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Home My WebLink AboutApplication and WC/ AND ; � � � TOWN OF YARMOUTH BOARD OF HEAL'�'I3�" �- ' �R� . APPLICATION FOR LICENSE�PEIFMIT-2011 ,,. . � �� * Please complete form and attach a11 neces�ary dc�eumenfs by�D ember IS 20I0. � Failure to do so will result ia the retum of your applicatio a L�� ii��i. ESTABLISHMENT NAME��Gc_� �eP� � ¢ (rri�� TAX ID� LOCATION ADDRESS: ?2O �n�c �/4 TEL.#: ��2 -soC��' MAILING ADDRESS: �' �ockY�rcllc 120� /,7avn.i s /1�js o z � 38 OWNER NAME: .7amEs '��t c�i r CORPORATION NAME (IF APPLICABLE): �na E S ,�}, Lra d:r i=v c. MANAGER'S NAME: C'�r9�`�el U c7�er�e c TEL.#:SZY '7'7/_S%p MAILING ADDRESS: 1�M-�l-�,r-d POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) a�d attach a c4py of the certificati�to tlus for� __ _ _ _ _ 1. 2, Pool operators must list a minimum oftwo employees cun�entiy certified in basic water safety,standard Fnst Aid aud Conununity Cazdiopulmonary Resuscitation(CPR). Please list these employees below and attach copies ofemployee certifications to tivs forni. The Aealth Department will not use past years' records. You must provide ne�r- copies and maintain a Tile at your piace of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food sercice establislvnents az•e required to have at least one full-tnne em�loyee who is certified as a Food Protection Manaeer, as defined in t$e 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. 2. _ PERSON IN CHARGE: Each food establislunent must have at least one Person In Charge (PIC) on site durmg how•s of operation. I �YIiTf• ��e7fi<r�J�e 2 �� /a6iN HEIMLICH CERTIFICATIONS: All food seivice 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 tranied in anti-chokuie procedures below aud attach copies of employee certificatious to this forni. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. � / 1. JAn�nJ �c.r•3�� 2. �A S L✓�-f�er�� c � 3. �l Tr b,N 4, REST.A:URANT SEATING: TOTAL # OFFICE USE ONLY LODGISG: LICENSE REQUIRED FEE PERbIII� LICENSE REQUIRED FEE PER�IIT* LICENSE REQUIRED FEE PER�IIT R _B&B S55 _CABIN S55 il40TEL � S55 _INN S55 _rA��Lv c_; 5��1�MINGPOnT_ c80ea. _LODGE S55 _I"RAILERPARK SI05 �YHIRLpOOL S80ea. FOOD SER�'ICE: LICENSE REQUIRED FEE PERibIIT'�/ LICENSE REQUIRED FEE PER\-III'- LICENSE REQUIRED FEE PERbIff# �0-100 SEATS S8S I�OGp _CON'IINENI'AL 535 NON-PROFII' S30 _>IOOSEAI'S 5160 , �CO':VL'�fON�'IC. S60 -��.ny� _\sT-IOLESALE 580 RE7AII.SER�ICE: —RESID.K77CHEN S80 LICENSE REQUIRED FEE PER'�4Ir� LICENSE REQUIRED FEE PERbIII'� LICENSE REQL'IRED FEE PE&YSII'# _<50 sq.ft. S50 _>25,000 sq.ft. 5225 VEIv"DING-FOOD S25 _<25,OOOsq.ft. S80 _FROZENDESSERT S40 TOBACCO S55 �a�Ecxn�cE: s�s AMOUNTDUE _ $ i�{5.00 "*"*"PLEASE TtiR\OVER A\D CO�iPLETE OiHER SIDE OF FOR�I"**** ♦ 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 Inswance. THE ATTACHED STATE WORKER'S COMPENSAT'ION 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 pernuts. PLEASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LODGING E5'tABLISHMENTS TRANSIENT OCCUPANCY: For purposes ofthe limitations of Motel or Hotel use,Transient occupancy shall be limited to the temporary and short term 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 ofresidence 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 OPENIlVG: All 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 pnor to opening.PLEASE NOTE:People are NOT allowed to sit m the pool area 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 inspechon three (3) days prior to opening. