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Home My WebLink AboutApplication and WC, ' �" . ,-a'`"� � a TOWN OF YARMOUTH BOARD OF HEALTH Q��s�°"`' .;�r ' ` APPLICATION FOR LICENSE/PERMIT -2015 ro� Ja�� i 3 2ot * Pleas complete form and attach all necessary documents by Dece ber I S 2014. 'lure to do so will result in the return of your application pa ket}{EALTH DEPT. ESTAB�ISH yAME: Irl.taric-e�� Siu.tu �L�nrniySr/�.�L TAXID• LOCA DRESS:��rhhs�.uf C�u� �,�-+ (�,- T✓�rY[._z �taunt ,sv1- TEL.#: 5zsz »Y �f� MAILING ADDRESS: S� '3 E-MAIL ADDRESS: /� n:� 'v� d�rc�;wo! �c�1 �4 c�a OWNERNAME: 17�tits I�uurr� Qcb-iaY✓ytc ScnecY. r'J <Y�� CORPORATION NAME (IF APPLICABLE): MANAGER'SNAME: �oc,vei PQ��1% TEL.#: �ob' -39�-�6ao MAILING ADDRESS: �74 6 simru�v Av� Sour�+ �/AA.vu�� /YIA- a16G 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, 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 prov�de 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. `l}`Tfi 7E"- �.e FF�Nu 2• _ 13EIZJOI�INCHA1RCiE: -- ----- Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1.�� S.JD 2. 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. �. c�� .� 2. r 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 a11 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 file at your place of business. l. �st�y /l��FiNa 2. 3.^-- 4. RESTAURANT SEATING: TOTAL# --- -_ - _ — _ _ _ _ OFFIC� USE a1VZY - - -__ __ _ LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERM[T# B&B $55 CABIN $55 MOTEL $l10 INN $55 CAMP $55 SWIMMINGPOOL$IlOea LODGE $55 7'RAILERPARK $105 _WHIRLPOOL $IlOea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# L�ENSE REQUIRED FEE PE,J2MIT$� 0-100 SEATS $125 _CONTINENTAL $35 NON-PROFIT $30 �/s l >100 SEATS $200 � COMMON VIC. $60 WHOLESALE $80 � — —RESID.KITCHEN $80 RETAIL SERVICE: � LICENSE 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. $150 —FROZENDESSERT $40 _TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE _ $ l�A 1✓G—l� *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM**•*• ,.. ; nni�ilrns�ruamlaN , . Under Chapter 152, Section 25C,Subsection 6,the Town of Yannauth is now required ta hold issuanoe or renewal of any Iicense or permit ta operate a business if a person oc company does not have a Certificate of Worker's Compensation Instcrance. THE ATTACHEll STATE W012KER'S COMPENSATtON INSUI2ANCE AFFTDAVIT MUST BE COMPLETF,b AND SIGNED, UR CF,R"Z'. QF iNSURANCE A'CTACHED OR WORKER'S COMP. AFFII7AVIT SIGNED AND A'I'TACHED 'Town of Yarmouth taxes and liens rnust be paid prior to renewal ar issuance of your permits. FLEASE CHBCK APPROPRIA,TELX IF PAID: YES iV0 MOTELS AND OTHER LODGING FSTABLISHMEN'I'S TRANSIENT OCCUPANCY: For purposes ofthe limitations of Motel or Hotel use,Transient occupancy shall be limited to the temporary and short tezm occupancy,ordinarily and customarily associated with motel and hotel use. Transient accupants must have and be able to desnanstrate that they maintain a princigal place of residence elsewhere,Transient occupancy shall generally re£er to continuous occupancy of not more than thirty(30)days,and an aggregate o£not more than ninety(90)days within any six(h)month period. Use of a guest uniC as a residence or dwelling unit shall not be cansidered transient. t?ecupancy that as subjecti to the collectian af Roam Occnpancy Excise,as defined in M.G.I,. c. 64G ar$30 CMI2 64G, as amended, shall generally be considered Transient. roa�.s POOL OPENINCG:All swimming,wading and whirlpoals which have been closed for ttte season must be inspected by the Health