IF APPLICABLE): (jo•c�Is u,,. jg�.T o,,.ol, 1.�. � MANAGER'S NAME: Sv1,'c, �/tc,�a�.n . �t�,;,. 1�loP� � TEL.#: SUk- ?9'v�gsov ',, � MAILING ADDRESS:_ _ s^I I 1��-� 2Q !�• ��rwn s�-1'�- �O 2-6�� ' Q POOL CERTIFICATIONS: �-�_�- �"`" A��---� , � h'a&,,��.�. The pool supervisor must be certified as a Pool Operator,as required by State law. Pl list the designa " j � Pool Operator(s)and attach a eopy of the certification to this form. D�C 1 3 z016 � � l. 2. � �e�- r��T. � Pool operators must iist a minimum of two employees currently certified in standard First Aid and Commumty Cardiopulmonary Resuscitation (CPR), having one certified employee on premises at all times. Please list the employees below and attach copies of their certifir.ations to this form.The Health Departm��ll�aet ase past years' records. You must provide new copies and maintain a file at your place of 6us��. ` � �� 1. : Z, .. �_„ : � 3. 4. i FOOD PROTECTION MANAGERS-CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Pmtection 11�tanager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. PIease attach copies of certification to this application. The Health Department will not nse past ye.ars'records. You must provide new copies and maintain a file at your establishment. 1. � �J l�'� �d r d�,,� �qs 7 �� s_� 2. � PERSONIN CHARGE: Each food establishment must have at least one Person Tn Charge(PIC)on site during hours of operation. l. �Jjr��c.. �0��,•� 2. �icv�'h l''�,or�a�L� ALLERGEN CER'TIFICATIONS: All food service establishments are required to have at least one full-time employee who has A1lergen 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 ye�rs' records. You must provide new copies and maintain a file at your establishment. l. �vl��. Ililnra... / /Z.6� 3�f / 2. HEIlVII,ICH 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-chokuig procedures below and attach copies of employee csrtifications to this form. The Health Department will not use past years'records. You mast provide new copies and m�intain a file at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# f � ,�F- �5-�3C33-02. OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PBRMIT# LICENSE REQUIRED FEE PERA+[IT# B&B a55 CABIN S55 MOTEL 5110 IIdN SSS CAMP S55 _SWIIuIIVtING POOL SI IOea. � �,ODGE $SS �TRAILER PARK �105 _WHIRLPOOL S110ea. FOOD SERVICE• LICENSE REQUIRED FEE # LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �0-100 SEA'1'S 5125 I�l CONTINEIVTAL S35 NON-PRO�Tf S30 >100 SEATS a200 �COMMON VIC. S60 1'l��j — HOLESALE �80 —RESID.KITCHETI S80 � .� � _-_---_-- -- ------ -- ---�-------- ------ ------- --� ---- CERT. OF INSURANCE ATTACHED OR WORKER'S COMP.AFFIDAVIT SIGNED AND ATTAC�iED� Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPRCSPRIATELY IF PAID: YES� NO MOTELS AND OTHER LODGING ESTABLISHMENTS 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 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 t}ie collection of Room Occupancy Excise,as defined in M.G.L. c. 64G or 83Q CMR 64G,as amended,shall generally be considered Transient. POOLS POOL OPEIVING: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 Departxnent to schedule the inspection three(3) days prior to opening. PLEASE NOTE: People are NOT allowed to srt in the�ol 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 qvarterly thereafter. ' POOL CLOSING:Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE SEASONAL F4QD SERVICE OPENING: All food service establishments must be inspected by the Health Department prior to opening. Please contact the Hea1th 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 requu�ed Temporary Food Service Application form 72 hours prior to the ca#ered event. These forms can be obtamed at the Health Department,or from the Town's wehsite at www.yazmouth.ma.us under Health Department, Downloadable Forms. FROZEN DESSERTS: Frozen desserts must be tested by a State certified lab prior to opening and montlily thereafter,with sample results submitted to the Health Depaztment. 