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Home My WebLink AboutApplication and WC �z. TOWN OF YARMOUTH BOARD OF HEALTH i`�, Vv...,:a1! o I APPLICATION FOR LICENSE/PERMIT-2014 \ *Please complete form and attach all necessary documents by December IS 2018. NOTE:ALL BUSINESSES WITH LIQUOR LICENSES MUSTRETURNFORMSBYNOVEMBERI5'a. Failure to do so will result m the return of your application packet. ESTABLISHMENT NAME: T CS — Z .r : . ID• .. LOCATION ADDRESS: i 2 7 ' d .t al #:.fid' -6- -7/Y3 MAILING ADDRESS:'—'i O `C a& Ld j`i SM A o .G G 4` E-MAIL ADDRESS: ` : * T Z. to : •0 G sl^ OWNER NAME: r' ae "'wt I-re_ r _ CORPORATION NAME APP ABLE): k 4 («� ,h MANAGER'S NAME: 41 a T f °i ,, TEL.#: 50 V 1 7 !,� Sa� MAILING ADDRESS: O ea Y•. L co S - ...5e, /Q r r1 w^ M A O !G y POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Poolperator(s) attache copy of the certificrof to this form. 1. \ 416: k---'4 CI C— t 2. 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 rn rrl - employees below and attach copies of their certifications to this form.The Health Department will not use past y c-) li il years'reco . You must rovide new pies and maintain a file at ur place of business. 1. +c^ 4 t'_.. a.0 t'c.. . 2. b�l 0 -.) C, 3 4 FOOD PROTECTION MANAGERS-CERIIFICATIONS: 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 State 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. 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. I 1. 2. 0 ALLERGEN CERTIFICATIONS: "�i All food service establishments are required to have at least one full-time employee who has Allergen certification, n ' as defined in the State Sanitary Code for Food Service Establishments,105 CMR 590.009(G)(3)(a). Please attach ,,;.01 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. 2. HEIMLICH 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-choking 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. 2. ¢0lit—IS 1857-0l 3. 4. 13000$P46.—i1308-41 RESTAURANT SEATING: TOTAL# O i94801-44 OFFICE USE ONLY LODGING: LICENSE.REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE P # B&B $55 CABIN $55 LMOTEL $110 0ID INN $55 •CAMP $55 _L SWIMMING POOL$1104:a. ICT_�0 —LODGE $55 TRAILER PARK $105 WHIRLPOOL Sl10ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE T# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 1CONTINENTAL $35 a�! NON-PROFIT $30 1 >I00 SEATS $200 COMMON VIC. $60 —WHOLESALE $80 =RESID.KITCHEN$80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# .5O Wit $50 >25,000 ft. $285 VENDING-FOOD $25 � _<25,000 sq.ft =FROZEN FROZEN DESSERT$40 -TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE = $-1:55.00 PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM ADMINISTRATION Under Chapter 152,Section 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 Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR • CERT.OF INSURANCE ATTACHED OR WORKER'S COMP.AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES X 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 the collection of Room Occupancy Excise,as defined in M.G.L.c.64G or 830 CMR 64G,as amended,shall 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 opening. Contact the Health 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 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 quarterly thereafter. POOL CLOSING:Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE SEASONAL FOOD SERVICE OPENING: 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 notify the Yarmouth Health 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.yarmouth.ma.us under Health Department,Downloadable Forms. FROZEN DESSERTS: Frozen desserts must be tested by a State certified lab prior to opening and monthly thereafter,with sample results submitted to the Health 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 with waiterhvaitress service),must have prior approval from the Board of Health. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. TOBACCO PRODUCT PERMIT CAP A tobacco permit holder who has failed to renew his or her permit within thirty(30)days of the previous year's permit expiration date is considered an expired license,and the tobacco license cap is reduced. NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15,2018. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MOST BE REPORTED TO AND APP' a VED BY THE BO OF TH PRIOR TO COMMENC _ RENOVATIONS MAY RE !'A A S DATE: I r t / o SIGNATURE: t �J PRINT NAME& !TILE: t w Q,-'( Q t CG n ��e%,,, �v>i Rev.10/23/18 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE Associated Employers insurance Company 54 Third Avenue, Burlington,Massachusetts 01803-0970 (800)876-2765 NCCI NO 40959 POLICY NO. WCC-500-5018861-2018A PRIOR NO. NEW ITEM 1. The Insured: Shooshaloo Inc DBA: The Escape Inn Mailing address: PO Box 1054 FEIN:"-`"" South Yarmouth,MA 02664 Legal Entity Type: Corporation Other workplaces not shown above: See Location 2. The policy period is from 05/08/2018 to 05/08/2019 12:01 a.m.standard time at the insureds mailing address. 3. 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: 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 Replaced 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 determined by our Manuals of Rules,Classifications,Rates and Rating Plans. All information required below is subject to verification and change by audit. Classifications Premium Basis Rates Code Estimated Per$100 Estimated No. Total Annual Of Annual Remuneration Remuneration Premium INTRA 954436 INTER SEE CLASS CODE SCHEDU_E Minimum Premium $292 Total Estimated Annual Premium $994 GOV GOV Deposit Premium $257 STATE CLASS MA 9052 State Assessments/Surcharges $684.00 x 4.5600% $31 This policy,including all endorsements,is hereby countersigned by �/- -" 05/17/2018 Authorized Signature Date Service Office: Starkweather&Shepley Ins Brkg Inc 54 Third Avenue PO Box 549 Burlington MA 01803 Providence, RI 02901-0549 WC 00 00 01 A(7-11) Includes copyrighted material of the National council on Compensation Insurance, used with its permission.