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Home My WebLink AboutApplication and WC � --�r—,�s � � " � TOWN OF YARMOUTH BOARD OF HEALTH U��`"�"��"'J I �� APPLICATION FOR LICENSE/PERMIT - 2015 i,��,� ; �.� .��»� `'' * Please complete form and attach all necessary documents by Dece ber 1 S 2014. Failure to do so will result in the retum of your applicatron palcke�=��' �" ' " !Y]hT�t( ,uiUDLE Sc/�IIOL __ ESTABLISHMENT NAME: r�t'�Un/�s_ ii�,ut�-rr� Qc� �..,i�,�,�.0 ��,snz�� TAX ID• LOCATIONADDRESS: yoo !f/6�rtit C.eo��cc ,2p i,�. ,L,t�.,�o�cnd .tike�� TEL.#: sor�-��-7y79 MAILING ADDRESS: 5�-ntE E-MAIL ADDRESS: �i n n�r� �y- Re o ro��cc(. K ia,rrr� , ws OWNERNAME: Di�,zec,n�,1c svtc,a� o�snz�c�- CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: �.00NE/�iLi.0 i TEL.#: s oy 39g - 7laG� MAILING ADDRESS: �yG Srvh-in.v �fvE �i,�rH ✓�hz.Hnsn� M? azroG Y 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 currently certified in basic water safety, standazd 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 file at your establishment. 1. rhu�EL ��S�C�,L�n 2. __ �'ERS9I�3��IARGE: —_ _ --_ -__ _------------ - - Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. �A«�.+�Z I�isrih[�0 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. .hukEL Vl s�cEz"rLin 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 �le at your place of business. 1. �A�.�cct (/i sccc�(�o 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 $ll0 INN $55 CAMP $55 SWIMMINGPOOL$110ea LODGE $55 1RAILERPARK $105 WHIRLPOOL $IIOea FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE P�� 0-100SEATS $125 _CONTINENTAL $35 �NON-PROFIT $30 >100 SEATS $200 _COMMON VIC. $60 WHOLESALE $80 —RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQU[RED FEE PERMIT# LICENSE REQUTRED FEE PERMIT# <50 sq ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 <25,000 sq.ft. $150 _FROZEN DESSERT $40 _TOBACCO $110 NAME CHANGE: $IS AMOUNT DUE _ $ WAIVEll ***•*PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** ADMINISTRATION Under Chapter 152, Section 25C,',Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal af any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE AT1'ACHELI STATE W072KER'S C{?MPENSATION IN3URANCE AFFIDAVIT MUST BE COMPLETED AND SIGNEll, OR CF.RT. OF INSURANCE ATTACHED�. OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal or issixance of your permits. PLEASE CHECK APPROPRIATELY IF PATD: XES__ NO MOTELS ANA OTHER LODGING ESTABLISHMENTS TRANSIEIYT OCCUPANCY: For purposes of the limitations of Mote1 or Hotel use,Transient occupancy shall be lirnited to the temparary and shart term occupancy,otdinarily and custc�marily 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 rnore Yhan thirry(30)days,and an aggregate of not more than ninety(90)days within any six(6)manth period. Use of a guest unit as a residence or dwelling unit shall not be considered transient. Qccupancy that 3s subject to the collection of Room t?ccupancy Excise,as defined in M.G.L. a 64G or 834 CMR 64Ci, as amended,shall generally be considered Transient. POQLS POOI�OPENING:All swimming,wading and whirlpools which have been closed far the season must be inspeeted by the Health Department prior to opening. Contact the Health Department to achedule the inspection three(3) days prior to opening. PLEASE NdTE: People are NO'C allowed to sit in the paol area until the pool has been inspected and opened. PQOL WATER T'ESTING: The water must be tested for pseudamonas,total coliform and standazd plate count by a State certified lab, and submitted to the Health Department three (3} days prior to opening, and quarterly thereafter. POt3L CI.