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Home My WebLink AboutApplication and WCr , -.,�- G2it_t.E kT ^ �� TOWN OF YARMOUTH�OARD OF HEALTH L�u^SCa(�� APPLICATION FOR LICENSE/PERMTI'-2011 �.. �� p7n * Please complete form and attach all necessary documents by De ember 1522�O1i7�� Failure to do so will result in the return of your applicatio a CK9LTH DEPT. ESTABLISHMENT NAME: �� TAX ID: LOCATION ADDRESS:�p 2 /�tid,wl,(�,PeAe TEL.#� SOIl' 398 p�9 MAILING ADDRESS:� (p�,��yx �e„n — ,Yi�,V,� .Ne o�GG�! OVVNER NAME: i,,,,.»�e¢ Y,ek,�tiu,TM CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME:�e�, /�lQw�,US TEL.#• Sq�j' 398 QO �T,g MAILING ADDRESS: lea�?/��k r��n POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator, as required by State Iaw. Please list the designated Pool Operator(s) and attach a copy of the certffication to this foim. _ _ 1. 2. Pool operators must list a mnumum of two employees cun•ently certified in basic water safety,standard Fn•st Aid aud Commiuiity Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies ofemployee certifications to tlus forni. The Health Department will not use past years' records. You must provide ne�� copies and maintain a �le at your place of business. 1. 2_ 3. 4. FOOD PROTECTION MANAGERS - CERTffICATIONS: All food service establislunents are required to have at least one fixll-tune employee who is certified as a Food Protection Manager, as defined in the State Sa�utary Code for Food Seivice Establishmeuts, 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. 2. PER50N IN CHARGE: Each food establislunent must have at least oue Person In Charee (PIC) on site dming hours of operation. i. ��,., �aeu�ung 2. Frzen ��+�o�-o HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Hevnlich Maneuver on the premises at all times. Please list your employees tranied in anti-choking procedw•es below azid attach copies of employee certifications to this foint The Health Department will not use past years' records. You must provide new copies and maintain a �le at your place of business. �. R�, y�� z. F�Po ��,n�n 3. vw� A2rr�ea L"eu�' 4. RESTAURANT SEATING: TOTAL # �pD 1.v/e.+�y rac�w�� 1?ft a��o �� OFFICE USE ONLY LODGI\G: LICENSE REQUIRED FEE PE&YIIT� LICENSE REQUIRED FEE PER�4Ii= LICENSE REQUIRED FEE PER�I[I'fi _B&B S55 _CABIN 555 _\10TEL 555 —� `�` _CA,'� SSy _S�i�-LYLvL�iiGPGOL SeUea. . � _LODGE S55 _TRAII.ERPARK SI05 �V-t-IIRLPOOL S80ea. � FOOD SERVICE: LICENSEREQUIRED FEE PERVIII'= LICENSEREQUIRED FEE PER\11T= LICENSEREQUIRED FEE PER�fIi= I 0.100 SEATS S85 �DO _CONIINENiAL S35 NON-PROFIT S30 _>100SEATS 5160 I CObT:�fON�'IC. S60 �_—� _�igpLESALE S80 RE7.UL SER�'ICE: —RESID.KITCHEN S80 LICENSE REQUIRED FEE PER�IIr� LICENSE REQUIRED FEE PER\III'� LICENSE REQLrIRED FEE PERtiiIT# _�50 sq.ft. S�0 _>25,000 sq.ft. 5225 VENDING-FOOD S25 _<25,OOOsq.ft. S80 _FROZENDESSERT S40 . iOBACCO S55 sa�e c��cE: sis AMOUNT DUE _ $ I 00 **"*"PLEASE TC1t\OVER A�D CO�iPLE'LE OTHER SIDE OF FOR�1""**'* ��C� t�� V ADMINIST�2ATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yazmouth 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 A'I"1'ACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVI'T MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your perntits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO MC'C�L�:�ll;C OTHER I.�DC�:G EST'AEL:S�LMENT3 TRANSIENT OCCUPANCY: For purposes ofthe limitations ofMotel 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 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: 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 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 CLOSTiVG: 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 inspect�on three (3) days prior to opening. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by Sling 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.varmouth.