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Home My WebLink AboutApplication and WC D � d � TOWN OF YARMOUTH BOARD OF HEALTH �, APPLICATION FOR LICENSE/PERMIT - Oi� � ��C U.S PO 14 ��Zb �� * Please complete form and attach all necessary doc e ts by De e, ber EPT. Failure to do so will result in the return of your-applieation p ESTABLISHMENT NAME: �< <U Mb R r T � TAX ID• LOCATIONADDRESS: I6� S. Sho�e. � • TEL.#: 5e6-399- 9aa$ MAILINGADDRESS: S��rrno�.�.� M44 O�aC� �'t E-MAILADDRESS: '�n�,> @ Sur�co,�be� c� ��oce'�n . coM . OWNER NAME: '}�r�r� S.N G-o�-D CORPORATION NAME(IF APPLICABLE): S,,c�caMbu �n c • MANAGER'SNAME: �uSlS� s�4o�d TEL.#: 508 34� 9430 MAILINGADDRESS: �v'� 5 Sho�A �D✓. S• �ZtMGv.�� MFr O'a.�� POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as requ9red by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. i. �uS�� "��d�c� . 2. 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. �Ks��c� �nQC�IQ. 2. �2v�2� `IUC.�orov2� 3^,n d� ['o�� 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one fixll-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: -- - Bach foo� establishment must hav�at t�ast a�f'Srsori TnT'.tiarge�IC'� on site duririg hours of operation: 1. 2• ALLERGEN CERTIFICATIONS: All food service establishments aze 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 file at your place of business. 1. 2. 3. 4. RESTALJRANT SEATING: TOTAL# OFFICE USE ONLY LODGING: L[CENSE REQUIRED FEE PERMIT# LICENSE REQIDRED FEE PERMIT# LICENSE REQUIRED FEE PE�31 B&B $55 CABIN $55 I MOTEL $110 $ INN $55 CAMP $55 �SWIMMINGPOOL$ll0ea�#-IS_nSy _LODGE $55 —TRAILER PARK $105 WHIRLPOOL $ll0ea. FOOD SERVICE: LICENSE REQUIRED FEE PERM[T# LICENSE REQUIRED FEE PERMIT# L[CENSE 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: L[CENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 =<25,OOOsq.ft. $I50 =FROZENDESSERT $40 —TOBACCO $1I0 NAME CHANGE: $15 � AMOUNT DUE _ $ Z20.00 ****"PLEASE TURN OVER AND COMPLETE OTHER SI E OF FORM****• �. Y�O� ��er p�ZcA�ed Qec�d �t 3�.o� -w.�� we sa.w�a e..�y vA�r � � �i�2Sz4o i,, /o�i s� �3s— ;��s.�w+�d `-t � cws hy Dec.s� ,a.o,v, ADMINISTRATION Under Ghapter.152, SeCtion 25C, Subsection 6,the Town of Yarmauth is now required to hold issuance or renewa] of any license or permit ta oparate a business tf a person or company does not have a Certifiea#e of Worker's Compensation Insurance. Tl-IE ATTACHEI) STATE WOI2KER'S CClMPENSATION INSUI2ANCE AFFIDAVIT MLJST BE COMPLETED AND SIGNED, C1R C�RT. OF INS'URA,NC,E ATTACI�D� OR WORKER'S COMP. AFFII�AVTI' SIGNED ANI7 ATTACHED Town of Yarmouth taxes and fiens rnust be paid prior to renewal ar issuance of your permits. PLEASE CHECK EIPPROPRIATELX IF PAID: YES�_ NO MOTELS ANI3 OTHER LOI)GING ESTxiBLTSHMENTS TRANSIENT OCCi7PANCYt For purposes of'the limitations of Motel or Hotel use,Transient occupancy shall be limited to the temporaty and short term occupancy,ordinarily and customarily assoeiated with matel and hotei use. Transient occupants must have and be able ta demanstrate that they maintain a principai piace of residence elsewhere.Transient occupancy sha11 generally refer to cantinuous occupancy af not rnore than thirry(30)c�ays,and an aggregate of not rnoxe than ninety(90)days within any six(6)month period. IJse af a guest unit as a residence or dwellzng unit shall not be canszdered transient. Occupaney that is subject to fhe collectian of Room Qocupancy Excise,as defined in M.G:L. c. 64G or$30 CMR 64G, as amended, shall generally be cansidered Transient. POdLS PQOL t}PENiNG:All swimming,wading and whirlpools which have been ciosed far the season must be inspected by the Health Departrnent prior to opening. ConYact khe Health Department to schedule the inspection three(3) days prior to opening. PLEASE NQTE: People are NOT allawed to sit in the poal area until the pool has been inspected and apened. POOL WATFR TES'I'ING: The water must be tested for pseudamonas,total coliform and