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Home My WebLink AboutApplication and WC � TOWN OF YARMOUTH BOARD OF HEALTH APPLI�ATION FOR LICENSE/PERMIT-2018 ~ *Please complete form and attach a11 necessary documents by December i5 2017. Failure to do so will result in the return of your appiicahon pac cet. ESTABLISHMENT NAME: �C� � � - '1 S-(0�13'� LOCATION ADDRESS: I' �n v�� TEL.#: 0 � MAILING ADDRESS: fJ�S E-Mt1II.ADDRESS: �' �1_ t.,�o w� 5 W''�t. �1 a ne c:G.�r� c� - OWNER NAME:�1J�\�G�m `��t v�r� m __ CORPORATION NAME(IF APPLICi'�BLE):�5� C,(�(D -� MANAGER'SNAME: W. ��c.r Z�,,.��,,,�.r TEL.#: 33y� ��.;- S�y� MAILINGADDRESS: a.t ��l�,i�c;�-.,.� S �. `�uc�nc.,��. +�(]. oi,C.7� POOL CERTIFICATIONS: The pool supervisor must be certified as a Poot Operator,as required by State law. Please list the designated�"--�-------� Pool Operator(s)and attach a copy of the certification to this form. 1. 2. .,� � C 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. i � � ` -. ;,-i 1. 2. , 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�tate Sanitary Code for 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. �.. _i��c•C �--o��+�n� 2. �'` PERSON IN CHARGE: �' ,y�'� Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. � �� :,,, 1. \� . �e�t �.vti+�.T 2. ��.�<;.� ALLERGEN CERTIFICATIONS: ' Ali food service establislunents aze required to have at least one full-time employee who has Allergen certification, as defined in the State Sanitary Code fdr Food Service Establishments,105 CMR 590.009(G)(3}(a). Please attach copies of certification to this applicatiop. The Health Degartment witl not use past years'records. You must provide new copies and maintain a file at your establishment. 1, � , �� ++�e„� 2. HEIMLICH CERTIFICATIONS: All food service establishments with�S seats or more miust have at least one employee trained in the Heimlich Maneuver on the prernises at all times.; Please list your employees trained in anti-chokuig procedures below and attach 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. �. t�-e-��C �+��--t-.� 2. 3. 4. RESTAURANT SEATING: TOTAL�# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# '.LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOT'EL $110 �NN $55 —CAMI' $55 _SWIMMING POOL S110ea _LODGE $55 TRAILERPARK $105 _WHIRLPOOL S110ea FOOD SERVICE: LICENSE REp UIRED FEE PERMIT# !LICENSE REQUIRED FEE PERMTT# LICENSE RE UIRED FEE PERMIT# >100 EATSS 5200 CONTINEN'I'AL S35 NON-PRO�IT $30 � �� COMMON VIC. S60 �� `IVHOLESALE $80 =RESID.KITCHEN S80 RETAII.SERVICE: LICENSE REQUIRED FEE PERMIT# ;LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50sq ft. S50 >25 000 ft. 5285 VENDING-FOOD $25 =<25,000 sq.ft. E150 �FRdZEN�ESSER�"S40 =TOBACCO $ll 0 NAME CHANGE: $15 AMOUNT DUE _ $ '.�0.OO *"***PLEASE TURN OVER ANA COMRLETE OTHER SIDE OF FORM***'�* Bo��- l 5-5`�5l-03 ; , ADMINISTRATION i Under Cha.pter 152,Section 25C,Subsection 6,the Town af 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 COMPLET�D AND SIGNED,OR CERT.OF INSURANCE ATTACHED i / OR V WORKER'S COIWIP.AFFIDAVIT SIGNED AND ATTACHED Town of Yannouth taaces and liens must be paid prio to nenewal or issuance of your permits. PLEASE CHECK APPROPRTATELY IF PAID: YES NO MOTELS A1wTD OTHER LOD�GING ESTABLISHMENTS TRANSIENT OCCUPANCI': For purposes of the limitations of Motel or Hotel use,Transient occup&ncy sha11 be limited to the temporary and short term�occupancy,ordinarily and customarily associated with motel and hotel use. i Transient