The URL can be used to link to this page

Home My WebLink AboutApplication and WC � � � �- TOWN OF YARMOUTH BOARD OF HEALTH �� c� �� APPLICATION FOR LICENSE/PERMIT -2015 �A� � q ?��F # " * Please complete form and attach all necessary documents by Dece ber IS 2014. Failure to do so will result in the return of your application p ckeHEALTH DEPT. ESTABLISHNIENTNAME: ��AAvEt�c�^rwMst-� ��r.cc- TAXID• LOCATIONADDRESS: �7G Srrna� /ivc= Sw.�-n+�if,z.wauT-1 ��4 o?66i< TEL.#: S�C'-7�a-s�cc) MAILING ADDRESS: s.a� E-MAILADDRESS: /��t,'n��Cy-/�erqieKa�•Kl1.h'+h •uS OWNER NAME: Drw Ni s i��he�uuwri+ �¢.c��.J trc �tmn� r73�zi�f" CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: �.,.��u=v PQ;AJ", TEL.#: SVY >s,�'-�c ao MAILING ADDRESS: asC� S�vtrrvn� � 5 i/i4,Zdcdu iW r�'Ifi �G6� POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operatar(s) and attach a copy of the certification to this form. 1 . --_ � - - -- - �. 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 provide new copies and maintain a file at your place of business. 1. Z• 3. 4• FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one fixll-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. ��r"ssh G',,4u✓i�J 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. !/1��ics/} 1��<�!i �) 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. 1. j'1�c2�S S,4 G/�uJi.0 2. 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-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 file at your place of business. l.�/�r21?aA ��.�V .J 2. 3. 4. RESTAURANT SEATING: TOTAL# — —- -- - --- — LODGING: � LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $110 INN $55 CAMP $55 SWIMMINGPOOL$110ea. LODGE $55 TRAILER PARK $I05 WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-IOOSEATS $125 _CONTINENTAL $35 �NON-PROFIT $30 >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 —<25,000 sq.ft. $I50 _FROZEN DESSERT $40 _TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE _ $ W A lJ� *•***PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** ADMINISTRATION �� . b Under Chapter 152,Section 25C, Subsection 6,the Town oFYarmouth is now required to hold issuance or renewal c7£any lioense or permit to operate a business if a person or company daes not have a Certificate of Worker's Compensation Insurance. THE AT'!'ACHED STATE W{?RKER'S COMPENSATION IIVSURANCE AFFTDAVIT MUST BE COMPLETED AND SIGNEll, OR CERT. OF INSURANCE ATTACHFD OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTEI.GHED Town of Yarmouth taxes and liens rnust be paid prior to renewal or issuance of your perrnits. PLEASE CHECK APPROPRIATEI,Y IF PAID: YES NO MOTELS ANA OTHER LODGING ESTABLISFIMENTS TRANSIENT OCCITPANCY: For purposes of Ghe limitations of Motel or Hotel use,Transient occupancy shall be limited to the temparary and shart term occupancy,ordinarily and custornarily associated with motel and hotel use. Transient occnpants must have and be able to demonstrate that they maintain a principal place af residence elsewhere.Transient occupancy shall generally refer to continuous occupancy of not more than thirry(30)days,and an aggregate of not more than ninety(90)days within any six(6)month period. iJse of a buest uniC as a residence or dwell'sng unit sha1I not be considered transient. Occupancy that is subject to the collection of Itoam t}ccupancy Excise,as defined in M.G.L. c. 64G or$34 CMR 64G,as amended, shall generally be considered Transient. POOLS POOL OPENING:A 11 swimming,wading and whirlpools which have been ciosed far the season rnust be