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Home My WebLink AboutApplication and WC 1 • ,":`, TOWN OF YARMOUTH BOARD OF HEALTH RECEIVE D ' APPLICATION FOR LICENSE/PERMIT-2019 *Please complete form and attach all documents by Dipcimliff 15 201& JAN c 8 2019 NOTE ALL BUSINE S'ES WIT LIQUOR LICENSESST RETURN FORMS YISOVEM•BER 134. Failure to do so will result m the return of your application packet ' LOCATION ADDRESS: II- Summer S}� )ism out/. ?ort, 024,75 TEL.#: 50 375 05-9 0 MAILING ADDRESS: PO (3o( 371 , yaaPori , oa6%5 E-MAIL ADDRESS: stoy tminnatcA C n'• OWNER NAME: Michae_J - 14e -n GosselS CORPORATION NAME(IF APPLICABLE): The Inn at Cap-e_ (. , LL C I i MANAGER'S NAME: Ci S o1/46 04 e„. TEL.#: oo S p.b ove MAILING ADDRESS: •' POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please • deesignated Pool Operators)and attach a copy of the certification to this form. /eT 1. 2 Pool operators must list a minimum of two emplo = i tly certified in standard First Aid and Community Cardiopulmonary Resuscitation(CPR),ha ' • certifiedloyee on pp at all times. Please list the employees below and attach copies of . + certifications to this TheHealth Department will not use past years'records. You must pro% new copies and maintain a file at your place of business. 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 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. ��'e✓1 Grt Sse)s 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. 1. }4 zieA Ca spa Ls 2. ALLERGEN CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who has Allergen certification, as defined in the State Sanitary Code for Food Service Establishments,105 CMR 590.009(GX3)(a). 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. )4akn GASSQ 2. HEIMLICH CERTIFICATIONS: ( 4 All food service establishments with 25 seats or more must have : one u ployee trained in the Heimlich Maneuver on the premises at all times. Please list your : .,ees trained in anti-choking procedures below and attach copies of employee certifications to this f.• +e : Department will not use past years'records. You must provide new copies and 11 a file at your place of business. 1. 2. 3. 4. ' • AURANT SEATING: TOTAL# /30}Al.-CS-A-j2.g-0q OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT It LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55CABIN $55 _MOTEL $110 f INN SSS / CAMP $55 _SWIMMING POOL SI10ea. _LODGE $55 TRAILER PARK $105 WHIRLPOOL S110ea FOOD SERVICE: LICENSE REQUIRED FEE LICENSE REQUIRED FEE PERMIT# LICENSE R NON-PROFIT FEE PERMIT# 0-100 SEATS $125 �y 1 CO C $6600 .1L e ' —WHOLESALEFTE $30 $80 —RESID.KITCHEN$80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT <50 .11. $50 >25,000 sq ft. $285 VENDING-FOOD$25 =Q5,..i sq.ft $150 FROZEN DESSERT$40 =TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE = $ 240.00 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 " 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 m the suspension or revocation of your Frozen Dessert Permit until the above teens have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress 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.),MUST BE REPOR1ED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: t/ai1'j SIGNATURE: PRINT NAME TITLE: I-te.le.n C scdS ) —OW Rev.10/23/18 WORKERS COMPENSATION AND EMPLOYERS' LIABILTY INSURANCE POLICY---INFORMATION PAGE INSURER: POLICY NO: WE084424A NORFOLK & DEDHAM MUTUAL FIRE INSURANCE COMPANY 222 AMES STREET RENEWAL DEDHAM, MA 02026 NCCI Company No: 21059 Account No: 862009099 ITEM 1. NAMED INSURED AND MAILING ADDRESS: AGENT NAME AND ADDRESS: THE INN AT CAPE COD, LLC ROGERS & GRAY INS. PO BOX 371 AGENCY, INC SOUTH DENNIS YARMOUTHPORT, MA 02675 OFFICE 434 ROUTE 134 SOUTH DENNIS, MA 02660 AGENT NO.: 20577 LEGAL ENTITY: LIMITED LIABILITY COMPANY (LLC) OTHER WORKPLACES NOT SHOWN ABOVE: (See Workers Compensation Classification Schedule) ITEM 2. POLICY PERIOD: From: 12/01/2018 To: 12/01/2019 Effective 12:01 A.M. Standard Time at the Insured's mailing address. ITEM 3. COVERAGE: 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: Part Three of the policy applies to the states, if any, listed here: SEE ENDORSEMENT WC 20 03 06 B D. This Policy includes these Endorsements and Schedules: See Schedule of Forms and Endorsements. ITEM 4. PREMIUM:The premium for this Policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required on the Workers Compensation Classification Schedule is subject to verification and change by audit. Total Estimated Minimum Premium: $ 231 Annual Premium: $ 1,216 Audit Period: PJUA Additional/Return Premium: Comments: Issued At: Date: 10/22/2018 Countersigned by WC 00 00 01 A Copyright 1987 National Council on Compensation Insurance PRODUCER COPY