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Home My WebLink AboutApplication and WC ' a TOWN OF YARMOUTH BOARD�Q�-�IE�TI�� , ,� L`�L�S [�� APPLICATION FOR LICENSE/P��T-201 ` �`- h'OV 0 ) 2011 � * Please complete Form and attach all necessary�ocu�te�Y�'b ' �'Ce � r 15 2011. Failure to do so will result in the return of your application pac et. EALTH DEPT. ESTABLISHMENT NAME: S TAX • - LOCATION ADDRESS: I '�14� ►7'lrr i ra C�-� pT•. 25Y TEL.#:(�q4 -�f 61� MAILING ADDRESS: OWNER Nt1ME:�/+�/+�'tZl kRl� q- C'2y2P. CORPORATION NAME IF APPLICABLE): U�' MANAGER'SNAME: 'Y�f=�Z'-�, l�,A�T=i_ TEL.#: �('�S( '4b75� MAIL.ING ADDRESS: �—�r��,�. POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) an�attach a copy of the cenification to this form. �. I�O�r v,�� n�rz�---f � z. a,o� m � �a�e�.— Pool operators must list a minimum of two employees currently certified in basic water safety, standazd First Aid and Community Cardiopulmonary Resuscitation (CPR). Please list these employees 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�le at your place of business. �. p�U��s.� n� ,��0 2. —Ti�x,�. � � P�-e�_ 3..(^'!�nn!�_ Ct�,'.a"S e'� 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. 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Chazge(PIC) on site during hours of operation. 1. 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee uained 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. 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIItED FEE PERMIT# LICENSE REQUIRED FEE PERMTT# LICENSE REQUIRED FEE PERMIT# _B&B $55 CABIN $55 I MOTEL $55 ��2'W3 �t i2-0 _L`viJ $�5 _CANi� $55 �-SWIMMINGPOOL $8(ka.#/2-(�S _LODGE $55 _7RAIC,ERPARK $105 IWHIRLPOOL $SOea��OO� FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PHRMIT# LICiNSE REQUIRED rEE PERMIT# _0-100 SEATS $85 1CONTINENTAL $35 �00 _NON-PROFTT $30 _>100 SEATS $160 _WMMON VIC. $60 _WHOLESALE $80 RETAIL SERVICE: —RESID.K17'CHEN $80 LICENSE REQUIRED FEE PERMTf# LICENSE REQUIRED FEE PERMIT# LICENSE R6QUIRED FEE PERMIT# _<50 sq.ft. $50 _>25,000 sq.ft. $225 _VENDING-FOOD $25 _Q5,000 sq.ft. $80 _FROZEN DESSERT $40 � _TOBACCO $95 NAME CHANGE: $15 AMOUNT DUE _ $_3 3 0.00 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*•••* ADMINISTRATION Under Chapter 152,Section 25C, Subsection 6,the Town of Yarrnouth 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. AFf�'IDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to newal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO &YOTEI.S AND OTI�IER LODGING ESTABLISHII7ENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be lnnited to the temporary and short term occupancy,ordinarily and customarily associated with motel and hotel use. Transient occupants must have and be able to demonsuate 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. a 64G or 830 CMR 64G, as amended, shall generally be considered Transient. POOLS POOL OPENING:All swimming,wading and whiripools which have been closed for the season must be inspected by the Health Deparunent prior to opening. Contact the Health Department to schedule the inspection three(3)days pnor to opening.PLEASE NOTE:People aze NOT allowed to sit m the pool azea until the pool has been inspected and opened. POOL WA1'ER 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 gound 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 Yazmouth must notify the Yumouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtaiued 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 Pernut until the above terms have been met. OUTSIDE CAFES: �:[si�e�»f��:�:;�:�:sazting saiEk�t=.�aiter,/waitess service?,T*!ust have prior apnrovaJ from the Boud of Health. OUTDOOR COOKING: Outdoor cooking,preparation,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. