HomeMy WebLinkAboutApplication and WC TOWN OF YARMOUTH BOARD OF HEALTH '� �'kaASSfFD�K
` �� APPLICATION FOR LICENSE/PERMIT-5201 ' � '
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�� * Please complete form and attach all necessary documetits���ce e�l"5C2017120t0 , ��
Failure to do so will result in the return of yoi�r,8pphcation p et� ,,,_, T_"���
ESTABLISHMENT NAME: TAX ID:
LOCATION ADDRESS: I So• EL.#:
MAILING ADDRESS:
OWNER NAME: ° }�
CORPORATION NAM F APPLICABL ):
MANAGER'S NAME: �Q�-p/L_ �C�.�I-el TEL.#: -�d4'f� �f� �-(.�.��
MAILINGADDRESS: s�— Sq�-,-,.� —�
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator, as required by State law. Please list the desienated
Pool Operator(s)_and attach a copy of the certificationxo tlus fornt._ _ _---__- — . -
�. P���s h o��� 2.�?,�.�.�p�-�P
Pool operators must list a mniimum of two employees cun•ently certified in basic water safety,standard First Aid and
Commmiity Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies ofemployee
certifications to ttus form. The Health Department wili not use past years' records. You must provide new
copies and maintain a file at }�our piace of business.
I. 2.
3. 4.
FOOD PROTECTION MANAGERS - CERTIFICATIONS:
All food service establislunents az•e required to have at least one full-time employee who is certified as a Food
Protection Manager, as defined 'ui the State Sanitaiy 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 establislunent must have at least one Person In Charee (PIC) on site dming hours of operation.
1. 2.
HEIMLICH CERTIFICATIONS:
All food seivice establishments with 25 seats or more must have at least one employee ri•ained in the Heimlich
Maneuver on the premises at all times. Please list yow employees trained in anti-chokuig 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 �le at your place of business.
1. 2.
3. 4.
RESTAURANT SEATING: TOTAL #
OFFICE USE ONLY
LODGI\G:
LICENSE REQUIRED FEE PER'�fII'* LICENSE REQUIRED FEE PERVIIT.'-` LICENSE REQL�IRED FEE PERVIIT r
B&B S55 CASIN S55 1 D40I'EL S55 ��'QZSe
_ _ a Sl�'L�L�Lrn'G PQOL SROea. (�52
TNN S5i C4�P Sjj _
_LODGE S55 _TRAII,ERPARK 5105 �\y"I3IRLPOOL SSOea. �—aZI
FOOD SERVICE:
LICENSE REQUIRED FEE PERMII'= LICENSE REQU[RED FEE PER\41T- LICENSE REQUIRED FEE PERL[IT=
_0-1005EATS SSS �CON7-INENIAL S35 �14_���_O _NON-PROF[7 S30
>100 SEATS 5160 CO�fON VIC. �S60 �FHOLESALE S80
RE'I:11L SER\'ICE: —RESID.KIICHEN S80
LICENSE REQUIRED FEE PER'14II'# LICENSE REQUIRED FEE PER�fIT# LICENSE REQUIRED FEE PERYfIT#
_<SOsq.H. S50 _>25,OOOsq.ft. S2?5 _VENDING-FOOD S25
� _<25,000 sq.ft. S80 _FROZEN DESSERT S40 TOBACCO S55
�a�zE c��cE: sis AMOUnT DUE _ $ 330.00
"*""*PLEASE TLR\04ER A\D CO�fPLE'fE OiHER SIDE OF FORSi***•*
ADMINISTRATION � �
Under Chapter 152, Section 25C, Subsection 6,the Town ofYarmouth 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. AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth taxes and liens must be paid prior t renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES NO
M03`L-�LS Aivl� �7TH1�.R LODGIIV"�1�.STr�BLISHMENZ'S
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 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 sv�(6)month period. Use of a guest unit as a residence or
dwelling unit shail 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 Depaztment 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 in 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 ceRified lab, and submitted to the Health Department three (3) days prior to opening, and quarterly
thereafter.
POUL 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 ins�ected 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 Department 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.yarmouth.ma.us under Health Department,Downloadable
Forms.
FROZEN DESSERTS:
Frozen desserts mast 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 Boazd ofHealth.
OUTDOOR COOHING:
Outdoor cooking,prepazation, or display of any food product by a retail or food service establishment is prohibited.
