The URL can be used to link to this page

Home My WebLink AboutApplication and WC. ! � t �.�. ` � TOWN OF YARMOUTH BOARD OF H AL�`'�� Cc,n��SSioN �� APPLICATION FOR LICENSE/PERMI -2D1!$ ? � 9n 1 F �T�7 * Please complete form and attach all necessary doc en r 1 4 Failure to do so will result in the return of yo /fihlf SCltoe� ESTABLISHMENTNAME:_I��v.nlis !/ilXruo��/t-Ni2c-��,v,i��,fa�� I��rJ�/Cz- TAXID: LOCATION ADDRESS: �Z�a s7�na.vih�E Sa,�m ��h�tiuw.��ri hrA ��Gr,s� TEL.#: MAILING ADDRESS: s�.uc E-MAILADDRESS: �/�n�`��y-VpelnnQl , K�2 �rm .u( OWNERNAME: I�-.�NiJ ��{,¢.uouri pe�iural xk�cd �ir1�2�c,� CORPORATION NAME(IF APPLIC�BLE): MANAGER'S NAME: �o a Ncy r',Qiu� TEL.#: �8'-39 Y- 7�Ov MAILINGADDRESS: o29b ST'h-iuu /1vE .biwri-I 4�Mc�cn1 �A 0zG6�/ 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 provide new copies and maintain a file at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments aze 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. �/�'lilt�lS Jt)VNl,�1•U - Z. �E177'/ YILESfWC7J0 PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. l�iV�/IS `�C�va�1sG� 2. X�7N PllEasU2a� � 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 Establishxnents, 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. (7(�An�tS Dtrvu�Srr�U 2. l��-r�+ �r2�s�cuo 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-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. 2. 3. 4. RESTAURANT SEATING: TOTAL# _ -- -----�FF7CF, LISE 91YI Y__ _ _ _ --— ---_-- - --- ---- — --__ LODGING: �-� LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $SS CABIN $55 MOTEL $I10 _I1ViV $55 � CAMP $55 SWIMMING POOL$l l0ea. _LODGE $55 _TRAILERPARK $105 WHIRLPOOL $110ea FOOD SERVICE: � LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE P R�T$_ 0-100 SEATS $125 _CONTINENTAL $35 �NON-PROFIT $30 f5'�3 >100 SEATS $200 _COMMON VIC. $60 WHOLESALE $80 RETAIL SERVICE: —RESID.KITCHEN $80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUTAED 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 _ $ 1),){��V� *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** � t � ADMINISTRA'TION ' ' 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 businass i£a person or company does not have a Certificate of Worker's Compensation Insuranee. TI3E ATTACHED S'TATE WQI2KER'S COMPENSATION INSIIRANCE AFFIDAVIT 1VIUST BE COMPLETED AND SIGNED, OR CERT. OF iNSURt�NCE A'CTACH�D OR WORKER'S COMP. AFFR)AVI'I`STGNBD AND ATTACHEF3 Tawn of Yarmouth taxes and liens tnust be paid priar to renewal or issuance of your permits. PI.EASE CHECK APPROPRIATELX IF PAID: YES,� NO MOTELS AND OTHER LODGING ESTABLISHMEIVTS TRANSIEN7'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 austornarily associated with motel and hotel use. Transient occupants must have and be able to demonstrate that they maintain a principai place af residexica elsewhere.Transient occupancy shal l generally re£er to continuous occupancy of not more than trurry(30)days,and an aggregate of not mote than ninety(90)days within any six(6)manth periad. i Tse of a guest unit as a residence or dwe2ling unit shall not ba cansidered transient. Occupancy that is subject ta the colfection of Room Occupancy Excise, as defined in M.G.L. a 64G or 834 CMR 64G, as amended, shall generally be considered Transient. raar�s P4QL OPENING:All swimming,wading and whirlpools wh3ch have been ciased far the season must be inspeoted by the Health Department prior to opening. Contact the Health Departrnent to schedule the inspection three(3) days