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Home My WebLink AboutApplication and WC i �► TdWN aF YARMOUTH BOARD OF HEALTH APPLICATION FOR LICENSE/PERMIT-2U18 ` *Please complete form and attach ali necessary documents by December 1 S.2(/l7. Failure to do so witl result in the return of yaur application p c� ESTABLISHMENT AtAMEc � r ca -D^� '��►C �A N • LOCATTONADDRESS: ►Q� 5. Sho�e. �r. 5• ya�Mo�h TEL.#: So$ 34�I- 8430 MAILINGADDRESS: ►o'�' S Skov� 17r 5 `Idtnnoc,•�t� MPr 0916�<.r E-MAILADDRESS: �vsko�d @ Ino�nna�1. �a�r. OWNER NAhRE:• r G 6 � CORPORATFON NAME(IF ICABLE): u�r-�co.ah er 2r�c. . ___ 1 MANAGER'SNAME; 3v�S�� S�no�old TEL.#: 5a$ 4�I QQ30 � MAILING ADDRESS: 1b� S • S1.n+� �,.. S.�±mc�i�► I��c�.��i POOL CERTIFIGATIONS: The pool supervisor must be certitied as a Pooi Operator,as required by State law. Please list the designatad Pool Operator(s)and attach a copy of the certification to this form. � p � i � � 1._,�µ��-�n TanA�c�. -- 2. C? � —I N Pool operators must list a minunum of two employees currenily certified in standard First Aid and Gommunity z W � Cardiopulmonary Resuscitation(CFR),having one certified empioyee on premises at all times. Please list the Q N � employees below and attach copies of their certtfications to this form.The Health Department will uot use past � o � , years'records. You must provide new copies and maintain a file at yaur glace af basiness. -{ � � l. 7'us�;� S�►el� 2. �;sa eoed �► -- 3. 4- ; `�-q FOOD PROTECTION MANAGERS-CERTIFICATIONS: #' " � Ali food service establishments are required to have at least one fuli-time emptoyee who is certified as a Food - ' Protection Manager,as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. -�, f Please attach copies of certification to this application. The Iiealth Deg�rtment wiIl not use past years'records. �' ,, � You must provide new copies and maintain a Ste at your e.stabtishment. � �-- 1. 2. � � ,, � PERSON IN CHARGE: �� iEach food establishment must have at least one Person In Charge(PIG)on site during hours of operarion. � ��:� i 1_ 2. � ! ALLERGEN CERTIFICATIONS: All food service establishments are reyuired to have at ieast one full-time emp3oyee who has Allergen certificarion, as define<i in the State Sanitary Code for Food Service Estahlishments,105 CMR 590,OQ9(G)(3xa). Please attach copies of cerkification to this applieation. The Health Departraeut will not use past years'records. You must provide new copies and maintain a file at yaur establishment. L 2• HEIMLICH CERTIFICATIONS: ;; All food service establishments with 25 seats or more must have at least one employee trnined in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures belo�v and attach copies of employee certifications to this form. Tfie Health Department will nat use past years'reeords. You must provide new copies and maintain a file at your place of business. 1. �. 3. 4• I bo��-l�-1o8��-OZ RESTAURANT SEATING: TOTAL# �°l �P�cb-co9qi--6�-- OFFICE USE ONLY LODGINGs LICENSE RE IJIRED FEE PERMIT# LICEAISE REQUIRED FEE PERMIT# LtCENSE REQUiRED FEE P T# Q �ia �00 a&B s s s c n s� $s s M a�L a ;�-� _[NN S55 CAMP $55 �SWIMMING POOL$110ea-��8�'�� — 1 105 WH7RLPOOL S110ea. LOflGE $55 TRAILER PARK S _ FOOD SERVICE: LICENSE REQUIRED FEE PERivIIT# LiCENSE REQUIRED FEE PERMIT# L1CfiNSE REQUIRED FSE PERMIT# 0-100 SEATS 5123 _ .�4N7TNENTAL $35 NON-PROFIT S30 —>L00 SEATS $200 �C4MMON V1C. $60 WHOLESALE S&0 — —RESID.KITCHEN S80 RETAIL SERVICE: il LICENSE REQUIREIl FEE PERMIT# LICENSE REQUIRED FEE PERM[T# LICENSE REQUIRED FEE PERMIT# GSpsq ft, $50 >ZS,QOQsq.R $285 VENDING-FOOD $25 =Q5.000 sq.ft. 515p _FROZEN DESSERT S40 _TOBACGO . SI IO I - NAME GHANGE: $15 AM�UNT DUE _ $ Z?'�'0� •*4**PLEASE TURN QYER AND COMPLETE OTHER SIDE OF FQRM*•*** � i ADMINISTRATION IUnder Chapter 152,Section 25G,Subsection 6,the Town of Yarmouth is now required to hold issuance or renewai jof any license or permit to operate a business if a pe�rson or company daes nat have a Certificate of Worker's � Compensarian Insurance. THE AT'TACHED STATE WORKER'S COMPENSATIOI�T INSURANCE AFFIDAVIT MUST BE GOMPLETED ANU SIGNED,OR CERT.OF INSIIRANCE ATTACHED�� OR WORKER'S COMI'.AFFIDAVTI'SIGNED AND ATTAGHED I 'Town of Yarmouth taxes and liens must be paid prior ta renewal or issuance of your pernuts_ PLEASE CHECK APPROFRIATELY IF PAID: YES�� NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OC�UFANGY; For purposes of the limitations of Motel or Hote1 use,Transient occupancy