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Home My WebLink AboutApplication and WC - N d TOWN OF YARMOUTH BOARD OF HEALTH � ��° �� APPLICATION FOR LICENSE/PE 2 %utt; 'L 9 '1014 - �c3, , �: � * Please complete form and attach all necessar}z��En1��e ber I S 2014. Failure to do so will result in the return of y�ux�,�;�p�a�ho "' acld�Al EPT. ESTABLISHMENTNAME• ! `�• '� s C�t (J e �n h TAXID: /� LOCATION ADDRESS: F-Z ov� TEL.#: �o�� 9Y 7iS3 MAILING ADDRESS: �O �5 a sc 1 c� 5�`/ 0 4 r w� o � o �GG �/ E-MAIL ADDRESS: '�`l `�� l�� .'t� z' � G M 4 � � � G�^'� OWNER NAME: � C G G- ��a CORPORATIONNAME IF PLICABLE : ho�a s�4 bG `^C MANAGER'S NAME: � � �ac, �w ,r r c i . T�L.#: � 397 /d'.S°� MAILING ADDRESS•�' � o't. �a 'S-'`{ S o < r wt c� u `F� m c2 GG �F POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Pl,�ase list the c�es�nat�:l � Pool Operator(s) d attac a co of the certificati n to this form. �, ;�` -��c � p c+(a c a��P -- - ` �,,t t"�ii+' -#r� �-- � 2. � n r i r e P �a-� 1. ..� � C�acC �{`��" 1 '^_5.-.� .. Pool operatars must list a minimum of two employees currently certified in basic water safety, standard First Aid and Communiry Cardiopulmonary Resuscitation (CPR), having one certified employee on premises at all times. Please list the employees below and attach copies oftheir certifications to this form. The Health Department will not use past y ars' records. You must prov e new copies and main �n a file at your place of bus► ess. i. I \� �ac�l �� r �' �� z. �la�\�c Q�v��4 �r �f� t 3. 4. (.vil c�o.V� c v[� n R�/ IhC(J��_� � Ct�c e�Qeh FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishxnents 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. l. 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. Z• HEIMLICH CERTIFICATIONS: All food service establishxnents 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-chokmg 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. Z• 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUTAED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# L�CENSE REQUIRED FEE P RMIT# B&B $55 CABIN $55 MOTEL $l10 _0`{3 INN $55 CAMP $55 =SWIMMINGPOOL$110ea. LODGE $55 TRAILER PARK $105 _WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE p,ERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $l25 �CONTINENTA[, $35 3� S—1 NON-PROFIT $30 >100 SEATS $200 COMMON VIC. $60 WHOLESALE $80 — — —RESID.KITCHEN $SO RETAIL SERVICE: LICENSE REQU[RED 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 —FROZEN DESSERT $40 _TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE _ $ 2-5 S. O O *•***PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** KKC-�p ��'�� C��87� 42.{z`l`t� 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 WORK�R'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED� OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth tases and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES� NO MOTELS AND OTAER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be limited to the temporary and short term 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 of residence 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 shall not be considered transient. Occupancy that is subject to the coliection 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 far the season must be inspected by the Health Deparhnent prior to opening. Contact the Health Department to schedule the inspection three(3) days prior to opening. PLEASE NOTE: People are NOT allowed to sit in the pool area until the pool has been inspected and opened. POOL WATER TESTING: 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. POOL CLOSING: Every outdoor in ground swimming 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 inspection three (3) days prior to opening. CATERING POLICY: Anyone who caters within the Town of Yannouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Heatth Department,ar from the Town's website at www.varmouth.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 of Health. OUTDOOR COOHING: Outdoor 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 RESPONSIBILITY TO RETCJRN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 15, 2014. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENC ENT. RENOVATIONS MAY RE A T LAN. + DATE: �u2 p�C�v �� SIGNATURE: PRINT NAME & TITLE: �i q e- ��q�p� , S`�S i z'�v� Rev. I I/03/14 BERKSHIRE HATHAWAY workers'Comoensation and Emplover's Liabilitv Policy INSURANCE �'1O�UARD Insurence Campany - A Stock Company G UARD COMPANIES Policy Number SHWC586933 Renewal of SHWC470869 NCCI No.[25844] Policy Information Page [S]Named Insured and Maiting Address Agency Shooshalo Inc COMPUPAY INS. SVCS., INC. 1237 Route 28 1401 Forum Way South Yarmouth, MA 02664 Suite 500 West Paim Beach, FL 33401 Agency Code: FLAAOCIO Federal Employer's ID Insured is Corporation Additional Names of Insured (N2) The Eswpe Inn �Z� Policy Period From May 22, 2014 to May 22, 2015, 12:01 AM, standard time at the insured's mailing address. [3] Coverage A. Workers' Compensation Insurance - Part One of this policy applies to the Workers' Compensation Law of the following states: Massachusetts + B. Employer's Liability Insurance - Part Two of this policy applies to work in each of the states listed in item [3]A. The limits of our liability under Part Two are: Bodily Injury by Accident -each accident $100,000 Bodily Injury by Disease -each empioyee $500,000 Bodily Injury by Disease - policy limit $500,000 C. Other States Insurance - Part Three of this po!icy applies to all states, except any state listed in item [3]A. and the states of North Dakota, Ohio, Washington, and Wyoming. D. This policy indudes these endorsements and schedules: See Extension of Information Page - Schedule of Forms [q] Premium The Premium Basis and, therefore, the premium will be determined by our Manual of Rules, Classifications, Rates, and Rating Plans. All required information is subject to verification and change by audit. (Continued on another page) Total Estimated Policy Premium $ 586 TotalSurcharges/Assessments $ 11.00 Total Estimated Cost g 597.00 INTERNAL USE xx Pa9e - 1 - Information Page MGa : SHWC586933 � WC OO�OOlA Da[e : OS/07/2014 MANOTE 16 South River Street.P.O. Box A-H•Wilkes-Barre, PA 18703-0020.www.guard.com