{}SI.�G: Eve;y outdoar in ground scvimming pool m�st be drained or covered within seven(7)days af closing. FOOD SERVICE SEASONAL FOOD SERVICE OPENING: All food service establishments rnust be inspected by the Health Deparhnent prior to opening. Please contact the Health Degartment to schedule the iuspection three(3) days prior to opening. CATERIIYG POLICY: Anyone who caters within the Town of Yarmouth must noGify the Yarmouth Health Department by filing the required Temparary Food Servfce Application form 72 hours priar ta the catered event. Thesa forms can be obtained at the Health Department,or from the Town's website at www;yarmouth.ma.us under Health Deparhnent, Downloadable Forms. FROZEN DESSERTS: Frozen desserts must be tested by a 3tate cerfified lab prior to apening and monthly thereafter,with sampla results submitted to the Health DeparGment. Failure to do so will resuIt in the suspension or revoaation of your Frozen Dessert Permit until the above terms have been met. OUTSID� CAFES: Outside ca£es(i.e.,outdoor seating with waiter/waitress service),must have prior approval frorn the Board of Health. .—.--_ _ __ __ _ _ — — .. _ ___ _ OUTL10l]R 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 ta December 31. P['I5 YOUR RESPONSIBILITY TO RETURN THB COMPLET`ED RENI3WAL APPLICATIQN{S)AND KEQUIRBD FEE{S} BY DECEMBER 15,2Q14. �LL RENOVATIONS TfJ ANY FOOD ESTABI.ISHMENT, MOTEL OR POOL (i.e., PAINTTNG, NEW EQUIPMENT, ETC.}, MUST BE REPORTEI?T'O AND APPR{}VED BY THE BC14R.D OF HEALTH PRtOR TO CQMMENCEMENT. RENOVATTONS MAY I2EQUIRE A SITE PI,AN. DATE: SIGNATURE: PRINT NAME&TI'I'LE: Rav.i 1t03114 indivFduai Seif-Insured �� t� � Excass Workers' Gampe»saticn and L+iIISi� �� Employers Liabiiity Indemnity Policy �,t asarrr.axinsrrwrrr. � Schedute Page PoEicy No.: EWC0069i 1 indemnity Coverage Provided: Specific and Aggregate Excess WoAcers'Compensation and Emplayers liaDility#nderttnify __ �, � 1. insured: Dennis Yarmouth Regional School District - - JAIY I J %1,�1.'� 2. Mailing Address: 296 Station Avenue `�n,;'_��„� ��^ . South Yarmouth, MA 02664- 3. Narr�ed Sfates: Massachusetts 4. E�luded States: None 5. Policy Period: (a) From: 07/01/2014 (b) To: 07lOtt?01S Bath days start at 12:01 R.M. standard Nme at the Insured's address shown in Item 2 oi this schedule. 8. Specific Retentior�: (a) Each Accident: y45p,Op0 {b) Each Empioyee far D�&ease: 3450,000 7. Speciflc Limit Each Accident: {a} Policy PaR One,Wcxkers'Compensatrc�n: STATtlTORY (b) Policy Part Two, Emplayers Liability: $1,040,000 8. Specific Limit EaCh Employee far Disease: {a) Poiicy Part One, Workers'Compensadon; STATUTORY {b) Pol�y Part Two, EmRbyers i.iabifify; $1.400,{1�0 9. Aggregate Retenfron: (a) Rate as a Percentage of Nc�tmai Premium: 309.22% (b) Estlmated Narmal Premium; $27p,ppp {c) Min�num Retentian: $8i8,t96 (d) Aggregate Loss Limitatlon: $4�p,ppq 10. Aggregate Lim'rt: S3.00d,000 11. Classifipiion of Operatlons: See Endorsement (a) Experisnce Modification Factor: �,ppppppppQ (b) Other Madification Factor. �,pqpppppqp CMB-SCH (&-13) 14755 North Outer Forty Drive,Suits 300 Ghesterflekf, M4 63417 page i of 2 (b36)-049-7000 www.mwecc.cwn