HomeMy WebLinkAboutApplication and WC d TOWN OF YARMOUTH BOARD OF HEALTH �
��� APPLICATION FOR LICENSE/PERMIT 2,01;1 � `s
�. * Please complete form and attach a11 necessary�la�u�it�y� r 1� 2D10 � �
Failure to do so will result in the retum of your applicaUon pac et. �;,_,�3 ��, 4��A,�T�
ESTABLISHMENT NAME: l��D� ��� 0� I<,j✓1(cbCJ '� �I'AX ID:
LOCATION ADDRESS: � �G5 "'� TEL.#: -�64?- �("i
MAILING ADDRESS:
OWNER NAME: �'� r�"YVl i
CORPORATION NAME IF APP ICABLE): �o ) "�
MANAGER'S NAME: � � TEL.#:6 ' 33
MAILING ADDRESS: � S 0 G - �?�o(o `�
POOL CERTffICATIONS:
The pool supervisor must be certiTied 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. 2.
Pool operators must list a minimum oftwo employees currently certified in basic water safety, standard First Aid aud
Community Cazdiopulmonary Resuscitation(CPR). Please list these employees below and attach copies ofemployee
certifications to tivs 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 empioyee 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 wiil not use past years' records.
You must provide new copies and maintain a file at y�our establishment
I. �65`� � C ��N 1 �K_ 2. (`v t�j �O
PERSON IN CHARGE:
Each food estabfislunent musf have at teast one Person In Charge (PIC) on site duiin hours of operation.
1. c�T(,�PXI V�CR(T ( ( 2. l�(�Q�C� ��
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 aud
attach copies of employee certifications to this foim. The Heatth Department will not use past years' records.
You must provide new copies and maintain a �le at your place of business.
�1. ��� � 2. �� �ctw�C-eX
3. 4. c c�6�CI.�
RESTAU NT SEATING: TOTAL #
OFFICE USE ONLY
LODGI\G:
LICENSE REQUIRED FEE PER'�IIT?� LICENSE REQUIRED FEE PER�4IT� LICENSE REQUIItED FEE PERNIIT=
B&B S55 CABIN S55 _MOiEL 555
INN S�5 CAMP S�i _5���[�[�YIINGPOOT. SROea.
_LODGE 5» _IRAII.ERPARK 5105 _��1-IIRLPOOL S80ea.
FOOD SER�ICE:
LICENSE REQUIRED FEE PERVII7� LICENSE REQUIRED FEE� PER�4IT� LICENSE REQUIRED FEE PER�IIT�
0-100 SEA75 S85 _CONIIIVENI'AL S35 /� _NON-PROFIT S30
� >100 SEATS 5160 '�f f�D?� I C01TibION VIC. S60 .��-6�7 �_�y1-IOLESALE 580
RE7.11L SER�'ICE: —RESID.KITCHEN S80
LICENSE REQUIRED FEE PER'�II"I# LICENSE REQUIRED FEE PERbII7- L[CENSE REQUIRED FEE PER'�fII'u
_<50 sq.ft. S50 >25,000 sq.R. 5225 _VENDING-FOOD S25
_�2i,000sq.fl. S80 —FROZENDESSERI' S40 _TOBACCO . S55
���E ct��cE: sis AMOUNT DUE _ $ 220 .00
•**`•pLEASE 7L'R\OVER ASD COYIPLE'IE OTHER SIDE OF FOR�1"`*"• -
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
AFFIDAVTP MUST BE COMPLETED AND SIGNED, OR
CERT. OF INSURANCE ATTACHED
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth taa�es and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES NO
PvYOTELS Ai�TI3 O'T�EIt Y.OTiGL�iG ESTABi,iSH�'IENTS
TRANSIENT OCCUPANCY: For purposes ofthe limitations ofMotel or Hotel use, Transient occupancy shall be
limited to the temporary and short tenn 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 ofresidence 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 sha11 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
pnor to opening.PLEASE NOTE: People are NOT allowed to sit m the pool area until the pool has been inspected
and opened.
POOL WATER 1'ESTING: 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.
PUOL CI.OSING: Every outdoor in ground swirruning 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 inspect�on three(3) days prior to opening.
CATERING POLICY:
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by Sling the required
Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtvned 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 ofHealth.
OUTDOOR COOHING:
Outdoor cooking,preparation, or display of any food product by a retail or food service establishment is prohibited.
NOTICE:Pemuts run annually from January 1 to December 31. IT IS YOUR RESPONSIBILiTl'TO RETIJRN
Tf� COMPLETED RENEWAL APPLICATION(S) AND REQITIltED FEE(S)BY DECEMBER 15, 2010.
ALL RENOVATIONS TO ANY FOOD ESTABLISf�VV1EEIVT MOTE R OOL (i.e., PAINTING, NEW
EQUII'MENT, ETC.), MUST BE REPORTED OVE Y T� BOARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS AY A SI FLAN.