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 Hea1th. OUTDOOR COOKING: Dutdoor cooking,preparation,or display of any food product by a retail or food service estabiishment is prohihited. NOTICE:Permits nm annually from January 1 to Deceml�r 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 � Tlre Co�enro�wealtlt ofMassachrtsetts Deportnient of Indr�strial Accidents O,�ce of Irrvcstigations 1 Congress Stree�SWite l00 Boston,MA 0211�2017. www mas�gov/dia Workers' Compensation Insnrance Affidavit: General Bnsinesses Analicant Information Please Print Le�iblv Business/Organizatian Name: I��.a�,l� a,�...�, t3 c.��Y•.�-- �..�-G �— aaaress: 3 ► � �'+.a..�-�, s�. LcJ. y�w,.a��.. City/State/Zip: p Z�, 7 � Phone#: SU� - ��'(D � £�So 0 Are yon an employer?Check the appropriste boa: Busin�s Type(reqairedj: 1.,� I am a employer with�_employees(full and/ 5. ❑Retail or part-time).* 6. �RestaurantrBar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no �, � p��a/or Sales(incl.real estate,airto,etc.) employces working for me in any capacity. [No workers' comp.insurance required] 8. ❑Non-profit 3.❑ We are a co ration and its officers have exenccised 9. ❑Entertainmeut � their right of exemption per a 152,§1(4),and we have 10.0 Manufacturing no employees.[No workers'comp.insurance requireciJ* 1 l.�Health Care 4.❑ We are a non-profit organization,staffed by volunteers, with no employees. jNo workers'comp.insurance req.] 12.�Other 'AnY ap�plic�t thst d�Cs box#I must also fill out the s�bdow showing tbea w�laers'o�Policy informa�ion. "`If the oorporate officezs have exemptcd themgelves,but the co�poration has othc employees,a wo�s'oompensa6on policy is�equiied and such an organizatia�should check box#1. I am an employer that�s prov�ig workers'corxpu�sation insurance for my employeeS Bclow is the pr�lfcy i�ejornnat�on. ^ Insurance Company Name: f�•�• �• /'�u-�ua.l �;..s u ro.n.��. C .M.�e....� Insurer's Adaress: /?C�_ /.�o� �O�� _ c�ri�sr�ziP: ��►� �d� r�.� 6 ��SO3 -o Q 7 0 Policy#or Self-ins.Lic.# i/(.tIG -/oo �-�olSa3S-,201 LA Expiration Date: O 7�30 / 7.�/� Attach a copy of the workers'compensation policy decls�ration page(showing the policy nnmber and ezpiration dste). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,SOO.OQ and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER aud a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do kereby certify,under the pa�its arcd penallies of perjury rhat the inforniation provided above�s true and correc� ��nature --�-`�" �� Date / ��_�,l� Pnone#: So�- ?9v - �5 o a O,f�clal use only. Do not write in this Qrea,to be co�npleted by c�ty or town oJ,�'rciaL City or Town: PermitlLicense# Issaing Aathority(circle one): 1.Board of Heaith 2.Baildiag 13epartmeat 3.City/Town Clerk 4.Licensing Board 5.Seiectmen's Office 6.Other Contact Person• Phone#: www.mass.gov/dia C��-\ NOTICE -� � NOTICE X To � To A EMPLOYEES EMPLOYEES � �� The Commonwealth of Massachusetts DEPARTI�'IENT 4F INDUSTRIAL ACCIDENTS 1 Congress Street, Suite 100, Boston, Massachu.setts 02114-2017 617-727-4900 As required by Massachusetts General Law,Chapter 152, Sections 21, 22, &30,this will give you notice that I(we)have provided payment to our mjured employees under the above mentioned chapter by insuring with: A.I.M. Mutual Insurance Company NAME OF INSURANCE COMPANY P.O. Box 4070 Buriington,MA 01803-0970 ADDRESS OF INSURANCE COMPANY VWC-10t}-6015935-2016A 07/30/2016-07/30/2017 POLICY NUMBER EFFECTIVE DATES 396 Main Street Marshafi K Lovetette Ins Agcy West Yarmouth, MA 02673 (50$)775-4559 NAME OF INSURANCE AGENT ADDRESS PHONE Bagels 8�Beyond LLC 311 Main St West Yarmouth, MA 02673 EMPLOYER ADDRESS 07/22/2016 DATE MEDICAL TREATl��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 Compensation Ac�t. A copy of the First Report of IuLjury must be given to the injured empioyee. The employee may select his or her own physician. The reasonable cost of the services provided by the treating physician will be paid by the insurer, if the treabment is necessary and reasonably connected to the work related injury. In cases requiring hospital attention, employee�s are hereby noti�ed that the insurer has arranged for such attention at the NEAREST AND BEST MEDICAL FACILITY HOSPITAL ADDRESS TO BE POSTED B� EMPLOYER