prior to opening. PLEASE NOTE: People are NQT allowed to sit in the poa] area until the poal has been inspected and opened. POClL WATER TESTING: "1'he water must be tested for pseudomonas,total coliforrn and standard plate count by a State certified lab, and submitted to the Health Department three (3) days prior to o�ening, and quarterly thereafter. P(}QL CLQSING: Every outdoar in ground swimming pooi must be flrained or covered within seven(7)days of closing. FOOD SERVICE SEASONAL FOOD SERVICE OPENING: All food service establishments must be inspe�cted by the Fteaith Department prior to opening. Please contact the Health Department to schedule the inspection three(3) days prior to opening. CATERING POLICX: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application farm 72 haurs priar to the catered event. These forms can be obtained at the Health Deparirnent,or from the Town's website at www.varmouth.ma.us under Health 17eparhnent, Downlaadable Forms. FROZEN DESSEI2TS: Frozen desserts must be tested by a State certified 1ab prior to opeixing and monthly thereafter,with sample results submitted to the Health Depariment. Failure to do sa will result in the stzspension or revocation of your Frazen Dessert Permit untii the above ternts have been met. dUTSIDG CAFES. Outside eafes(i.e.,outdoor seating with waiter/waitress service),must have prioc approval from the Boazd of Health. OUTDOOR COOHING: f7utdoor 000king,preparation,or display of any food pzoduct by a zetail or faod service establishment is prohibited. NOTICE:Permits run annually from January 1 ta December 3 I. IT IS YOUR RESPONSIBILI'1'Y Td R�Tt3RN THB COMPLETEI3 RENEW.�.L APPLICATION(S}AND REQIJIRt"sD FEE{S}BY DECEMBER 15, 2014. ALL RENOVATIONS TO ANY FOOD EST1iBI.ISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.}, MUST BE FZEPORTED TO AND APPROVED BY THE BOAKD OF HEALTH PRIOR 'I"O COMNIENCEMENT. RENOVATIONS NL#Y REQUIRE A SITE PLAN. DATE: SIGNATLJRE: PRINT NAME& TITLE: Kev.ift431i4 . �� individuai Setf-Insured �� Eucess Workers' Gompensatian and Emplaysrs 1_iability Indsmnity Poiicy �BERKLBY'CCNfPANY�� . Scfiedule Page Poticy No.: EWC006911 Indemnity Goverage Provided: Specific and Aggregake Excess Warkers'Compensatian and Empiayers Liability Indemnity 1. (nsured: Dennis Yarmouth Regional Schtxol District C c^^^P,n^� � J�!�: ± u !Ll`!;,, ; � i 2. Mailirsg Address: 2�Station Avenue �'''x'�.� South Yarmouth, MA 02664- 3. Named States: Massachusetts 4. Excluded St�tes: None 5. Policy Period: (a) From: 47l41l2414 (b) To: O7l01l2415 Both days start at 12:01 A.M. standarcf iirne at the insured's address shown in item 2 af this scheduie. 6. Specific Ratention: (a) Each Accident ��O�d� (b) Each Emptoyee for DiseBse: $450,000 7. Specific Limit Each Accident: (a) Pakicy Part OnB,Workers' Compensat�n: STATllTORY (b} Policy PartTwo� Emp{oysrs Liability: S1Ad0,600 8. Specific Limii Each Empioyee far pisease: {a} Palicy Part One,Waricers'Cornpensation: STATt1TORY (b) Policy Past Two, Employers Lisbility: $1,4dp,000 9. Aggregate Retention: (a} Rate as a Psrcentage af Narmaf Premium: 3d922`Yo (b) Es6mated Normat Premium: $270,000 (cj Min9mum Reten6an: 5818,196 (d) Aggregate Loss Limitation: 5450,000 'I0. Aggregate LimiC $3,ODO,OqO 11. Ciass'fiication of dperatfans: See Endotsement (a) Experience Modificafion Factor. 1.000044000 (b) Qther Modification Factor. i.000000000 CMB-SCM (8-13} 14755 North puter frorty Drive, Suite 300 Chestefield, MQ 63417 Page 1 of 2 (636) 449-7000 www.mwacc.com