shall be limited to#he temporary and short term occupancy,ordinarily and customarily assaciated witih motel and hotel use. Transient occupants must have and be able ta 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 af a guest unit as a residence or dwelling unit shall not be considered transient. Occugancy 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 generaily be considered Transient. ; POOLS � POOL OPENING;Ali swimming,wading and whirlpools which have b�n closed for the season must be inspected by the Health Depamnent prior to opening. Contact the Health Departmen#to schedule the ir►speetion three(3} days prior to opening.PLEASE NOTE;Peopie aze NOT ailowed to sit in the paol azea until the pool has k�een inspected and opened. POOL WATER TESTING: The water must be tested for pseudomonas,total coiaform and standard plate count by a State certified lab,and submitted to the Health Deparhnent three(3)days priar ta opening,and quarterly thereafter. POOL CLOSING:Every outdaor in ground swimmmg pool must be drained or covered within seven(�days of ciosing. i FOOD SERVIGE � SEASONAL�OOD SERVICE OPENING: � All food service establishments must be inspected by the Health Department prior to opening. Please contact the Health Department to schedule the inspeetion three(3)days prior to opening. CATERING FQLICY: Anyone who caters within the Town of Yarnlouth must notify the Yarmouth Heaith Department 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.yacmouth.ma.us under Health Depaitment, Downioadable Forms. j FROZEN DESSERTS: � Frozen desserts must be tested by a Stats certifieti lab grior to opening and monthly ttiereafter,with sample results submitted to the Iiealth Department. Pailure to da so will result in the suspension or revc�eafion of your Frozen Dessert Perrnii unti2 the above te�ms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. OUTD�OR Ct30KING: Outdoor cc�oking,prepazation,or display of any food product by a retait or food service establishment is prohibited. �i I NOTIGE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO ItETURN I THE CQMPLETED RENEWAL APPLICATION(S)Al*TD REQIJIRED FEE(S)BY DECEMBER 15,2017. I � ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR PO�L (i.e., PAINTING, NEW � EQUIPMENT,E`TC.),MUST BE REPORTED TQ AND APPROVED B THE BOARD()F HEALTH PRYOR � • TO COMMENCEMENT. RENOVA'I'IONS MAY RE A SITE N. � DATE: l_b_I�pi I 1'�- SIGNATURE: � ' ` PRINT NAME&TITLE: �1u.5 �� S l � ��.ion�ri� � WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE PO�ICY INFORMATION PAGE - Associated Employers Insurance Company 54 Third Avenue, Burlington, Massachusetts 01803-0970 (800)876-2765 NCCI NO 40959 POLICY NO_ WCG500-5017560-2017A � PRIOR NO. NEW � ITEM � 1. The insured: Surfcomber Inc — DBA: Mailing address: 107 South Shore Drive FEIN:'*=*' South YarmoutM, MA 02664 � � Legal Entity Type: Corporation � Other workplaces not shown above: � �. 2 The policy period is from 07/01/2Q17 to 07/01/2018 12:01 a.m.standard time at the insured's mailing address. ; � 3. A. Workers Compensation Insurance:Part One of the policy appiies to the Workers Compensation Law of the � states listed here: MA B. Employers'L.iability Insurance:Part Two of the policy applies to work in each state iisted in item 3.A. � r � The limits of 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 $ 500,000 each employee � � C. Other States Insurance:.Coverage Fteplaced by Endorsement WC 20 03 06 B � D. This Policy includes these Endorsements and Schedules: SEE SCHEDULE � � 4. The premium for this policy will be detennined by our Manuals of Rules,Classifications, Rates and Rating Plans. � All information required befow is subject to verification and change by audit. � Class�cations Premium Basis Rates � Code Estimated Per$100 ; Esfimated � No. Total Annual Of ; Annual Remuneration Remuneration � Premium � � � INTRA 0120204 ' 1 � i INTER SE CLASS CODE SCHEDU E � . ' � Minimum Premium $292 Tatal Estimated Annual Premium $3,585 GOV GOV Deposit Premium $940 STATE CLASS State Assessments/Surcharges ' MA 9052 $175 $3,125.00 x 5.6000°l0 i hereb countersi ned b �`'�� 06/30/2017 This policy,including all endorsements, s y g y Authorized Signatura Date Service Office: HUB Intemational New England LLC 54 Third Avenue 299 Ballardvale Street Burlington MA 01803 Wilmington,MA 01887 WC 00 00 01 A(7-11) � Includes copyrigMed material of the National Council on Compensabon Insurance, used with i�perm�ssion.