HomeMy WebLinkAboutApplication and WC . ,.. Y�_ �B
TOWN OF YARMOUTH BOAR�?�OF.HEALTH � ' �
� ��� APPLICATION FOR LICENSE/PET�VI�T-`p2 1� fj `
'"' �_s � ,` � (a-� i �. -�r� � �
* Please complete form and attach all necessary docum y Dece be S 2010.
Failure to do so will result in the return of your application PT.
ESTABLISHMENTNAME:�/�S,aSs �►i�2 r��C�3 TAXID•O�{-�3T'f877
LOCATION ADDRESS:�c� ��uT.S���c.G'.N.a�1•� ln.,g�.. , S �i9l1»�da4./?l TEL #� - 9f0/
MAILING ADDRESS: /�rs .L oY /$^�i S C-�� o � G G 5!
OWNER NAME:
CORPORATION NAME (IF APPLICABLE):
MANAGER'S NAME: TEL #�
MAILING ADDRESS:
POOL CERTIFICATIONS:
The pool supervisor must be certiCed as a Pooi Operator,as required by State law. Please list the desienated
�
Pool Operator(s) and attach a copy of the certification to this forni.
l. Z,
Pool operators must list a minimum oftwo employees currently certified in basic water safety; standard First Aid azid
Community Cardiopulmonaiy Resuscitation(CPR). Please list these employees below and attach copies ofemployee
certifications to this form. The Health Department will not use past years' records. You must provide ne«�
copies and maintain a Gle at your place of business.
1• 2.
3. 4.
� FOOD PROTECTION MANAGERS - CERTffICATIONS: � •
All food service establislunents are required to have at least one full-time employee �vho is certified as a Food
Protection Manaeer, as defined 'ui the State Sanitary Code for Food Seivice Establislunents, 105 CMR 590.000.
Please attach copies of certification to this application. The Heaith Department will not use past pears'records.
You must provide new co ies and maintain a file
P , at your establishment.
1. 2: ,
� PERSON IN CHARGE: .
Eacli food estabuslunent must have at Ieast one PeTson In Charge (PIC) on site during hours of operation.
1. . Z ,
i HEIMLICH CERTIFICATIONS:
All food service establishxnents with 25 seats or more must have at least one employee trained in the Heirrrlich
Maneuver on the premises at all times. Plea'se list your employees tra'vied in anti-choknig procedures below and
attach copies of employee certificatious to this foini. The Health Department will not use past years' records.
You must provide new copies and maintain a file at ��our place of business.
1. ' 2
3. 4.
RESTAURANT SEATING: TOTAL #
LODGI\G:
OFFICE USE ONLY
LICENSE REQUtRED FEE PER'�II'I a LICENSE REQUIRED FEE PERVIIT F LICENSE REQUIRED FEE PER�III'�
_B&B S55 _CABIN S55 _D20I'EL S55
—� �„ —`�'A`�u' S�> _S��'L�LYIIIQGPOv'i S8Gea.
_LODGE S55 _TRAII,ERPARK 5105 _�LI-IIgI,pOOL S80ea.
� FOOD SER�'ICE:
LICENSE REQUIRED FEE PERbiI7# LICENSE REQL7RED FEE PER\4II'_ � L[CENSE REQ[.nRED FEE PER�Iff Y .
_0-100 SEAI'S S85 _CONTINENiAL S35 � NON-PROFIT 530 I'O�
_>100 SEATS 5160 CO'vLbION VIC. S60
— _«'HOLESALE S80
REt:1IL SER\10E:
—RESID.ffiTCHEN S80
LICENSEREQ[IIRED FEE PER�fIT= LICENSEREQUIRED FEE PER\-II'i- LICENSEREQUIRED FEE PERVIII'�
_a50sq.ti. S50 _>25,OOOsq.ft. 5225 _�'ENDQdG-FOOD S25 �
_QS,OOOsq.ft. S80 _FROZENDESSERT S40 _70BACC0 S55
�A�1E CIL�\GE: S 15 AMOUNT DUE _ $ 3 0 .o0
""'"*pLEASE I'L'R\OVER A\D CO�iPLETE OTHER SIDE OF FOR�i"**** �
.. • 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 CertiScate of Worker's
Compensation Inswance. 1'HE ATTACHED STATE WORKER'S COMPENSATION INSURANCE
AFFIDa1VIT-MUST BE COMPLETED AND SIGNED, �R .
� CERT.QF INSitRANC�ATTACHED
OR '
WORKER'S COMI'. AFFIDAVIT SIGNED AND ATTACHED
�w� 6os oq - 30�.,
Town of Yazrnouth 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 ESTA�LISHMEI�TS
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 sha11 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 aze NOT allowed to sit in 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 qnarterly
thereafter.