occupants must have and b� able to demonstrate that they maintain a principal place of residence elsewhere.Transient occupancy shall generally refer to comtinuous occupancy of not more than thirry{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 sha11 not be considered t#ansient. Occupaxticy that is subject to the collection of Room Occupancy i Excise,as defined in M.G.L.c.64G or;830 GMR 64G,as amended,shall generally be considered Transient. � POQLS POOL OPEI�IING:All swimming,wafling and whirlpools which have been closed for the season must be inspected by the Health Department prior to open,ing. Contact the F+Iealth 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 wa�er must be tested for pseudomonas,total coliform and standard plate count i u erl b a State certified lab and submitted�to the Health De arhnent three 3 da s rior to o enin , and art Y , P � ) Y P P g q Y thereafter. POOL CLOSTNG:Every outdoor in gRound swiinming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE SEASONAL FOOD SERVICE OPEIVING: 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 norify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72�►ours prior to the catered event. These forms can be obtained at the Heaith Department,or from the Town's website at www.,yarmouth.ma.us under Health Department, Downloadable Forms. FROZEN DESSERTS: Frozen desserts must be fested by a State certified lab prior to opening and monthly thereafter,with sample results submitted to the Heal4h 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 witli waiter/waitress service),miist have prior approval from the Boazd of Health OUTDOOR COOKING: 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 RESPONSIBILTTY TO RETURN T'HE COMPLETED RENEVJAL APP�.ICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15,2017. ALL RENOVATIONS TO ANY FOIOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPI�RTED TO AND D BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY RE SI PL . DATE: r ( z� �� SIGNATURE: PRINT NAME&TITLE: \t�[, �e.�-e d �c s+.w.a,.�.,(� ��.ia�u» �� The Commonwealth ofMassachusetts p�'�'�FO��' s ; �� " ��"' Department of Industrial Accidents � �. � � �� Office of Investigations �- � -�--;� 1 Congress Street, Suite 100 �, � . Boston,MA 42114-2017 ' � �� www.mass.gov/dia � Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legiblv ; ' Business/OrganizationName:�-I�C� G�-�'�-L��S�-�'�5--��1,�.�.rar�-� i ' Address: a\ �`\nG�C�(� ��t�'�' � ; '^ ' City/State/Zip: V�v�,�S 1"�Gl 0�-�20� Phone #: `�d� �' � � S �' ��3� ; Are yo an employer? Check the appropriate boz: Business Type(required): 1. I am a employer with��employees(full and/ 5. ❑ Re 1 or part-time).* 6. estaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no �, � Office and/or Sales(incl.real estate, auto, etc.) employees working for me in any capacity. [No workers' comp. insurance required] 8• ❑Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, 1 4 , and we have § � � 10.❑ Manufacturing no employees. [No workers' comp. insurance required]* 11.❑ Health Care 4.❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.❑ Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#1. I am an employer that is providing workers'compensation insurance for my employees Below is the policy information. Insurance Company Name: ��,�Kt� (��c�v v.�� W�. ��.,� t`(1 C� . Insurer's Address: �C� ��1` �� a �— � �''�� City/State/Zip: �Gl.l n��-PP, ��.G�, b�� Policy#or Self-ins. Lic.