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HomeMy WebLinkAboutApplication and WC sc CAPE Potnrr t&o- " TOWN OF YARMOUTH BOARD OF HEALTH aGC�G�bED E ►,� APPLICATION FOR LICENSE/PERMIT -2015 IJ � " f r ' , �1 ; .16 [014 * Please complete form and attach all necessary be ents try 13ec rib)r 13, 014. Failure to do so will result in the return of your application packet. HEALTH DEPT ESTABLISHMENT NAME: Cape P,,,D T TAX ID: LOCATION ADDRESS: 176 44411V Sty, e el Wtst• yAk M evt h TEL.#: &i — 3‘.2 - S7G MAILING ADDRESS: 176 MAtN S`fRee,7 W,esi yid kmo0- IN Aa_ 0.263 2- E-MAIL ADDRESS: ?cc RAI,zi Gt.) CLO 1• cco M OWNER NAME: -C)oalrs-,de Nate( CORPORATION NAME (IF APPLICABLE): Pa'art Ak C- MANAGER'S NAME: -Pit V t- S LOA 12l Z TEL Agar 36.2 .F72-4 . MAILING ADDRESS: 6 07 P(,e a,S,t ,v? Au{ Ce.,Je&ot Li -e Mia 0143 22 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. 51-e oe kc ske 1 f 2. 11/ Gel 62, -1N Pool operators must list a minimum of two employees currently certified in basic water safety, 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. 1. Ill&t..tc Cc,enioizz,eA 2. Ch&cy/ ete"rttar•r-dig" 3. To n't.viy NcJu y#0 iv 4. JZtS 6 e S:brcsO 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. 1-6frIna-1- K c se 1 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. ; e�- � f1--/S,c-v.? 1 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. Janet 115- el 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. Th"et- k. 55�1 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 I MOTEL $110 INN $55 _CAMP $55 XSWIMMING POOL$110ea. LODGE $55 TRAILER PARK $105 1 WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# I 0-100 SEATS $125 CONTINENTAL $35 —NON-PROFIT $30 >100 SEATS $200 1 COMMON VIC. $60 =WHOLESALE $80 KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <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 = $ 7 3S•OO *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** :k 1M-1--1- iziva(14 t 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 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 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. 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, 2014. 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 /e> f/ DATE:/;e7. 10. / SIGNATU' "' t om —Amt. PRINT NAME& TITLE: - :5i. Ade Rev. 11/03/14 Inter Island Telephone P.Q. Box 1172 INVOICE South Yarmouth, MA. 02664 778-1500 November 22, 2014 The Cape Point invoice# B224240 476 Route 28 West Yarmouth MA 02673 Account# 0240 Request Code 02 Install dialer orrthe pool phone-to-allow dir=e - =- up. Service Performed Ordered and installed the automatic dialer on the pool extension and prvgreed itattomaticlly dial out to 911. Tested and changed the listing inside to the phone box to say callers go directlyto 911. Materials 1 1Single line automatic dialer $128.38 $128.381 ( 1 f Labor Materials $128.38 November 22,2014 1.00 Labor $90.00 TAX $8.02 Travel Delivery MISC Total Invoice $226.40 Printed Y Completed Y Paid N Payments Date Paid Check# Balance Due $226.40 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE CERTIFICATE INFORMATION PAGE Producer: Agent# 137 MA Retail Merchants WC Group Inc. Boynton Insuarance Agency Inc. PO Box 859222-9222 72 River Park St Braintree, MA 01285 Needham, MA 02194 (Carrier Code: 34355) Certificate #: 014005033479114 Prior Certificate #: NEW 1. The Employer: Dockside Hotel Group Inc Mailing Address: 476 Main Street West Yarmouth, MA 02673 Fein: Other workplaces not shown above: Type of Business: Corporation SEE SCHEDULE OF OPERATIONS Risk ID: 2. The certificate period is from 12:01 a.m. on 1/01/2014 to 12:01 a.m. on 1/01/2015 at the insured's mailing address. 3. A. Workers Compensation Coverage: Part One of the certificate applies to the Workers Compensation Law of the states listed here: MA B. Employers Liability Coverage: Part Two of the certificate applies to work in each state listed in Item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident $ 1,000,000 each accident Bodily Injury by Disease $ 1,000,000 certificate limit Bodily Injury by Disease $ 1,000,000 each employee C. Other States Coverage: D. This certificate includes these endorsements and schedules: WC000000A(04/92) WC000310(04/84) WC000414(07/90) WC000422A(09/08) WC2003O1(04/84) WC200302(05/86) WC200303B(07/99) WC200405(06/O1) WC200601(06/92) 4. The contribution for this certificate 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 Code Contribution Basis Rate Per Estimated No. Total Estimated $100 of Annual Annual Remuneration Remuneration Contribution SEE SCHEDULE OF OPERATIONS Total Estimated Annual Contribution 12,667.00 Minimum Contribution $ 306.00 Expense Constant $ .00 WC 00 00 01 A Issue Date: 2/03/2014 Countersigned by • • • ii SCHEDULE OF OPERATIONS FOR: PAGE: 1 Dockside Hotel Group Inc Certificate # : 014005033479114 476 Main Street Fein: West Yarmouth, MA 02673 OTHER WORKPLACES : Cape Point Hotel The Point LLC • 476 Main Street, Route 28 • West Yarmouth, MA 02673 Fein: 043418497 • Mariner Motor Lodge Mariner Motor Lodge The Mariner Motor Lodge LLC . 573 Main Street, Route 28 476 Main Street, Route 28 West Yarmouth, MA 02673 West Yarmouth, MA 02673 Fein: 043418500 • Town 'N Country Motor Lodge Town 'N Country Motor Lodge Cape Town & Country Motor Lodge LLC . 452 Main Street, Route 28 476 Main Street, Route 28 West Yarmouth, MA 02673 West Yarmouth, MA 02673 Fein: 043418499 I ' WC 00 00 01 A .