standard plate count by a State certified lab, and submitted to the Health Dapartment three (3} days prior to opening, and quarteriy thereafter. POOL CLOSING: Every ouidaor in ground swimming paoi must be tlrained or covered within seven{7)days of olosing. FOOD SERVICE 9EASONAL FOC►D SERVICE OPENING: AII food service establishments must be inspected by the Health Department prior to opening. Plaase contact the Health Department to schedule the inspection three (3) days prior to opening. CATGRING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Aepartment by filing the required Temporary Foad Service Application farm 72 hours prior to the catered event. These forms can be obtained at the Health Deparhnent,or frorn the Tnwn's website at www.yarmouth.ma.us under Health Deparhnent, Doumloadable Forms, FROZEN DESSERTS: Frozen desserts must be Yested by a State cerkified lab priar to opeiiing and rnonthly thereafter,with sample results submitted to the Health Department. Failure to do sa will result in the suspension ar revocation of your Frozen Dessert Permit until the abave terms have been met. C}UTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waitar/waitress service),must have prior approval from the Boazd of Health. OUTDOOR COOHING: Outdoor cooking,preparation,or display of any faod product by a retail or£aod service establishment is prohibited. NOTICE: Permits run annually from January 1 to December 3 I. I'T IS YOUR I2ESPONSIBILITY Td RE`i'tJI2N THE COMPLETED RENE,WAL APPLiGATION{S)AND REQtTIRED FEE(5}BI'DECEMBER i 5,2014. ALL RENOVATIONS TO ANY FOOB �STABI.ISHMENT, I�10TEL OR POOL (i.e., Ff1IN'T`ING, NEW BQUIPMENT,ETC.},MUST BE REP(?RTED 'l'O A1VD APPRd, 17 BY THE BOARD OF FiEALTH PRTOR TO COMMENCEMENT. RENOVATIONS MAY QUIRE A S E PLAN. DATE: ta— '� — ab��l SIGNATURE: • PRINT NAME 8c TIT'LE: ��tS 'n � tJ�� . Rev. llt43114 � '. v . � , WORKERS COMPENSATIQN AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATIQfV PAGE A.I.M. Mutual Insurance Company 54 Third Avenue, Buriington, Massaafrusetts 81803-097Q (80U)$76-2T65 NCGI NQ 2st5s PdLiGY NO. AWC-400-?426651-2014A PRIOR NO. AWG400-7026851-2013A ITEM 1. The Insured: Surfcomber tnc DBA: Maili�g address: 167 8outh Shore Drive FEiN:`="* South Yarmouth, MA 02664 Legai Entity Type: Corporation Other workplaces not shown above: See Locatian 2. The policy period is from 07/01/2074_ fo 07/01/2015 12:01 a.m. standard time at the insured's mailing address. 3. A. Workers Compensation Insurance: Par#One of the policy applies ta the Workers Campensatian�aw of the states listed here: MA B. Employers'Liability Insuranee:Part Two of the policy applies to woric in eaah state Iisted in item 3.A. The Iimits of Iiability under Part Two are: Bpdily Injury by Accident $ 560,000 each eccident Bodily Injury by Disease $ 500,000 policy limit Bodi�y Injury by Disease $ ^500,006 each emplayee C, Other States Insurance: Coverage Replaced by Endorsement WC 20 03 O6 B D. This Policy includes these Endorsements and Schedules: SEE SCHEDULE 4. The premium for ihis policy will be determined by our Manuals of Rules,Classifications, Rates and Rating Plans. All information required helow is sul�jecf to veriflcation and change by audit. Classifications Premium Basis flates � Gode Estimated Per$100 Estimated No. Tatai Annua! Of Annual Remuneration Remuneretion Premium lRITRA 120204 : INTER SE CtASS CODE SCHEDU E , L��. .._ ... ...... Minimum Aremium $284 Total Estlmated Annual Premium $3,277 --, Deposit Premium $3,373 GOV GQV �STATE CLASS � 9Q�2 MA Assessment Chg. $2,$35.Op x 3.4000% $96 This policy, including al4 endorsemeots,is hereby countersigned by �J~�"��'"�`"�`�—'^". 05(2Q12014 AuMprized Signa[ure Date Service Office: HU@ International New England 54 Third Avenue 2g9 BaI(ardvale Streei Burlington MA 01803 Wilmington,MA 01$87 WC 00 00 Ot A(7-11) Inciudes copyrighted materiai M the Netionai Counctl on Compensation tnsurance, used with its permiaBlon.