# �� C�0 �s C7�l Ll� � �� Expiration Date: 010� � Attach a copy of the workers' compensation policy declaration page(showing the policy numbe an expiration date). 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 $1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and 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 hereby certify, under the pains and penalties of perjury that the information provided above is true and correc� Si atur . Vv1 � Date: �1 � Phone#: ' Official use only. Do not write in this area,to be completed by city or town officia� City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3. City/Town Clerk 4.Licensing Board 5. Selectmen's Oftice 6.Other Contact Person: Phone#: www.mass.gov/dia INFORMATION PAGE RENEWAL AGREEMENT Insurer: PRODUCER: Agent�� 644 MA Retail Merchants WC Group Inc. Lawrence-Carlin Insurance Agency, � Box 859222-9222 230 Jones Road Suite 3 �.�:aintree, MA 42185 Falmouth, MA 02540 (Carrier Code: 34355) Carrier Policy ��: 014000502147117 Carrier Prior Policy �k: 014000502147116 1. The Insured: CINN Corp Coonamessett Inn Mailing Address: 311 Gifford Streat Falmouth, MA 02540 Eein: Other workplaces not shown above: Type of Business: Corporation SEE SCHEDULE 4F OPERATIONS Risk ID: 2. The policy period is from 12:01 a.m. Qn 1101/2017 to 12:01 a.m. on 1/Ol/2018 at the insured's mailing address. 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Co�ngensation Law of the states listed here: MA B. Em�loyers Liability Insurance: Part �ao of the policy applies to work in each st�te li�ted in Item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident $ 500,000 each accident Bod�.ly Injury by Disease $ 500.000 policy limit �-% Bod�.1y Ir�jury by Disease $_. 500 000 each employee C. Otper St�tes Iz�surance: D. Th�s pol�.cy includes t�iese �ndo�sem�nts a�d schedules: COOOOOOC 1 15 WC000308{04/�4) WCOQQ406(�8/84) WCOOQ414(07/90} WC000422$(�1i15) W � / ) P WC200301(0�/84} WC200302(05/86J WC2Q0303B`(07J99) WC200306B(06/13) WC�00405(06/O1) WC200601A(Q7/08) 4. The pr�mium �or this policy wi11 be determine,� by our Manuals of Ru;�es, Classi�icatinns, Rates and Rating P�ans. All information required below is su}�ject ta verxficat�.on and change by audit. Classi�icatipns Code Premium Basis Rate Per Estimated No. To�al Es�imated $10� of Annual �nnu�l Rem�.neration Remuneration Premium $EE SCHEDUL� OF OPERATIONS Total Es�timatec� Annual Premium $ 30,5�7.00 Minimum Premiuia $ 533.00 Expense Cc�nstant $ .00 Deposit Premium $ .00 ��.. SCHEDULE OF OPERATIONS FOR: PAGE: 1 ' "� Carrier Policy #: 014000502147117 Coonamessett Inn CINN Corp � 311 Gifford Street Falmouth, MA 02540 DIV #: 00000 E/L Number: 0000000001 4THER WORKPLACES: Swan River LLC E�f date: 01/01/17 ; g Upper County Road NAICS: 722511 Dennis, MA 02638 DIV #: 00008 Mailing• E/L Number: OOOQ000001 311 Gifford Street Falmouth, MA 02540 Sailor' s, Inc. The Flying Bridge Restaurant gtate Risk ID#• 0189593 220 Scranton Avenue Eff date� 01j01/17 Falmouth, MA 0254Q NAICS• • 722511 DIV #: 00002 Mailing: E/L Number: 0000000001 311 Gifford Street Falmtouth, MA 02540 ' `�' RH Inn LLC ' I Red Horse Inn State Risk ID#: 01.89593 28 Falmouth #ieights Road Eff ' da�e: 0�./01/27 Falmout�h, MA �254Q NAICS• 722511 � DIV #: OQ007 Mail.ing: E/L Number: 000000{J001 311 Gi£fo�rd S�.reet - Falmouth, MA `02540 ' �AS � Tugboats E£f date: 0�,/01/�7 21 Arli,ngton Street �ICS. '7?2511 �yannia, � �2��1 DIV #• 00005 E L Number: 0000000001 Mailing: / 311 Giffard S�:reet Falrc}outh, MA 02540 �..,