Departrnent prior to apening. Contact the Health Departrnent to schedule the inspectian three(3) days priar to opening. PLBASE NOTE: People are NOT allowed to sit in the pool area untii the poat has been inspected and opened. PQOL W ATER TESTING: The water must be tested for pseudamanas,total coliforrn and standard plate count by a State certified Iab, and submitted to the Health DepartrnenC three (3) days prior to opening, and quarterly thereafter, i'OQL�LQSI1tiG: Every outdaor in ground swin=ming paal nust be drained or coverad within seven{7}daps nf closing. FO011 SERVICE SEA30NAL FOOD SERVICE OPENIN(>: .A,II food service establishments must be inspected by the Iiealth Depariment prior to opening. Please contact the Health Departrnent to schedule the inspection three{3) days}�rior to opening. CATERING P4LICY: Anyone who caters within Yhe Town o£Yarmouth must notify the Yannouth Health Department by filing the reqwred Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health L7epartment,or fram the Town's website at www.�n2nnouth.ma.us under Health Department, Downloadabie Forms. FROZEN DESSERTS: Frozen desserCs 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 sp will result in the suspension or revooation of your Frozen Dessert Permit until the abave 2erms have bcen met. f1UTSIDE CAFES: _ _ Qutside ca£es(i.e.,outdoor seating with waiter/waitress service),must have prior approval,from tha Board of Health. OUTDOOR COOHING: Outdaor cooking,preparation,or display of any faod pzoduct by a retail ar food service estabtishment is prohibited. NOTICE.Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILII'I'TO RE"PtIRN THE COMPLETED RENEWAL APPLICATION{S)AND REQLTIRED FFE(S}BX DECEMBER I5, 2di4. ALL RENOVATIONS TQ ANY FOQD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NI;W EQUIPM�NT, ETC.},MUST BE REPORTED TO AND APPROVED BY THE BOARI}OF HEALTH PRIQR TO COMMENCEMENT. TtENOVATIONS MAY REQUIRE A SITE PLAN. DATP: SIGNATURE: PRINT NAME& TITLE: Rev.11103t14 � �� ,�,��:�.,i�� individuai Seif-insured l�,,., "�� Excess Workers' Com}sensation artd r+A.'f�1 �� Employers Lfability Indernoity Palicy �BERKLBY'CA!'dPdZ+tY�� ' Scheduie Page PoEicy No.: EWGOO6Si 1 indemnity Coverage Providad: Specific and Aggregate F�ccess Workers' Compensation and Empioyers Lia4itity lndemoity 1. tnsured: Dennis Yartnouth Regional School District G=,_...��'�__'� f J?d`e ! ,5 Ll��.`� s 2. Mailing Address: 296 StaCion Avenue F r�-'�� -=� South Yarmouth, MA 02664- 3, Nemed 8tates: Massachnsetts 4. Excluded States: Nane 5. Poficy Reriocl: (a} From: 071p112014 (ta) To: 4710112015 Both days start at 12:01 A.M. standard time at the Insured's address shown in Item 2 of this schedule. 8, Specific Retention: {a) Each Accident: g450,00Q {b) Each Emplayee far E?isease: ' $450,400 7, Spec�c Limit Each Accident: {a) Policy Part Qne,Warkers'Compensation: S3RTUTORY (b) Policy Part Two, Employers Liability: $1,000,000 8. Speciflc Limit Each Er�t�toyee tor Disease: (a) Policy Part One, Workers'Cornpensation: STATUTORY {b) PaC�ey Part Two, Erttpioyers liabiiitp: $1,000,000 9, Aggregate Retention: {a) Etate as a Perc�ntage of Nwmai Premium: 34922% (b) EsUmated Nprmal Premium: $27p,00p (c) Minimum Reten6an: $818,19& (d) Aggregate Loss�imitation: $450,004 1Q. Aggregate�imit: $3,000,004 71. Ciassif'�calion of Operations: See Endorsement (a) Experience Madification factor: 1.000400000 (b) Other Modiflcafion FaCtor. 1.000000000 CAiB-SCH {8-13) 14755 North Outer Wrty Orive,Suite 300 Chestertleid, M4 fi3417 Page 1 of 2 t�6) 449-7000 www.mwetc.wm