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Home My WebLink AboutApplication and WC �. � � . GiGCC,L�'Ol�lC'.:� TOWN OF YARMOUTH BOARD OF HEALTH �� APPLICATION FOR LICENSE/PERMIT -2015 ,la?� ? � p�� `' * Please complete form and attach all necessary documents by Decem er 1 4. Failure to do so will result in the return of your application pac CEPT. ESTABLISHMENT NAME: �r7UN�5- /�iNouri+ �.ou�tt_ ,lj��N scNao� TAX ID• LOCATION ADDRESS: ��U smnouq�E Sauni /i�n�,�un-i .M� o�c� �1 TEL.#: sa&' -39v�G3o MAILINGADDRESS: s�tmE E-MAII,ADDRESS: ��/';n��d -/e ; nz/, a. OWNERNAME: �=�Nis Un,tn+.ut� � R.ri.t`+ Scrrc� �;si��cr- CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: 126d�tlty �iQi,U', TEL.#: �� -34� - 7G0o MAILING ADDRESS:,�9(� sNtre�u rivt So�n-� �/�h��n� n+�4 daGl �f 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 Cazdiopulmonary 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 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. i. E,/�-��u�� 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hoars of operation. 1. �+�cZTI �,�z�o 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. �rLt2� �Y�Go 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 file at your place of business. 1. f�Ic�v �izco 2. 3. 4. RESTAURANT SEATING: TOTAL# --__ __ ___ _ _ __ _ - ----- - ___ OFFICE IJ�E ONLY LODGING: � � �---- LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $110 INN $55 CAMP $55 SWIMMING POOL$110ea. LODGE $55 TRAILER PARK $105 WHIRLPOOL $ll0ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE P RMIT# 0-100 SEATS $125 _CONTINENTAL $35 ( NON-PROFIT $30 15 —lSZ =>100 5EATS $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 _QS,OOOsq.R. $l50 =FROZENDESSERT $40 � _TOBACCO $I10 NAME CHANGE: $15 AMOUNT DUE _ $ WAIJCD *•***PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** 1 �� a 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 WORKER'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 taaces and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes ofthe limitations of Motel or Hotel use,Transient occupancy shall be limited to the temporary and short terxn 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 collection 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:Ali swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department 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 azea 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 Health Department,or from the Town's website at www.yarmouth.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 Boazd 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 I to December 31. IT IS YOUR RESPONSIBILITY TO RETURN 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 COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: SIGNATURE: PRINT NAME & TITLE: Rev. I UO3/14 • � �� individuai Setf-insured � �� Excess YYorkers' Compensation aEtc! � � �� Employers Liability indemniky Palicy �asaxLxxcaururn Schedule Page Foticy No.: EWC0069i'I indemnity Coverage Provided: Specific and Aggregat� Excess Workers'Compensation end Employers L'rability indemnity 1. Insured: Dennis Yarmouth Regional School District C c^-`P�n j� � J:a!`° � v LU��.`� i � 2. Mailing Address: 296 Station Avenue �'=--'�� -�� South Yarmoufh, MA 02664- 3. Mamed States: Nlassachusetts 4. Eaccluded States: None 5. Policy Periad: (�} From: 07701/2014 (b) To: 07/0112015 Both days start at 12:01 A.M. standard Yime at tha Insured's address shown in Item 2 0!this schedule. 6. Specific Retention: (a) Each Accident $450,000 {b} Each Empfoyee Yor Disease: $450,000 7. SpecifiC Eimft EBch ACcident: (aj PoSicy Part One,Warkars'C4mpensat�n: BTATUTORY (b) Palicy Part Two, Empiayers Liability: $1,0OO,OpO 8. Specific limii Each Ernpioyee for pisease: {a} Policy Part One, Workers'Compe�rsa6on: STATUTORY (b) Palicy PaR Two, Empioyers Liabit'sty: $1,OdQ000 9. Aggregate Retenfwn; (a} ftate as a Percentage ai Normai Premium: 30922% (6) Espmaked Normal Premium: $270,OOp (c} Minimum Reten6an: $918,19$ (d) Aggregate Loss Limitation: $450,�OQ i0. Aggregate k.imit: $3,OOQ,fl00 11. Ciass�calian of Operations: See Endorsement 4a? Expsrience Modification�actor. 1.Q0040QOA0 (b) Other Modification FaCtor. 1.00OOp000p CMB-SCH (&-13) 14755 Norkh Outer forty Drive,Suite 300 Chesterffeld, M6 63417 Page 1 of 2 (636} 449-7000 www.mwea.com