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Home My WebLink AboutApplication and WC' .a TOWN OF YARMOUTH BOARD OF HEALTH ��6��d�� Y � �� APPLICATION FOR LICENSE/PERNIIT - �;,,��a` Ut� 3-0 ZU14 `" * Please complete form and attach all necessary documents by Dece ber 1 S 20Y4. i Failure to do so will result in the retum tsf your application p etHEALTH DEPT. ESTABLISHMENT NAME: C- TAX ID: LOCATION ADDRESS: TEL.#: S� - MAILING ADDRESS: E-MAIL ADDRES� i OWNERNAME: I ,Y11P. i1MC�'1 � CORPORATION NAME (IF APPLICABLE): I MANAGER'S NAME:�� TEL.#: - 7 MaiL�rrGaDD�ss: qR�1 � � uY✓lr.�_ _ ouo(o 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. _ - -- _ -- - - - - -- -_ - __ � I 2 I 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 attach copies of certification to this application. The Health Department will not use past years'records. You must provide new copies and.maintain a 61e at your establishment. 1. 2. PERSON IN CIIARGE: Each food establishment must have at least one Person In Chazge (PIC) on site during hows of operation. _— --_- -- - _ _ - - - - _ _ - - _ _ __ - - - __ L 2. ALLERGEN CERTIFICATIONS: All food service establishments are required to haue 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 Deparhnent will not use past years' records. You must provide new copies and maintain a file at your establishment. 1. Z• 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. 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 SWIMMING POOL$110ea � LODGE $55 TRAILER PARK $105 WHIRLPOOL $I l0ea. FOOD SERVICE: UCENSE REQUIRED FEE PERMIT# L[CENSE 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 REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# � <50 sq.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 �Q5,000 sq.ft. $150 S_n�� —FROZEN DESSERT $40 _TOBACCO $1IO NAMECHANGE: $15 AMOUNTDUE _ $ IS0. 00 *"***PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** �'C'-` ��'� , cV�-t�3�7Z i�3o`�� . � ADMINISTRATION Undar Chapter 152,Section 25C,Subsection 6,the Town of Yannouth is naw required to hold issuance or renewal af any Ticense or permit to operate a business if a persan or company does not have a Certificate of Worker's Compensation Insurance. TTiE ATTACAEll STATE WORKER'S COMPENSATIQN INSURANCE AFFIDAVIT MUST BE COMPLETk',D AND SIGNED, OIZ CERT. OF INSLIRANCE ATTACHED OR WORKER'S COMP. AFFII3AVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens rnust be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATEI.Y IF PAID: YES_� NO _ MOTELS ANA OTHER LODGING ESTABLISHMENTS : TRAN5IENT OCCUPANCY: For purposes of the 1 imitations of Motal or Hotel use,Transient occupancy shall be limited to the temporary and shart term occupancy,ordinarily and custarnarily associated with matel atid hotel use. Transient occupants must have and be able to demonstrate that they maintain a principal place of residence elsewhere.Transient occupancy sha11 generally refer to continuous accupancy of not more Yhan thirty{30)days,and an aggregate o£not more than ninety(90)days within any six(6)month period. Use af a guest unit as a residence or dwelling unit shall not be considered transient. Occupancy that is subject to the collection of Roam Occupancy Excise, as defined in M.G.L. c. 64U or 834 CMR 64G,as amended, shall generally be considered Transient. P40LS 1'OOL OPENING:All swimming,wading and whirlpools whach have been closed for the season must be inspected by the Health Department prior to opening. Contact the Health Depazfrnent to achedule the inspection three(3) days priar to apening. PLEASE Nd"I'G: Peopla are NOT allawed to sit in the pool area unril the pool has been inspected and opened. POOL VVATER TESTING: The water must be tested for pseudomonas,tata!coliform and standarfl plate count by a State certified lab, and submitted to the Health Department three (3) days prior to opening, and quarterly thereafter. POOL CL4SING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days af closing. FC►011 SF.I2VICE SEASONAL FOOD SERVICE OPENING: All food service estab(ishments must be inspected by the Health Department prior to opening. Pleasc contact the ' IIeallh Department to schedule the inspection three{3)days griar to opening. CATERING PQLiCY: Anyone who caters within the Town of Yarmouth must notify the Yannouth Health ]7epartment by filing the reqwred Temparary Food Service Applicatian farm 72 haurs prior ta tl�e catered event. These forms can be obtaitted at the Health Department,ar frpm the Tawn's website at www.yarmouth.ma.us under Health Department, Downloadable Forms. FROZEN DESSEI2TS: Frozen desserts must be tested by a State certified lab prior to apening and monthly thereafter,with sample results submitted to the I-�ealth Departtnent. Failure to do so will result in the sixspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSID�CAFES: Outside cafes(i.e.,autdoor seating with waiter/waitress service),must have prior approval from the Board of Health. OUTDOOR COUHING: Outdoor aooking,preparation,or display of any food product by a retail or faad service establishment is prohibited. NOTICE:Permits run annualTy from January 1 to December 31. IT IS YOUR ItESPONSIBILITY TO RETLJRN THE C4MPLETED RENEWAL AI'PLICATION(S}AND R�,QUIRED F`BE(S}BX DECEMBF.R 15, 2014. ALL RENOVATIONS TQ ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPNI�N7",ETC.),MUST BB REPQRTED TO AND APPROVEI7 BY THE BOARD O�HEALTH PRIOR TO CQMMENC MENT. RENOVATIONS MAY REQUI �A SITE PLAN. DATr: �"� SIGNATUItE: {,�,.1"� PRiNT NAME& TITLE:1,(}}��,IY}�y�(y��(Df�� Rev.i 1l03114 � �+ � � N%ORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE Associated Employers Insurance Company 54 Third Avenue, Burlington, Massachusetts 01803-0970 (800} 876-2765 NCCI NO 40959 POLICY NO. WCCS00-5013432-2014A PRIOR NO. NEW ITEM 1. The Insured: Cape Cod Tafty Co Inc DBA: Cape Cod Water Taffy Mailing address: 984 Route 28 FEIN:"-'*` � .. ._.3oatk Yartnouth:MA 02864 _ ._ . . . _ _ . - . ..-__----— . ._ __ . ._. . Legal Entlty Type: Corporatlon Other workplaces not shown above: 2. The policy period is from 05/20/2014 to 05J20(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. Employere'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 acddent 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 06 B ._ _ . _ . _.._. D:-�'His PoI' -...__ � ca red.�_ . �cyr'.-"'�'z"� - - -- _-...�nts-and Me�ules:-SEE SEHEDULE- -- ---- - - - ---- - 4. The premium for this policy 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 Premium Basis Rates Code � Estimated � Per$700 Estimated No. � Total Mnual Of Mnual Remuneration i Remuneration Premium INTRA 0157421 � �i INTER SEEICLASS CODE SCHEDULE i '� ; � i Minimum Premium $287 Total Esymated Annual Premium $1,786 GOV GOV � Deposft Premium ' $459 STATE� Mq ppq� � MA Assessment Chg. ' $1,364.00 x 3.4000% $46 This policy,including all endorsements,is hereby countersigned by �J-'��t--�-K!/n 06/02/2014 Authorized SignaWre Date Service Office: Commonwealth Insurance Partner 54 Third Aven�e 25 Newport Ave Ext 1 st Fl Burlington MA 01803 North Quincy,MA 02171 WC 00 00 Ot A(7-11) Includes copyrighted material of the Natlonal Couneil on Compensadon Insurance, � usetl wkh its pemdssion.