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Home My WebLink AboutApplication and WC % _ � _ S a�s Irl a � ��u`lS�''�.iI.SL �,� TOWN OF YARMOUTH BOARD OF HEALTH �ys+a� �"�� APPLICATIONFORLICEN� T-20T�T"' ��GV 14 ��3 x * Please complete form and attach all nec " ��gn��y � m �Q2B?T- Failure to do so will result in the r �ro�ap�3liea -n . ESTABLISHMENT NAME: (�liuS i�� csQ2T TAX ID: � LOCATIONADDRESS: �f J?�'�l� Z8 TEL.#: 4�-?)c-S/oG9 MAILING ADDRESS: � , YA-2vLt aU7t� t2�A O Z�-73 E-MAILADDRESS: 2S l� Ra�,su�Crtso�f. co..�. ; OWNERNAME: /?.�� d cZen4ie[ CORPORATION NAME (IF APPLICABLE): �,-y�,�s c v w I�}�. 1 nrL . MANAGER'S NAME:_ (Lo� S 2pty�K slc-i TEL.#: 5Z£S-�7,r SL,Gy MAII,ING ADDRESS: S .tiu� POOL CERTIFICATIONS: I The pool supervisor must be certi�ed as a Pool Operator,as required by State law. Please list the designated Pool � Operator(s)and attach a copy of the certification to this form. ' 1. CF}RlS C��2,q-v� S 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standazd First Aid and Community Cazdiopulmonary Resuscitation(CPR),having one certified employee on premises at all times. Please list the employees below and attach copies of their 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. C `'��S GkA- �� S 2. IM f�R►v s� Qhc4k 3. 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 Protecfion 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�iA KA- �'jiVk c n/�E/-�-1 2. PERSON IN CF�ARGE: iEach food establishment must have at least one Person In Chazge (PIC) on site during hours of operation. I 1. ��/��L v✓.��Lf� 2. - -- i ALLERGEN CERTIFICATIONS: All food service establishments are required to have at least one full-tnne employee who has Allergen certification,as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.009(G)(3)(a). Please attach copies of � certification to this application. The Health Department will not use past years' records. You must provide new i copies and maintain a file at your establishment. 1. g 1fR�h��f �'�v�-• a n1-�t u 2. HEIMLICH CERTIFICATIONS: All food service establishxnents with 25 seats or more must have at least one employee trained in the Heimlich i 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. c�RaS RitU�€P 2. IM <1RIv5� �rtc�.�}-K 3. 4, RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �N $55 _CABIN $55 �MOTEL �$55 -0�2 . $55 CAMP $55 SWIMMINGPOOL $SOea � -c[ G�� _LODGE $55 _TRAILER PARK $105 1 WHIRLPOOL $SOea." i� FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 1 0-100 SEATS $85 �- � Z3 �CONTINENTAL $35 UZsj NON-PROFIT $30 _>i00 SEATS $160 1 COMMON VIC. . $60 � -� _WHOLESALE $80 RETAIL SERVICE: —RESID.KITCHEN $80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $50 >25,000 sq.ft. $225 VENDiNG-FOOD�$25 _<z5,000 sq.ft. $80 �ROZEN DESSERT $40 =TOBACCO $95 NAME CHANGE: $15 AMOUNT DUE _ $ [�7,j,.�; •****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** � _ �- , ' . . - . _ � ._T_ __ _ _ \ ADMINISTRATION � � Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renew9l of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Inswance. 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 Yannouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES +�/ NO MOTELS AND OTHER LODGING ESTABLISHMENTS -- - __ _ _ _ _ __ __ _ __ _ TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use, Transient occupancy shall be limited to the temporary and short term occupancy, ordinazily 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, sha11 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 prior to opening.PLEASE NOTE:People are NOT allowed to srt 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 standazd 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 ground swimming pool must be drained or covered within seven (7) days of ' closing. _ __ _ __ _ _ _ __ _FOOI3 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 witLin 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.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 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. ' OUT5IDE CAFES: Outside cafes (i.e., outdoor seating with waiter/waitress service), must have prior approval from the Board of Health. � OUTDOOR COOHING: Outdoor cooking, prepazation, or display of any food producY by a retail or food service establishment is prohibited. ' NOTICE: Permits run annually from January 1 to December 3 L IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 13, 2013. � i ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO I COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: 1►' �i�� 3 SIGNATURE: � j PRIN'T NAME&TITLE: �?-C>� S2e GZe h 5 �i �2-cS . , Rev. 10/08/13 �. � , �...� , - - ___ / • WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY ; INFORMATION PAGE A.I.M. Mutual Insurance Company 54 Third Avenue, Burlington, Massachusetts 01803-0970 (800) 876-2765 NCCI NO 26�58 POLICY NO. WMZ-800-8003721-2013A PRIOR NO. WM28003721012012 ITEM 1. The Insured: Travis Hospitality Inc DBA: Bayside Resort Hotel Mailing address: Rt 28 . FEIN:"-"" 225 Main Street ��, O�� West Yarmouth, MA 02673 \ / V Legal Entity Type: Corporation �A� 1 � 2013 Other workplaces not shown above: See Location �q�� g�y q�' s�fr� �r� ��,L 2. The policy period is from 04/01/2013 To 04/01/2014 12:01 a.m.standard time 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: MA B. Employers'Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A. The limits of liability under Part Two are: Bodily Injury by Accident $ 500,000 each accident Bodily Injury by Disease $ 500,000 policy limit Bodily Injury by Disease $ 500,000 each employee C. OtherStateslnsurance: D. This Policy includes these Endorsements and Schedules: SEE SCHEDULE 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Classifications Premium Basis Rates Code Estimated Per$100 Estimated No. Totai Annual Of Annual Remuneration Remuneration Premium INTRA 362922 INTER SEE CLASS CODE SCHEDU E Minimum Premium $281 Total Estimated Anhual Premium . $13,752 GOV GOV Deposit Premium STATE CLASS MA 9052 � MA Assessment Chg. � . $619 This policy, including all endorsements, is hereby countersigned by "�" - "--��-�-�- pypg/2013 Authotlzed Signature Date Service Office: Eastern Insurance Group LLG 'lne Lakeshore Center 233 West Central Street ridgewater MA 02324 Natick, MA 01760 WC 00 00 Ot A(7-11) Inclutlen copyrighted material of the Netlonal Councll on Compense0on Insurence, ueed wHh ite permisslon. . �