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Home My WebLink AboutApplication and WC, � , � � TOWN OF YARMOUTH BOARD OF HEALTH '�i5��'�� APPLICATION FOR LICENS �UtC Z 9 Z014 ` * Please complete form and attach all neces , c�o � e,p��ece ber IS 2014. Failure to do so will result in the re�of 1tf'appl#cation pa et EPT. ESTABLISHMENT NAME: I�� AT �P� C o� TAX ID: LOCATIONADDRESS: �} SuMMEK ST , yFlRriouTr{ PoRT TEL.#: Sog 37S oS90 MAILING ADDRESS: P O (3 0 l� 37 I �` E-MAILADDRESS: Sha� Inn 0.�Cq��God-cor� OWNERNAME: M1GH8�t t HE�-EnJ GASSEL.S CORPORATION NAME (IF APPLICABLE): TH E 1�1 N H T �R�E CoD , ��. C MANAGER'S NAME: 0� S �.b o,/� TEL.#: a5 o.b a�� MAILING ADDRESS: ' ' 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. 2. Pool operators must list a minimum of two employees c ntly certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation , having one certified employee on premises at all times. Please list the employees below and attach co ' of their certifications to this form.The Health Department will not use past years' records. You must ovide new copies and maintain a Tle at your place of business. 1. Z• 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments aze 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/l Cg,SS ��S 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Chazge (PIC) on site during hours of operation. � C��-F a1 LA-SS� � - _ 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. i. N e�v� �sre�s 2. N��} HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at le e employee trained in the Heimlich Maneuver on the premises at all times. Please list your emplo ained in anti-choking procedures below and attach copies of employee certifications to this form. T a th Department will not use past years' records. You must provide new copies and maintain a your place of business. 1. 2• 3. 4. RESTAURAN�' ATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $110 LINN $55 -�! -OOS CAMP $55 _SWIMMING POOL$1 IOea LODGE $55 TRAILERPARK $105 _WHIRLPOOL $ll0ea FOOD SERVICE: '�' LICENSE REQU[RED FEE P IT# LICENSE REQUIRED FEE PERMTT# LICENSE REQUIRED FEE PERNTIT# LO-t00SEATS $125 �s 13�I CONTINENTAL $35 � NON-PROFIT $30 " >I00 SEATS $200 I COMMON VIC. $60 �6�J j _WHOLESALE $80 — —RESID.KITCHEN $80 RETAIL SERV[CE: LICENSE REQUIRED FEE PERMIT# LICENSE 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 $I10 NAME CHANGE: $15 AMOUNT DUE _ $ 2�4 O.00 *****PLEASE TURN OVER AND COMPLETE OTIIER SiDE OF FORM***** �G`'^ �Z�O`Q(� C� 37_tS�( l�Z�`l`� AnmirrisTuaTio�v ~ Undet Chapter 152,Section 25C, Subsection 6,the Town of Yarmauth is now required to hold issuance or renewal of any license or permit to operate a business if a person or cotnpany does not have a Certificate of Worker's Campensation Insurance. TFIE ATTACHEI? STATE W012KER'S COMPENSATI4N INSUR.ANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, pR CERT. dF 1NSURANCE ATTACHGD� OR WORKER'S COMP. AFFTI:3AVIT STGNED AND ATTACHED Town of Yannouth taxes and liens rnust be paid prior to renewal or issuance ofyour permits. PLEASE CI�CK �PPROPRIATELY IF PAID: YES � NO _ MOTEL3 AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For gurposes of the limitations of Ivlotel or Hotel use,Transient oocupancy shall be limited to the temporary and short term occu�ancy,ordinarily and customarily associated with motel and hotel use. Transient occupants must have and be able to demonstt-ate that they maintain a principa] place af residence elsewhere.Transient occupancy shall generally refer to continuous occupancy of not more than thircy{30)days,and an aggregate of not more than ninety(90)days within any six(6)month period. Use of a guest unit as aresidence or dweliing unit shall not be considered transient. 