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Home My WebLink AboutApp-License-Certification OE 2 02021 TOWN OF YARMOUTH BOARD OF HEALTH 40APPLICATION FOR LICENSE/PERMIT -2022 HEALTH DEPT. * Please complete form and attach all necessary documents by December 18, 2021. Failure to do so will result in the return of your application packet. ESTABLISHMENT NAME: '-T _1 flit o-I'- C.=.c TAX ID: LOCATION ADDRESS: k' Sum w -er 51 , /cv ,,�l-t,. 0 o ft TEL.#: 50$ 37� 0 59 0 13 MAILING ADDRESS: 0 37 I _ Ywr`1- X - PG �={- 1Y1R D D-b-7 5- E-MAIL ADDRESS: 5 eye i nr.ca-cac,..,2co4,c_o( ' OWNER NAME: 1N\i cho -r I-)Q Ae-n CaSSe1S CORPORATION NAME (IF APPLICABLE): _ \,,‘^ air �pe.. Coco , LA—C- MANAGER'S NAME: a 5 otyo o v e TEL.#: cv, & a fe MAILING ADDRESS: i\ v POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool 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. 1 ) Pool operators must list a minimum of two employee ently certified in standard First Aid and Community Cardiopulmonary Resuscitation (CPR), having : - certified employee on premises at all times. Please list the employees below and attach copies of t•-• certifications to this form.The Health 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. \-- 2` Cs s SeAs5 2. PERSON IN CHARGE: Each food establishment� 1must have at least one Person In Charge (PIC)on site during hours of operation. 1. rI P- € �SS2ls 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(G)(3)(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. CI . rICs�SS - 5 2. HEIMLICH CERTIFICATIONS: f\i 1 All food service establishments with 25 seats or more must have . -.- . e employee trained in the Heimlich Maneuver on the premises at all times. Please list yo. - -- . .yees trained in anti-choking procedures below and attach copies of employee certifications to ... . m. The Health Department will not use past years' records. You must provide new copies . , : amtain a file at your place of business. 1. 2. . - 4. 4_ RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT 4 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $110 INN $55 CAMP $55 SWIMMING POOL$110ea. /LODGE $55 TRAILER PARK $105 WHIRLPOOL $11Oea. FOOD SERVICE: LI CENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT 4 /-0-100 SEATS $125 fONTINENTAL $35 NON-PROFIT $30 >100 SEATS $200 COMMON VIC. $60 WHOLESALE $80 —RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT 4 _<50 sq.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 <25,000 sq.ft. $150 _FROZEN DESSERT $40 TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE = $ tv *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** 1 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 taxe_and liens must be paid prior to renewal or issuance of your permits PLEASE CHECK APPROPRIATELY IF PAID: YES V NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel vise,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 CAFÉS: 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(3D) 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 18, 2020. 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 TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: 2—) 1 oI O SIGNATURE: fl , PRINT NAME & TITLE: J 4 e I Gk$seRc / co -Owner Rev. 10/15/19 The Commonwealth of Massachusetts Fee Town of Yarmouth $55.00 Lodging License Number: BOHL-15-1724-07 Issue Date: 1/1/2022 Mailing Address: Location Address: THE INN AT CAPE COD, LLC 4 SUMMER ST INN AT CAPE COD YARMOUTH PORT, MA 02675 P.O. BOX 371 YARMOUTHPORT, MA 02675 IS HEREBY GRANTED A 2022 LICENSE TO OPERATE: Innholder This license is granted in conformity with the statutes and ordinances relating thereto, and expires December 31, 2022 unless sooner suspended or revoked and is not transferable. Conditions `RESTRICTION: 4 guest rooms, 1st floor, 5 guest rooms, 2nd floor. No rentals allowed in owner's residence (separate building). Board Hillard Boskey, M.D.,Chairman Mary Craig, Vice Chairman of Charles T.Holway, Clerk Debra Bruinooge Health Eric Weston . Bruce G. Murphy, • ' .S.,CHO Health Director The Commonwealth of Massachusetts Fee Town of Yarmouth $185.00 Food Establishment License Number: BOHF-15-1725-07 Issue Date: 1/1/2022 Mailing Address: Location Address: THE INN AT CAPE COD, LLC 4 SUMMER ST INN AT CAPE COD YARMOUTH PORT. MA 02675 P.O. BOX 371 YARMOUTHPORT, MA 02675 IS HEREBY GRANTED A 2022 LICENSE TO OPERATE: Food Service; Common Victualler This license is granted in conformity with the statutes and ordinances relating thereto, and expires December 31, 2022 unless sooner suspended or revoked and is not transferable. Conditions *RESTRICTION: For guests only. Board Hillard Boskey,M.D., Chairman Mary Craig, Vice Chairman of Charles T. Holway,Clerk Debra Bruinooge Health Eric Weston IP Bruce G. Murphy, PH,R.S HO ...... , # Health Director NOTICE -- NOTICE '' —u_ _ t '11➢I1111 i .�' X11 t 11A1rYlY ss■ +7 EMPLOYEES A. Mil EMPLOYEES The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS LAFAYETTE CITY CENTER, 2 AVENUE DE LAFAYETTE, BOSTON, MA 02111 (617) 727-4900 — www.mass.gov/dia As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30,this will give you notice that I (we)have provided for payment to our injured employees under the above-mentioned chapter by insuring with: NORFOLK & DEDHAM MUTUAL FIRE INSURANCE COMPANY NAME OF INSURANCE COMPANY 222 AMES STREET, DEDHAM, MA 02026 ADDRESS OF INSURANCE COMPANY WE084424A 12/01/2021 POLICY NUMBER EFFECTIVE DA FES 434 ROUTE 134 SOUTH ROGERSGRAY SOUTH DENNIS OFFICE DENNIS, MA 02660 NAME OF INSURANCE AGENT ADDRESS PHONE# THE INN AT CAPE COD, LLC YARMO�UTHPORT MA 02675 508-790-0590 EMPLOYER ADDRESS 10/22/2021 EMPLOYER'S WORKERS'COMPENSATION OFFICER(IF ANY) DATE MEDICAL TREATM 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 Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the ser- vices provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the OWE- Cob gosnT9L 2-7 WO< ST) i)yAi\ia ma o 6 6 I NAME OF HOSPITAL ADDRESS TO BE POSTED BY EMPLOYER Form WC 88 20 01 C Printed in U.S.A. INSURED COPY laThala ( H ?t& Dlprobvink I ry.i .c_J21-4S* Coff-iFcctz_ 1,31„Ascl. -kncle z y 1 nl e c -2 c l o s-PO b iAL ) s I ) 3e_k _ b-e-Fe -e we_ of)-42_(\ a n d �`i►, c r\ci y o-rl s o& 4 C�S�S cciDpr J U- S1rvtS E )100,-iv\ ppN C� P75 5o8 g75 o5>o ,i thE`g I 8 g g f c ^,o _ T rn fl Sao < E Rin MN .. 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