POOL GLOSING: 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 inspectron three (3) days prior to opening.
CATERING POLICY:
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Departmem 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 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 w�ll result in the suspension or revocation of your Frozen
Dessert Permit until the above tenns have been met.
OUTSIDE CAFES:
Outside cafes(i.e.,outdooa seating with waitedwaitress service),must have prior approval from the Boazd ofHealth. ;
OUTDOOR COOKING:
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. TT IS YOUR RESPONSIBIL.TI'Y TO RET[JRN
THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER I5, 2010. � .
ALL RENOVATIONS TO ANY FOOD ESTABLISfIMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIl'MENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
DATE: SIGNATURE: �� � ����
PRINT NAME&TITLE: Sl�rt ih,a M C �/� �� r-�- � ✓ —
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' � The Commonwerrlth ofMassachusetis
Deparhnent of[ndustria[Accidents
N�eaN�
600 Woshington Sbeet, �"Floor
i Boston,Mass. 02111
Worken'CompeesaHoa Iroarance ARidavk; gai�d�ag/pbmbi.�/Elect�M�Coetnctors �
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name: ��1� \ f �Yl y� �'A-�T (�f (�.
addnss: . — ..
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. work sih locatiao ffWl addressl� .
��.., U I�a homeowner perfomung all work myself. Pro�ect Type: ❑New Construc;don QRemodel
i ❑ I am a sole proprietor and have no one woricing in any capac;ty. �gw���g p����on
i ❑ I arn an employer providing workers'compeneation for my employees woiking on this job.
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❑ i am a sole R���,Seoeril cwtraetor,or homeowwer(ci�de on�)and have hiced the contracto�s listed below who have
the following workers'compensation polices: .
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npy af t�b afaeeseW vy 6e farw�rdM en the Oelee otl�e af tlie DIA for ar�era�e verlenlMa �r■o�.r. �ma.na■a m�,
/do kereby cereJY� �lwa and peiwhlet oJperfury lAat NYe twfonwa(lon proWAel abope Lt trre m,ArnirtcL
Signature ��(�t Datc �� ' 2.Z- /�
Print name �l� � Va� ��C S , Phone k_ �8 �'l 8- �7(}�
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, , Page � of �
� GRANiTE STATE INSURANCE C014+ANY
'� WORKERS' COMPENSATION INSURANCE AUDIT ADVICE SUMMARY
175 WATER STREET - EXECUTIVE OFFICES, NEW YORK, NY 10038
IINSURED BA55 RIVER YACHT CLUB, INC. �
POLICY PERIOD
ao eox is2 FROM: o�/o�/oe TO: o�/ot/�o
SOUTH VARMOUTH, MA 02864-0182
AUDIT PERIOD
; FROM: o�/o�/oe TO: o�/o�/�o
PRODUCER sMSTr�wiac a cuuace zNs sNc CANCELLED: ( ] PRO-RATA
386 U S ROUTE ONE [ ] SHORT RATE
FALNDGITH, ME 04105-0000
AUDIT TYPE: vo�urrtattv
IISSUE DA . >>/oe/to
� DIVISION: BRANCH: POLICY NO: DJUSTMENT:
013 ASSIC�IED RISK WC 005-09-3027 FINAL REVISED 007
---'------'--'-----'-----
013-88-0708-00
DESCRIPTION TA%ES/ASSESSMENTS/ pREMIUM
SUNCHARGES
THE PREVIOUS AUDIT DATED 09/30/70 HAS BEEN REVISED FOR THE FOLLOWING �
REASON(S) :
THE EXPOSURES WERE UPDATED FROM ESTIMATED TO ACTUAL
If you have questions about this Autlit Ativice Sumeary, please eontact the
Nitlit Department at (800) 341-5541.
For billing inqufries, please contaet Custaner Service at (S00) 645-2258.
TOTAL POLICY RE6RINERATION: 28,529
AUDIT EARIJED PREMIUM MqUNT 27 653
PRIOR ESTIMATED EARNED MIOUM 21 56g
TOTAL AP/RP AMOUNT 8 8
TOTAL AUDIT ADJUSTMENT g
THIS IS NOT A BI�L
PRIOR ESTIMATED EARNED AMdJNT IS TME ORIGINAL POLICY PREMIUM AND ALL PREMIUM BEARING EI�ORSEMENTS PLUS
INTERIM IUIDIT ADJUSTMENTS, IF APPLICABLE.
THIS AUDIT ADJUSTMENT DOES NOT REFLECT THE ACTUAL PREMIWI DUE FROM OR TO THE INSURED UNLESS ALL AMIXNiTS
PREVIOUSLY BILLED NAVE BEEN PAID.
WC990614
(Ed.4/97)(Rev'tl 12/09)