DATE: � � ' (� • f(� SIGNAT
PRINT NAME&TI � l
io�ae��o
� � The Commonwealth of Massachusetts
Depurtme»t af[adastrial Accidenls
M�'�N�S
60U Wcshington Streey 7"�Ftoor
Boston,Mass. 0212I
Workers'Compeneatloe Irnerance ARidavit: Baildiog/Plambieg/Elreclrkal Coatractors �
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work site(ocation(full addresyl'
❑ T�a homeowner petFortning ail wo[k myse(f. Project Type: Q New Constcuction[�Remodel
��e proptietor and have no one working in any capacity. ❑Builtling Addition
am an employer providing workees'com nsation far my emplayees working oa this job.
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� � - �� �. •��WO1LRffiRS COwP8N6ATYON AND BMPLOYERB LS7.BILITY 2N$pW�NCE CEATSAICATE - -
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' �..�. _ _- � - � . INAORHATION.FA6E � . RPNEWAL�AGR£RMENR'.._. ..-_.� � .
- .� . . . . � . �', � � . Producer: AgenL# Si8 . �
�� � MA Retail� Nerchante WC Group Inc. -� � . Thomas P 1'4efe Insuranee Ageney, I -
-_ : 10 Hritiah �rican Blvd. :� . � � - S1��Weac Cencral Screec PO 8ox K �
. � . Latham,� N7f Y2310 � ���. � _ - Franklin, MA D2038 �. �
� � (Carries Code:� 34355).� � � . � - . � . �Cercificace. #: �014005030285110 . � ' �
� � . � � � �� � � � PT10Y CCTCiflCdEe q: 014005030Z85.109 .
1. The. Employer: Ardeo - � �� . � � � � �
� � . Soueh Side �Tavern, LLC �. � � � � � �
. � . � Mailing ABdresa: 23V Whltea PaCh � � - � � . ' � � � ��� � �
. . . . - . SOuch Yax'mouch. MA 0266a - . . . � .
- � . . . . �. . � . . � . . . . � � . . . � �. � . Fein: � �
� � . Othcr Workplaces�noc showzi above: � � � _ � Type o£ -Sueiness: Limi[ed Liability Co� . .
� . .. . � � - SES SCEiEDVLE .OF OPERAT20N3 .- � . .� . . � - Aiek TD: � � �
� � � . 2. �- The cerclEicate period is, from 12:01 a.m. on 1/O1/2010 to 12:01 a.m. on . � . .
� . 1/01f2011 at. �de ineured•e mailing addreas.�. . . � � � �� �
- , 3. � A. workere Compensation Coverage: Parc One o£ che cerciPlcate appliee co che � � �
_ , . �- Workeze Compenaatloa Laa of Che atacea 1laced here: - � _ � � . �
- . . ..MA. . . . . . . � . .
B. Employera Liabilicy Coverage: Part Two of the certlEicace appliea to work in
�. . - . - ..each :etate liated in Item 3.A-. x'he limice of our liabilicy undar Part Tao are: - , � _
� - �. �- � � . Sodily Injury �y� Accident � 5 - So0.o00- each aceident � � .
� - � � Bodily. Tnjusy by DSseaee , $� 500,000� . - - cerci£ieace limit - , - � -
� - Hodily. Injury by Diaeaae � - $ 500.000� �esch employee� � -. �
� � C. oChtr Stacea Coverage: � � � - � - � . . . �. � � � � � �
� -� �D�. �Thie cezcificace includes cheee endoreementa and sehedalea: . �� � � . .
� � - � WC0060UOA(04/94) WC000308(04/8�) � W2000406A(OB/95� WC�0�414(O�f90) � WCOOOd22A(09/OB) ' . -_
_ _ _
� - . � WC200301(04/84)` WC200302(OSf86)� .WC2003030(09/991 WC200405(06J01) WCZ00601f06/92) �. � .
- �� s. 1'he concributioa far this certificace v111 be decezmined by, our Manuale of Rulee, - �
Claesifications, R.aCea and Rating Plans. All infozmaCion required below ie suhj�cc
co verificacion end change by audit. � � �. � � �
Classificationa Code Contribution Basia Race par Eecimaeed
� �- �� � . � .— - ,No. � -- Tocal Satimaced . � $100 0�� -- Annua�� � � �
- . �-�- � � — - -�—�Annual RemuneraCion � Remuneratioa ConCrtbuEion
. � � � . 9£E 3CHYDULP OP OPBRATIONS . . � . . � . . � .
� Total 8etimated Annual Contribucion 13,335.00 �. a53 DYgs �13�Sgg � . � � --
Minimum Contribution 5� 268.OD Expenee Conetanc $ - � .00 �
�... _. _ .. . :. � _`-..... . � .. ..._ .. . . _ . �.:: _ . .
-- WC 00 �00 02 AI �' ISBue Date: 1/11/201�. _ Countereig[�ed by - � � � .
�5-39�-3oy9
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, SCHEDULE .OF OPBRATIONS POR: FAGE: i .
Ardeo Ceztificate #: 014005030285.110 .
8outh Side Tavern, LLC : Fein: .
23V Whites Path .
3outh Yarmouth, MA 02664 .
OTHER WORKPLACES:' .
Ardeo . ' •
South Side Tavern, LT:C •
Kings Way
81 Kings Circuit
Yarmou[hport, MA 02675 ,
i .
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_ WC 00 06 Q1 A _ _ _
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