NOTTCE:Permits run annually from January 1 to'becember 31. IT IS YOUR RESPONSIBILTTY TO RETURN
THE COMPLETED RENEWAL APPLICATION(S) AND REQUIltED FEE(S)BY DECEMBER 15, 2010.
ALL RENOVATIONS TO ANY FOOD ESTABLISfIMEN'T, MOTEL OR POOL (i.e., PAIN`PING, NEW
EQLTIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY REQUJJZ A SI P
DATE: � I � I b SIGNATURE: -�
PRINT NAME&TITLE:
io�ae�io
' �\ The Commonwea/th of Massachusetts
Departntent ojlndustria/Accidents
N/IciN�
600 Washington Street, 7`"Flaor
Boston,Mass. 02111
Worken'Compensatios Iroarance Aftidavin gai�diog/pbmbieg/Ekcfrical Confncton � �
name• rit/��YAr � ����Q�f�
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work site 1 ation lfidl addreyst .
❑ I am a homeowner perfomung all work myself. Prqect Type: �New Cw��shuction❑Remadel
❑ I arn a sole proprietor ar�d have no one wodcing in any capacity• ❑Bwiding Addition
❑ i arn an�nployer providing workers'compensation for my employecs worlcing on this job.
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❑ f am a sole proprietor,geaeral cartrxtor,or homeowner(cvc%onel and have hired the contracto�s listed below who�have
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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICV
INFORMATION PAGE
Associated Industries of M a�ng onhen ssacn�sBusUa1 Insurance Company
N(�CI NO 20 =>H
(800)876-2765
POLICY NO. VWC 8008047072010 �
PRIOR NO. VWC 8008047012009 _�
ITEM
1. !he Insured Gaytri Krupe Corp dba�uallry Inn&Suifes
Mailing Adtlress: 1314 Route 728
South Yattnou;h tv A 02 i6�t
Town or Clty Counry Slete 2 a Cotle
(No. Sttes� -
❑ Indivlduel ❑ Partnership � Corporation �.] Other
FEIN
Other workplaces not show�ebove:
2. The policy perlotl is from03/09l20�0 ��03/09/2015 _�p;p� �,m.stendard tlme at the Insured's mailing�iddress.
3. A. Workers CompensaUon Insurence: Pad Or�e o4 ths poilcy applfes to the�Norkers Compensetion Law of the states listec���here;
MA
B. Employers Llebllity Insurance: Part Two of"ra policy epplies to work in each state Ilsted in item 3.A.
The limltsof our Iiebllityunder Part Two are� Bodily Injury by Accident $__ _. 1 D 0,000 each accident
� � BodllylnjurybyDisease $._._ SOa�o00,policylimit
Bodflyln�urybyDiseaae $_ 100,000 �chemployee
C. Other States Insurance:Coverege Repl2ced�y Endorsement WC 20 03 O6A
D. This policy includes these endorsements and schedules: SEE SCHEDI;LE
4. The premium far this policy will be determined by our Menuals of Rules,Clessificetlons,Rates and Rating plens �
All informatlon requlred bebw is subJect to vedfieatlon end change by eudit.
Classiticetions Premlum Besis Rates .,
EstimateJ Per 5100 slimatetl
Cotle ToleiAnnuei ol Annuel
No. Ramunerellan Ramunerellnn 'remlum
INTRA 240870 f
i
SEE EXT �:NSION OF INFOR AT10N PAGE
Minimum premium S 234.00 Total Estimatad Annual Premium $ 992.00 �
As intlicated,interim adjustments of premium sha11 be matle: Deposit Premium $ 1,043.00
� Annually ❑ Semi Annuelly ❑ Qusdedy ❑ Mantbly �
MA Assessment Chg.
$708.70 x 72000% $51.00
This poficy,including all endorsemenTs,is hereby countersignetl by ----��_�"""�� `�--- 02/6 ir2010
. _--- ..___._...____
AuMotlzetlSigneWre � �ate
GOV GOV KIND PLACING CLAIM NAME SAFETY
STATE CLASS AUDIT OFFICE OFPlCE CHECK GROUP J J Gilmartin&Son Agency Inc
MA 9052 2 BOA 1293 Post Road
�Varwick,RI 02888
WC 00 00 Ot A(11-88)
Inclutles copytlgntetl meleri4l oi ihe Ne�ionel Councll on Compensatbn Insurance,
usetl wifh Ils Fle�mission. �