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQUII2ED FEE(S)BY DECEMBER 15, 2011. Ai.i. RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL O OOL '.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY B OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQLt STI'E . . DATE: b p SIGNATURE: � PRINT NAME&T1TLE: Rev.10/25/11 � The Commonwealth of Massachuselzs . DepaRmeet ojlndustrial AcciJen[s N�Ni�r�ftlfM� 600 Washington.Sbeet, 7'"F/oar Boston,Mass. 02111 - Worlcers'Compeesatio�Iwsaraett Aifldavk:._ . . . � . . � . . . , . . . _ i. .1 address_ �' � . . _____ __�-- - ��--�-� �-�i�a-� rnr�'}-- �� m��: � : �h�;rc i«ae� s• ❑ [am a homeo petfoiming all w�ic myself. ❑ I arn a sole proprietor and have no one working in any p�city. ❑ [am an dnpl r providing wockecs'compensation for my empbyees wolking am t6is job. com rne• . . � - �- - . �- t � s M- le� 6 ❑ I arn a sole proprietor,Beaeral e tor,or homeowaer(circ%ou�)and have hired ihe contrxtas hs[ed below who have tLe following wake�s'compensation po . M- fesvaKe ee. � � � . . � . . . �[ . . . . . c : �. irm�ee . . . .. . . - _. . w�ra w�r.r�.r r..e...! Fa�re r xcve a�era�e s�eqdred udv SxtlN 2SA dMC,L 131 n�kad u tle i�pniW� pu.wn.t.e.e y a si3»-».w.r o�e ynn'IeprYwmt s weY a dN pmMln � tp�,Na SI(X WORIE ORDBR ud��e M.M a dq api�st�e. I ndenh�d Uq• cepy af t64�h0ewt v�6e b o(IsYqt�ottYe DIA fir ar�er�e verlen � . !do hereby rwds MI ptIlllNtl OIplffplf NIIf M[�1�f0111/OIMI�plBl'JIlCOA00!Id ay[ d cermt s� ' nea S �� Prim oame Phom M / .ef�dd ex edy do nM wrke d t6h�rea b De''arPMed 67 dlY er Mwa e9k41 . . � eiy x tewa: P��p � �Boidm�Dep�`iment ❑cReek Himedut rtq�me 6�eqdred . ��6 Bnrd . . �Seieelmn's q6a . ❑llt+M�De��da� � rnatact P�� pYNe A; ❑qge �M1.id sy.mm� . f Wesco Insurance Company ' A Stock Insurence Company 874 Walker Rd,Suite C Dover, DE 19904 WORKERS COMPENSATION WC 99 00 Ot B AND EMPLOYERS LIABILITY 1 of4 INSURANCE POLICY INFORMATION PAGE Ncci Code: 26135 l. Insured: Policy Number: WWC3022105 Gaytri Krupa Corp. DBA: Ambassador Inn&Suites Individual Partnership 1314 Route 28 X Corporation or South YarmoUth MA 02664 Federal Tax ID: Other workplaces not shown above: Risk Id: See Extension of Information Page Renewal of: New Producer. Cazdinal Comp,LLC c/o GH Dunn Inswance Agency,Inc. 55 Counry Road Mattapoisett MA 02739 2. The policy period is from 3/9/2011 to 3/9/2012 12:01 a.m.at the insured's mailing address. 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: Massachusetts B. Employers Liabiliry Insurance: Part Two of the policy applies to work in each stated listed in item 3.A. T'he lunits of our liability under Part Two aze: State Bodily Injury by Accident Bodily Injiuy by Disease Bodily Injury by Disease MA $ 500,000 each accident $ 500,000 policy limit $ 500,000 each employee C. Other States Insurance: Part Three of the policy applies to the states,if any,listed here: Ail states except ND, OH,WA,WY and State(s) Designated in Item 3A. D. This policy includes these endorsements and schedules: WC 00 00 00 A,WC 99 00 01 B,WC 00 01 13A,WC 00 03 08,WC 00 0414,WC 20 01 01,WC 20 03 01,WC 20 03 02,WC 20 03 03C,WC 20 04 01,WC 20 04 O5,WC 20 06 01A,WC 20 06 04 4. The premium for this policy will be determined by our Manuals of Rules,Classificarions,Rates and Rating Placis. All information required below is subject to verificatian and char,ge by audit. See E�cteacion of Infomiation Page TOTAL ESTIMATED ANNUAL PREMNM 805 STATE ASSESSMENT 33 TOTAL ESTIMATED COST 838 Minimum Premium 352 Deposit Premium 838 Issue Date: 3/30/2011 Countersigned by: Authorized Representative