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Departmerrt 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.yazmouth.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 Board ofHealth. _ OUTDOOR COOHING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. NOTICE:Pernuts run annually from January 1 to December 31. IT IS YOUR RESPONSIBII.ITY TO RET[JRN THE COMPLETED RENEWAL APPLICATION(S) AND REQUIIZED FEE(S)BY DECEMBER 15, 2010. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUII'MENT,ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQ RE A SITE DATF: �l .Z� /C� SIGNATURE: PRINT NAME&TITLE: J �ji0� io�oe to • ' 11-3D—'19 14;54 FBOM—BBYDEN&SULLIVAN I�5 5087901414 T-257 P603/0D3 F-069 GRANITE �JNSURANCE COMPANY 0070613-00 WC 003-7b-6258 13102 -•-------------------------•-----•---------- 013-66-0310-00 CHARTIS� _.� . JAMES A LUDIS INL � , ; 64 ROCKY R1DGE ROAO " c ' � pENN15, MA 02638-0000 A CAaRis compmy � H"4L7i-i DF"� EXECUTIVE OFfICES: SEE EXTENSION QF ITEM 7. OF THE INFORMATION PAGE - WC99D810 �75 Weter Street New Vork, NY 10098 i.D9 BRYDEN b SULLIVAN INSURANCE AGENGY INC WORKERS COMPENSATIOM AND EMPLOYERS Bg FALMOU7N RD LIABILITY POLICY INFORMATION PA6E HYANNIS, MA 02601-2759 MSUREG 1& � PREVIOUS POLICY NUMBER CORPORATIDN RENEWAL 00 42 1 OTHER WOqKPLACES NOT SNOWN ABOVE: S E FXTENSION OF ITEM 1. OF TME INFORMA710 PAGE - WC99b610 1IEM Y POLICY PEp��7k01 0.M1.standelE tlme a11M IlKulql•a mamnsada.ws FppM 03/O8/10 'ro Oj/0�/11 �a A. Workan Compansation Inwrenca: Part One of !M poliCy applias to tbe Warkers Compansation I.ew ot the StAtis ilsad her� MA 8. Employers WWlity Insuranw: Nrt Two W t119 poUOy epplies to t11a work in a9Ch stete listed 1� {t�m 3.A. � The Iimits of aur Il�bfl�ty undar PYrt Two are: btYlY Mjury Iry ACGdent S� eB1� eCCidaM 8odily In�ury 6y Disoaas f �00.000 poliry Ilmlt Bodlly Injury by Diseass S SOO.ODD ad� amployee C. Ochar SLtas Insurenea Mrt Throa of the pOlicy applle6 tD Me StatK, if�ny. IIsMd hare: SEE ENDORSENENT - WG200306A D. This poliey includes these SEE E%TENSION OF ITEM S.D. OP tME INFORMATION PAGE - WC990612 . �� 7hs promium for this pollcy will be datermfnad by our M�nuals ot Rulos, qaSSINcaGone, Rata and RNfnp llans. All iMarmadnn raquirad balow is SubJlCt 4o v9ritiutiop p11A cheilg9 6y wdlt. � eanm■ndTwei pebper EBIIMbC CI.riiliEMien9 Cotlo NVnhB� Mmunentbn =�pp pp pg AemW � Annas� 3 vwr �u^el'sib^ �Annual �3 Ywr SEE EXTENSION OF ITEM 4. OF THE INFORMATION PAGE - WC7754 -�/ TAXES/ASSESSMENTS/SURCHARGES (tUj O $66 .;� ��, 7PEN6E CON6TANT(Ef(CEPT WNtl1E APPLMdBLE BV S}ATE) 2 0 MA IWIIMIIM MlMIIYM 21 A �T��wM � Z I InEie�ltl hMOW, inOrim�4jus4oMi4 of pr�mium ahall OB m�d�: � � S�ml-AnMulry � �IRlslly � MonNp OEPO6RPNEMIUM �r �-ay�`�° �3/15/10 ASSIGNED RISK 66 "`' IBwe pet9 NeYing O%Ica AW11aliiod RBplewnlalNC WC 00 OD 01 01987 11Mve 04/09) .