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 resuhs submitted to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Pemut until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e., outdoor seating with waiter/waitress service),must have prior ap�roval from the Board ofHealth. OUTDOOR COOHING: Outdoor cooking,prepazation, or display of any food product by a retail or food service establishment is prohibited. NOTICE:Permits run annually from January 1 to December 31. TT IS YOUR RESPONSIBIIITI'TO RETURN THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 15, 2010. ALL RENOVATIONS TO ANY FOOD ESTABLISHIVIENT, 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 R QUIR A SITE PLAN. DA7'E:—� SIGNATURE: PRINT NAME&TITLE: /�y J�'s87') �lr p �uro6ae ' , . :_ � . The Cominonwealth ofMassachusetts ' � DepartmentojlndWstria/Accidentc NAfCIN� 600 Washington Street, 7`"Floar Boston,Mau. 02117 Workers'Compen�ation Imorantt Aftidavit: Bui�d�ug/p�ombieg/Ekctrical Contractors Aootlear atln• W.� �M'k�bh name: d�RSS: CIIY .__..— _—..—_—__—_ - smte� no ohone# work site location!(u11 addlessl. .. �,_J [am a 6omeowner perfoawng all work myself. Pro�ect Type: �New Constrvction QRemodel ❑ I xm a sole proprietor and have no one wocicing''ui any capacity. ❑Building Addition � I arn an employer providing workcts'compensation Tor my employecs working on this job. com �ame: � � O��-�� -�r� - .�_. , _ . .� .,_ ._.. ._. _: - �`-- .aa�: �/y,�/',��_�_.`�+� /�� cid: .�ou7H vM�W1Ool.T{� AAA� o�CG� oYaeex SOS �qQ'�T �.�.nro. M ❑ [am a sole proprietor,geoenl co■trae[or,or homeowner(.vd�one)and have hired�he cuntractrns Iisted below who 6ave the Collowing waicers'compensation polices: comwov eaoe• � �dltl9• CIIY• ohoee7! is�maeee[o. M ad�o�• ehy: o�a.s N im .- tp,. . _ . . . ___ __ - _ . __ . . .. _ ._. ... n�err.+arrr�wr.r.� � ___ — -- F�Bve d acemc wmade n'<9dred��S�efN�2SA N MCL 132 eu led b 1�e . . . . . °�Y�+i+'Impr4on�eat n weY a elr/pee�Mks In�6e ferf sf a 3T0�WORK ORDER�ee ddS30�l.P�MIe da me y 4 S1.SM.0�ud�r ropy�t Hh slafemefl m�y be furw�rdM b IAe Oeke of Iw�¢�ot t6e DIA tor ovenee veri6e�IMt Y 4�m�me. 1 oednshnA that a /Io hercby cnRfy rnder Me/q�wa nwd prna!!Ia ojperjury fArt�he iwfonnafJon provlded abovt G trye iwd corrrct Signalutc � Date PrinT narpe Plrone# af5dal use oWy do na1 wrke la tNs irei te be mmpleted by dty or bwu o0ki�1 . .. . .. � . dty or towo: . Permitltleeme# QBaW11oEDeputmee[ ❑cheeY Nimmedi�4 re�peme ia rtqalred ��nE Boaid �Seka�en's(NBte . t�.d�zam� P6we q; �NQ �q�+�4est , MIIA Property And Casualty Group, Inc. � One Winthrop Square WORKERS COMPENSATION AND BOSt011, MA 02110 EMPLOYERS LIABILITY DECLARATIONS CONTRACT# 70-210 #1 MEMBER NAME AND ADDRESS: YARMOUTH,TOWN OF TOWN HALL, 1146 ROUTE 28 SOUTH YARMOUTH, MA 02664 #2 CONTRACT PERIOD: FROM 07/01/2010 TO 07/01/2011 AT 12:01 AM STANDARD TIME AT THE ADDRESS SHOWN ABOVE #3 SCHEDULE OF COVERAGES: A. Workers Compensation Coverage: Part One of the contract applies to the Workers Compensation Law of the Commonwealth of Massachusetts. B. Employer's Liabiiity Coverage: Part Two of the contract applies to work in the Commonwealth of Massachusetts. The limits of our liability under Part Two are: Bodily Injury by Accident $1,000,000 Each Accident Bodily Injury by Disease $1,000,000 Contract Limit Bodily Injury by Disease $1,000,000 Each Employee Note: Contribution: The Contribution for this contract will be determined by our Manuals of Rules, Classifications, Rates, and Rating Plans. All information on the extension of information page is subject to verification and change by audit. #4 FORMS AND ENDORSEMENTS ATTACHED TO THIS CONTRACT: DEC 9, EXTENSION OF INFORMATION PAGE, MWC 001 (0799), MWC 002 (0799), MWC 003 (0704) (07/01/2010) DEC PAGE 9