4ccupancy that is subject to the collection of Room Oocupancy �xcise, as defined in M.G.L. c. 64G or 834 CMR 64G, as amended, shall generally be conszdered Transient. POClLS PQOL OPENING:All swimming,wading and whirlpaols which have been closed for the season must be ittspected by tha Health llepartment prior to opening. Conlact the Health Department to achedule the inspection three(3) days prior to opening. PLEASE NdTE: Peopla are NOT allowed to sit in the pool area unril the paol has been inspected and opeiled. P40L WATFR TESTING: The water must be tested for pseudpmanas,total coliform and standard plate count by a State cerfified Iab, and submxtted to the Health Department three (3) days pxior to opening, and quarterly thereafter. POCiL CLOSING: Every outdoar in ground swimming pool rnust be drained or cavered within seven{7}days of olosing. FdOD 9ET2VICE SEASONAL FOOD SERVICE OPENING: A11 faod service establishments must be inspected by the I Iealth Department prior to opening. Pleasa contact the Health Department to schedule the iaspection three{3}days prior to opening. CATERING P{}LICY: Anyone who caters within the Town of Yaamouth rnust notify the Yazmouth Health Department by filing the required Temporary Foad Service Appiicatian form 72 hours priar to the catered event. These farms can be abtained at the Health Department,ar from the Town's website at www.yarrnouth.ma.us under Health Deparhnent, Do�vnloadable Forms. F120ZEN DESSERTS: Prozen desserts must be tested by a State certified lab prior to opeizing and monthly thereafter,with sample results submitted to the Health Department. Failure to do so will result in the suspension or revooation of your Frozen Dessert Permit untii the above terms have been met. QUTSIDI; CAFES: Outside cafes(i.e.,autdoor seating with waiter/waitress service),must have prior approval from the Board of Health. OUTDOOR COOHING: Outdaor cooking,preparatian,or dispIay of any food product by a tetail or food service establishment is prohibi#ed. NOTICE:Permits run annually frorn January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETiJRN THE COMPLETEA RENF,WAL AI'PLICATION(S}AND REQUIRED FBE(S)BY I3ECEMBER 15, 2414. ALL RENOVATIONS T(7 ANY FOOD ESTABLISHMENT, MO'T'EL OR POOL (i.e., PAINTING, NEW EQLIIPMENT,ETC.}, MITST$E REPQItTED TO ANL?APPRC7VEI}BY THE B0.4RD OF HEALTH PRIt3R TO COMMENCEMENT. RENOVATIONS MAY 12EQIJIRE A SITI. PLAN. DATE: ! �T�-'� J !� SIGNATURE: �'�r—C-s:�i-� PRINTNAME & TI1'LE: �e.rPll �9,Ss�1S Cn-fl��e1' Rev.i1f03174 IVOTICE � NOTICE TO TO EMPLOYEES < EMPLOYEES The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston, Massachusetts 02111 617-727-4900 - http://www.mass.gov/dia As required by Massachusetts General Law, Chapter 152, Secrions 21, 22 & 30, this will give you norice that I (we) have provided for payment to our injured employees under the above-menrioned chapter by insuring with: NORFOLR & D$DHAM MUTUAL FIR13 INSIIRANCI3 COMPANY N FIN URAN E MPANY 222 AMBS STRSLT, DSDHAM, MA 02026 AD RE F W13084424A 12/O1/2014 POLI Y ER EFFECTIVE DATES 434 RODTS 134 SOIITH ROGSRS & GRAY INS. AGBNCY, INC DBNNIS, MA 02660 SOIITH DBNNIS OFFICB URANCE ADDRESS P ONE# 4 SLTMMER ST. 508-790-0590 THS INN AT CAPB COD, LLC YARffiOIITBPORT MA 02675 EMI'LOYER ADDRESS 10/21/2014 EMPLOYER'S WORKERS'COMPENSATION OFFICER(IF ANS� AfiE MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers'Compensarion Act. A copy of the First Report of Injury must be given to the injured employee. The empioyee may select his or her own physician. The reasonable wst of the ser- vices provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably connected to the work related injury. In cases requiring hospital attenrion, employees are hereby notified that the insurer has arranged for such attenrion at the NAME OF HOSPTI'AL ADDRESS TO BE POSTED BY EMPLOYER Form WC 88 20 07 C Printed in U.S.A. INSURED COPV