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Home My WebLink AboutApplication and WC a TOWN OF YARMOUTH BOARD OF HEALTH APPLICATION FOR LICENSE/PE�I�==20'10 �''� G�G C�G�d�� c��t� : * Please complete form and attach all necessary do ' s by c�c er .7`��9 :, Failure to do so will result in the retum ofyoui�spplicaUon pa et. FiEAL I H utr �. NAME OF ESTABLISHMENT: � �`J' TEL. # '�l ¢3`�� LOCATION ADDRESS: � ' �: 2 � ZCG ¢ MAII,ING ADDRESS: OWNER NAME: L � TAX ID (FEIN or SSNI• ! CORPORATION NAME (IF APPLICABLE): MANAGET2'S NAME: -�'� TEL. # ' ��.� MAILING ADDRESS: �- /6 �? r�C fLD , L— 4 /h✓d GvTcH� hA-- G ZS"37 POOL CERTIFICATIONS: 1'he pool supervisor must be certitied as a Pool Operator,as uired by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to " orm. 1. 2. Pool operators must list a minimum of o employees currently certified in basic water safety,standard F'vst Aid and Community Cardiopulmonary Re citation(CPR). Please list these employees below and attach copies of employee certifications to this form. T ealth Department will not use past years' records. You must provide new copies and maintain a C t your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establislunents are required to have at least one full-time employee who is cenified as a Food Protecrion Manager, as defined in the State Sanitary Code for Food Service Establistunents, 105 CMR 590.000. Please attach copies ofcertificarion 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. /V i�"rH1$7� �f�tr��2G 2. �1 �{�u A-7tMY1J �a rG(� PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on sife during hours of operation. 1._ �A'U�- �a�A2�1.o 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 enployees trained in anti-choking procedures below and attach copies of employee certificarions to this form. The Heahh Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. �Ef�7� f'l A�o n/ 2. �fZ+9�c'�e �r(l0 /�`Rf�h� 3. /V�9-rla»n��e,� 0 P2 4. _ ��Yn r��N l�o��y N�G2 RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LODGING: L[CENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FE6 PERMIT# LICENSE REQU[RBD FEE PERMIT# _B&B $55 _CABIN $55 _MOTEL $55 �INN R55 _CAMP $55 �SWIMNIINGPOOL $80en. _LODGE $55 _TRAILERPARK $105 WI3IRLPOOL $80ea. FOOD SERVICE: LICENS$REQUIRED FEE PERMIT# LtCENSE REQUIRED �EE PERMIT# LICENSE REQUIItED FEE PERMIT�s LO-300SEATS S85 �lb-Q�a- _CONT[NENTAL S35 g NON-PROFIT S30 _>IOOSEATS $160 �COMMONVIC. $60 `#'�a�O�Gi _WHOLESALE �80 RETAIL SERVICE: —RESID.KITCHEN �80 LICENSE REQilIRED fiEE PERMI'C# LICENSE REQUIItED FEE PERMIT iJ LIC£NSE REQtJIRED FEE PERMIT a _<50 sq.ft. � $50 _>25,000 sq.ft. $225 _VENDING-FOOD S25 _QS,OOOsq.ft. $80 _FROZENDESSERT $40 � TOBACCO $55 xnME CHnNGE: 3is AMOUNT DUE _ $ ��f 5-O d •'"•"pLEA5E TURN OVER AND COMPLETE OTHER SIDE OF FORM•"•*" ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or ren`ewal of any license or pernrit to operate a business if a person or company does not have a Certificate of W�rker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSiTRANCE , AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR / CERT. OF INSURANCE ATTACHED �� OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth t�es and liens must be paid prior to renewal or issuance of yow perniits. PI,EASE CHECK APPROPRIATELY IF PAID: / YES �+ NO MOTELS AND OTHER LODGING ESTABLISHIVV �I�NTS TRANSIENT OCCUPANCI': For purposes ofthe limitarions of Motel or Hotel use,Transiern 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 mairnain a principal place of residence eLgewhere. Transient occupancy shait generally refer to continuous occupancy nf nat more th�th3rty(30) daya, and au aggregate of not more than ninety(90) days within any six(6)raonth period. Use of a guest unit as a residence or dwelling unit shall not be considered transient. Occupancy that is subject to the wllection of Room Occupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as aanended, shall generally be considered Transiart. POOLS POOL OPENING: All swimming,wading and whirlpools