inspeoted by the Health Department prior to openzng. Contact the xiealth Departrnent to schedule the inspection three(3) days prior to opening. PLBASE N(JTE: People are NOT allowed to sit in the poai area until the paol has been inspected and opened. POClI.WAT�R 7"ESTING: The water must be tested for pseudamonas,total coliforn7 and standard plate count by a State certified lab, and submitted to the Health Departrnent three (3) days prior to opening, and quarterly thereafter. Pt}4L CLQS[NG:Every outdoor in ground swimmang paoi musC be drained or covered within seven(7)days af closing. FOOD SERVICE SEASONAL FOCID SERVICE OPENING: All food service estab2ishments must be inspected by the Health Department priar to openiag. Please confact the Health Departznent Yo schedule the inspection three (3) days prior to opening. CATERING PQLICI': Anyone who caters within the Town of Yartnoixth rnust notify the Yarmouth Health Department by filing the required Temporary Foad Service Application form 72 hours priar ta the catered event. These forms can be obtained at the Health Department,or from the Tawn's website at www.varrnouth.ma.us under Health Department, Downloadahle Fozrns. FROZEN DESSERTS: Frozen desserts must be tested by a State certified lab priar 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 cs�fes(i.e.,outdoar seatrng with waiter/w�itress service),must have prior approval from the Board of Health. OUTDOQR COOHING: Outdoor cooking,prepazation,or dispIay of any food product by a retail or faod service establishmen#is prohibited. NOTICE;Permits run annually from January 1 to December 31. IT I3 YOUR RE9PONSIBILI't`Y`I'O RETURN THE CdMPL�TED RENEWAL t1PPLICATION{S}AND REQUIREI}FEE(S}BX DECEMBER 15, 2014. ALL RENOVATIONS TO ANY FOOD �STABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.},MUST BE REP{7RT�D TC} AND APPROVEU BY THE BOARD f1F HEALTH PRIOR TO COMMENCBMENT. RENOVATIQNS MAY I2EQUIRE A SITF PLAN. DATF.,: SIGNATURE: PRINT NAME&TITLE: Rev. SIf03114 �a�� individuai Se1f-Insured � l Faccess Workers' Compensatian anc! � `�5�� 1�� Employers Liability Indemnity Policy �BERKLHX'CGMFANY+. . Schedu�e Page Poticy No.: EWGt106911 indemnity Coverage Pravided: Specific and Aggregate Excess Workers' Compensation end Emplpyers Liabifity Indemnity 1. Insured: Dennis Yarmouth Regional School District t:_:'�;-'.��"z"�.,=� i J?de ! � LU1�� 2. Mailing Address: 296 Station Avenue �'°_`-'�� -=�� Saatfi Yarmouth, MA p2664- 3. Named S#ates: Massach�setts 4. Excluded States: Nane ' 5. Palicy Period: (a) Fram: 07/p1/2Q74 (b} To: O7l0112415 Bath days start at 12:01 A.M. standard time at the Insured's address shown in Item 2 of this schedule. 8. Speeific Reterttion: (a) Each Accident: $450,OQ0 {b} Each Emptoyee for C?isease: �460,000 7. Specific Limit Each Accident: (a) Palicy Part One,Workers'Gompensairon: STATUTORY (b) Policy Part Two, Employers Liability: S1,OOO,DOp 8. Specific Limit Each Employee for Disease: (a) Policy Part One, Workers'Compensation: STATUTORY {b} Policy PaR 7wo, Emptoyers liabiEity: $1,fl46,a00 9. Aggregate Retention: (a) Rate as a Peresntage af Norma!Premium: 309.22% (b} Estimaked Normal Premium: $270,OOp (c) Minanum Ftetentian_ $818,196 (d) Aggregate Loss Limi2atlon: $45Q,04U 90. Aggregate�imi1; $3,Op0,400 11. Ciass�cation of Operations: Sea Endorsement (a) Experience Modification factor. 9.ORfl040000 (b) Other Modificafion Factor. 1.00OOQOOOp CMB-SCH {8-33) 14755 North Ot�ter Farty 6rive, Suite 300 Cheste�fletd, Md 63017 Page 2 of 2 (636) 449-7000 www.mwea.wm