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Home My WebLink AboutApplication and WC _ V��AGe W f� � TOWN OF YARMOUTH BOARD OF HEALTH �°,[��Uy�p �� APPLICATION FOR LICENSE -'2f015 r ^' �" * Please complete form and attach a11 necessa�` oc�n, nts��ec ber Q�SGz�1�.2014 Failure to do so will result in the retur�I"'o'f yo�ir apphcatron p ket��TH DEPT. ESTABLISHMENT NAME: Tlk� v i t,t,4v,G s�;� TAX ID: ,��, LOCATIONADDRESS: �lz ��-v�ce tpcti �,uua.�- P��2-� TEL.#: SU5s3caa-3i�rZ MAILINGADDRESS: Pv r�:-�c 1 `rar,4v�� Poric E-MAIL ADDRESS: T�c-v�u-A-ta�.�ivn� �a v&u� o ��r A-�Fct� c�.-� OWNER NAME: .�n a-,��,� uu�� CORPORATION NAME (IF APPLICABLE): MANAGER'SNAME: �Rrcw «��-� TEL.#: �Zk ��L-3ikZ MAILING ADDRESS: PO �5�v 1, YA-,'/��,�t on�- .�1/� �zco'tY 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. . ._ - ___. - __ - _ _-. .- _.___ .. . L. _ ._ ______ .__-_ _ _.. . _ . . 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. 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 altach 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 Chazge (PIC) on site during hours of operation. _ _ - —_—_ _ -- -- — _i _ _ 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. 2. HEIMLICH CERTIFICATIONS: All food service establishxnents with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at a116mes. Please list your employees trained in anti-choking procedures below and attach copies of employee certificarions to this form. The Health Department will not use past years' records. You must provide new copies and maintain a �le at your place of business. 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 MOTEL $110 �INN $55 CAMP $55 _SWIMMINGPOOL$IlOea LODGE $55 TRAILER PARK $105 WHIRLPOOL $IlOea FOOD SERVICE: LICENSE REQUIRED FEE PERMTT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �0-100 SEATS $125 _CONTINENTAL $35 NON-PROFIT $30 >100 SEATS $200 �COMMON VIC. $60 WHOLESALE $80 —RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQU[RED FEE PERMIT# UCENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 —<ZS,OOOsq.ft. $150 _FROZENDESSERT $40 _TOBACCO $1I0 NAMECHANGE: $15 AMOUNTDUE _ $ 24o.pC7 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** /-�CC-U �ZQQ`�� 1�� y ADMINISTRATION Under Chapter 152,Section 25C, Subsection 6,the Town of Yazrnouth is now required to hold issuance or renewal of ar�y 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 v OR WOIZKER'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 J NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations ofMotel or Hotel use,Transient occupancy shail be limited to the temporary and short term occupancy,ordinarily and customarily associated with motel and hotei 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 thirly(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. �4G or 830 CMR 64G, as amended, sha11 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 aze 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 standazd 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 Yazmouth 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 obtamed at the Health Department,or from the Town's website at www.yatmouth.ma.us under Health Departrnent, 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 ofHealth. OUTDOOR COOHING: Outdoor cooking,prepazation,or display of any food product by a retail or food service establishment is prohibited. NOTICE:Permits run annually from January i to December 31. IT IS YOUR RESPONSIBILITY TO RET'URN 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 UI SITE PLAN. DATE: !�_��,;�� SIGNATURE: ' PR1NT NAME & TITLE: j[��p,6h ��_P_� q,U�� Rev. I1/03/14 . Florio, Mary Alice From: Karen Hickey <thevillageinncapecod@yahoo.com> Sent: Tuesday, December 30, 2014 9:39 AM To: Florio, Mary Alice Subject: Re:2015 Licenses Ooops! I thought I forgot something! I'll mail it today. Thanks, Happy New Year Karen Hickey - — __ __. _ - --- — .._.._ From: "Florio, Mary Alice" <MFlorioCo�varmouth.ma.us> To: "'thevillageinncapecod@yahoo.com"' <thevillaqeinncaoecod(a�yahoo.com> Sent: Tuesday, December 30, 2014 8:26 AM Subject: 2015 Licenses Thank you for submitting your check#1728 in the amount of$200.00, ServSafe certification, and Workers Compensation information to the Health Department, but there was no aaplication enclosed for your 2015 licenses. Please send us your application as soon as possible, because we cannot process your 2015 licenses without it. Thank you. All the best in the New Year. MaryAlice Florio, Principal Office Asst. Yarmouth Health Department 1146 Route 28 South Yarmouth, MA 02664 508-398-2231, ext. 1241 i WORKERS COMPENSATION AND EMPLOYERS' LIABILTY INSURANCE POLICY----INFORMATION PAGE INSURER: POLICYNO: WE114594A NORFOLK & DSDHAM MUTUAL FIRE INSURANCE COMPANY � ^ a 222 AMES STREET RENEWAL DSDHAM, MA 02026 NCCI Company No: 21059 9 � � Account No: � �+ �¢ FEIN: � j = ITEM 7. NAMED INSURED AND MAILING ADDRESS: AGENT NAME AND ADDRESS: MALCOLM K FIICKEY & KAREN HICKEY DBA THE BRYDEN & SULLIVAN INS VILLAGE INN AGCY INC P O BOX 1 88 FALMOUTH RD YARMOUTH PORT MA 02675 HYANNIS, MA 02601 AGENT NO.: 20294 LEGAL ENTITY: pARTNERSHIP OTHER WORKPLACES NOT SHOWN ABOVE: (See Workers Compensation Classification Schedule) ITEM2. POLICYPERIOD: From: OS/25/2014 To: O5/25/2015 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 liabiliry 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 I�surance: 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 wili 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: $ 2gq Annual Premium: $ 2g6 Audit Period: p�pL Additional/ Return Premium: Comments : Issued At: Date: 04/15/2014 Countersigned by WC 00 00 07 A Copyright 1987 National Council on Compensation Insurence INSUREO COPV