which have been closed for the season must bem' speded by the Health Department prior to opening. Contact the Health Departmem to schedule the inspection tl�(3)days pnor to opening.Pi,EASE NOTE:Peopie aze NOT allowed to sit in the pool area until the pool has baen inspected and opened. POOL WATER TESTING: The water must be tested for pseudomonas,totat coliform attd standard plate count by a State certified lab, and submitted to the Health Department three (3) days prior to opening, and quartecly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE CATERiNG POLICY: Anyone who caters within the Town of Yarmouth must norify the Yarmouth Heaith Deputment by filing the required Temporary Food Service Applicarion fonn 72 hours prior to the catered event. These forms can be obtained at the Health Department. FROZEN DESSERTS: Frozen desserts mast be tested on a momhty basis�y a Statecertified-lab. Test resvlts must beseat tvthe I�ealtlr Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit wrtil the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e., outdoor seating with waiter/waitress service),must have prior approval fromtheBoaz�d ofHealth. OUTDOOR COOHING: Outdoor cooking,prepazation,or display of any food product by a retail or food service establishmetrt is prohibited. NOTICE:Permits run annually from 7anuary 1 to December 31. IT IS YOUR RESPONSIBILITY TO RET[JRN Tf�COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15,2009. ALL RENOVATIONS TO ANY FOOD ESTABLISI�vIENT, MOTEL OR POOL (i.e., PAINfING, NEW EQUIPMENT,ETCJ, MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTFI PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUTRE A SITE PLAN. DATE: I I��9l� � SIGNATURE:_P �Ll,�.� ��--�— PRINT NAME&TITLE: . a �� 09/25/09 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE Associated Industries of Massachusetts Mutual Insurance Company Burlington, Massachusetts (800)876-2765 NCCI NO 26158 POLICY NO. WMZ 8003885012009 ITEM PRIOR NO. WMZ 8003665012006 i. The Insured Seafood Sam's of S.Yarmanh, Inc.dba Seafood Sam's Mailing Adtlress: 1006 Route 26 SouHi Yarmouth MA 02664 (No. Sbad Town or Cf1Y CounN Slete 2ip COOe ❑ Indivitlual ❑ Partnership � Corporetbn ❑ Other FEIN Other workplaces not shown above: 2. The pdicy period is from 04/012009 �0 04/Ot/2070 �2;07 a.m.standard time at the insuretl's mailing addreas. 3. A. Workers Compensation insurance: Part One of the poliCy applies ro the Workers Compensation Law of the states listed here; MA 8. Employers Liabiliry InsuranCe: Part Two of ihe policy epplies to work in each stata listed in item 3.A. ThelimitsofourliabitityundarPartTwoare: BoditylnjurybyA�ident$ 500,000 eachacc(dent . BodilylnjurybyDisease $ 500.000 ppp�ypRu� � � Bodilyln�urybyDisease $ 500,000 eachemployee C. Other States Insurance:Coverage Replacad By ErMorsement WC 20 03 O6A � D. This policy includes these en�rserrrents end schedules: SEE SCHEDULE 4. The premium for this policy wilt be determined by our Manuafs ot Rules,Ciaulfications,Rates and Rating plans. All infortnatlon required below is subject to verificetion and change by audit. Classifications Premium Basis Rates �e E9�imateE Per$100 EafimalBC �. Tdsl Mnuel af pM�l Remunereiion RemwaraGan Prgmlum INTRA 213458 SEE EXT NSION OF INFOR ATION PAGE Minimum premium$ 218.00 Total Estlmated Mnual Premium $ 5,467.00 As indicated,interim adjustments of premium shali be made: Deposit Premium $ 1,453.00 ❑ Mnually ❑ Semi Annually � puarterly ❑ Monthly MA Assessment Chg. $5,464.80 x 6.3000% $344.00 This policy,includirg all endorsements,is hereby countereigned by � v '�""-'� l_l�DD 02/70/2009 GOV GOV KIND PLACING CLAIM NAME SAFETY A�O��nmure Da�a STATE CLASS AUDIT OFFICE OFFICE CHECK GROUP �MA �90�9 ��4 �8p4 � . .�_--('� Rogeis&Gray Insurance Agency �WC 00 00 01 A(11-88) . . � 20 Tndependence Drive InclWpe copyriphted materiel M the Nelimel Council on Canpenselian Insurance, Hya�n�5,MA�(�1-1999 ueotl wilh iis permieelon. . A.I.M. Mutual 1989 2009 INSURANCE COMPANtES 20 Years of Exceflence in Service