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Home My WebLink AboutApplication and WC . W�ND TR�tM ECL=� � TOWN OF YARMOUTH BOARD OF HEALTH ' �� APPLICATION FOR LICENSE/PE�ViI� -'G�O��'1r�,3 � t`,,Y ._ O �014 irr, , * Please complete form and attach all necessary docuinen s byDece er IS 2014. Failure to do so will result in the returri of your fipplication pa et. ALTH DEPT. ESTABLISHMENT NAME: — �� TAX ID• LOCATION ADDRESS: � 2,� TEL.#: 2 -39a�'-o� 7 MAILING ADDRESS: L. = ` E-MAIL ADDRESS: � ✓I- v 6 m o OWNERNAME: � n � � ✓t �� -f CORPORATION NAME(IF APPLIC L ): MANAGER'S NAME:�� r✓� TEL.#: 5��-76G-3S J� MAILING ADDRESS: iot 3 U✓ G i'�.— /��' .r' Y POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operatar(s) attach a copy of the certification to this form. ' . Y - — — .1�,:LZ �✓�v i hl ��r�!�2.— ---- - -- Pool operators must list a minimum of two employees currently certified in basic water safety, standazd 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�gcords. You must prov�de new copies and maintain a file at your place of business. i 1. C�' /I / �G�,�r �� ,,,�� z, 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• PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. _ _ _ _------_ 1. — --- -- - -- 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 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 £►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 PE IT# _B&B $55 CABIN $55 I MOTEL $l10 -�� _INN $55 —CAMP $55 �SWIMMING POOL$I l0ea. _LODGE $55 =TRAILERPARK $105 _WHIRLPOOL $tl0ea FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-]00 SEATS $125 _CONTINENTAL $35 NON-PROFIT $30 =>]00 SEATS $200 _COMMON VIC. $60 WHOLESALE $80 —RESID.K[TCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQU[RED FEE PERMIT I! <50 sq.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 —<25,OOOsq.ft. $150 _FROZENDESSERT $40 _TOBACCO $]10 NAMECHANGE: $15 AMOUNTDUE _ $ 2�_op *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*****�� -��,� ,�� ADMINISTRATION � ' Under Chapter 152, Section 25C, Subsection 6,t7�e Town af 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 ATTACIiED S'1'ATE WOI2KER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETF.D AND SIGNED, OIi CL^:RT. OF INSLTRANCE ATTACHEI? � � OR WORK.ER'S CdMP. AFFII)AVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens rnust be paid priar to renewal ar issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: 1'ES � N(} MOTF.LS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCi7PANCY: FoC purposes of the limitatioiis ofMotel ar Hotel use,Transient occupancy shall be limited to the temporary and shart term occupancy,ocdinarily and custornarily a,5sociated with motel and hotel use. Transient occupanis mnst have and be able to demonstrate that they maintain a principal place of residence elsewhere.Transient oacupancy shall generally refer to continuaus accupancy of not rnare than thiriy(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 residenae or dwelling unit shall not be considered transient. Occupancy that is subject ta tlie callectian of Room Qecupancy Excise,as defined in M.G.L. c. 64G or$30 CMR 64G,as amended, shall generally be considered Transient. POOLS POOL OPENING:All swimmiilg,wading and whirlpools which tzave been ciosed for the season must be inspected by the Health Department prior Yo opening. Contact the I-Iealth Department to schedule the inspection three(3) days prior to opening. PLEASE NOTE: Peogle are NdT allawed to sit in the pool area untiI the paal has been inspected and apened. POOL WATER'1'ESTING: The watex must be tested for pseudamonas,tatal coliform and standazd plate count by a State certified lab, and submitted to the Health Departrnent three (3} days prior ta opening, and quarterly thereafter. PQOL CLOSING: Every outdoor in ground swimming pooi xnust he drained ar covered within seven{7)days of closing. FOOI) SF,RVICE SEASONAL FOOD SERVICE OPENING: All food service establishments must be inspected by the HealYh Deparhnent prior to opening. Please contact fhe FIealth Department to schedule the inspectian three{3) days prior to opening. CATERTNG POLICY: Anyone who caters within the Town of Yarmoixth rnust notify the Xarmouth Health Department by filing the required Temporary Faad 3ervica Applicatian farm 72 haurs 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 sarnple results submitted to the I-�ealth Department. Failure to do so wili result in the suspension or revocation of your Frozen Dessert Permit until the abave terms have been met. OUT9IDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval frorn the Board of Health. OUTDOOR COCIKING: Qntdoor 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 RESPdNSIBILITY TO RBTURN THE COMPLETED RENEWAL APPLICATIQN{S}AND REQUIRE;D FEE{S}BX DECEMB�R 15, 2014. �LL T2ENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., FAINTING, NEW EQLTIPMENT,ETC.}, MUST BE KEPQRTED TQ AND APPROVED BY TFiE BQARD OF HEALTH PRTOR TO COMMENCEMENT. RENOVATTONS MAY UT A E , / / �/� DATE: ('//,�G /r �s SIGNATL)RE� /��i��`" �,;�/ �-- � PRINT NAME&TI'i'LE: ��°�/C'l�.r'fG t//f/7'/,�-� .�i�/,c//%L a�Y. 3 vos„a �j",�arP"� W liKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE i j A.I.M. Mutual Insurance Company 54 Third Avenue, Burlington, Massachusetts 07803-0970 �800�876'2765 NCCI N026958 POLICY NO. WMZ-800-8003576-2014A PRIOR NO. WMZ-800-8003576-2013A ITEM 7. The Insured: Sabina Family Trust(see Schedule} DBA: �ndjammer Motel Mailing address: 123 Wilfin Road FEIN:'=`•* South Yarmouth, MA 02664 Legal Entiry Type: Corporation Other workplaces not shown above: See Location 2. The policy period is from OMOt/2074 to 04/01/2015 12:01 a.m.standard time at the insured's 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'Liabiliiy Insurance: Part Two ot the policy applies to work in each state listed in item 3.A. The limits of Iiability 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 O6 A D. This Policy includes these Endorsements and Schedules: SEE SCHEDULE 4. The premium for this policy will be detertnined by our Manuals of Rules, Classifications, Rates and Rating Plans. All iMormation required below is subject to verification and change by audit. Classifications Premium Basis Rates Code Estimated Per$100 Estlmated No. Toml Mnual OF Mnual F�rnuneration Remuneration P2mium INTRA 342015 INTER � SE CLASS CODE SCHEDU Minimum Premium $281 Total Estimated Annual Premium $797 GOV GOV Deposit Premium $815 STATE CLASS Mq gp� MA Assessment Chg. $534.00 x 3.4000% $18 This policy,including all endorsements,is hereby countersigned by � �_�2-�lciz 0?J21/2014 AWrorizedSignature Date Service Office: Miller McCartin dba Dowling&O'Neil Ins Agcy One Lakeshore Center 973 lyannough Road Bridgewater MA 02324 Hyannis, MA 02601 WC 00 00 01 A(7-17)