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Home My WebLink AboutApplication and WC ♦�.�+�. T / � TOWN OF YARMOUTH BOARD OF HEALTH G„L��L�O��' "DD APPLICATION FOR LICENSE�RII�IT�3fl13 , �, � ��' r"'�` .��17:� n�'i 14 ' . . * Please complete form and attach a necess oc en�y ecember IS 2012. Failure to do so will result in�h�y retj�rn.of your app icat n pIN�FdtTH DEPT. ESTABLISHMENTNAME: Fi'u+-1cid�- �s��'�" TAXID: � _ , LOCATIONADDRESS: Z2s f2-�e Zs� TEL.#: 5�% -"i7i-S(�Co9 ' MAILING ADDRESS: w 'lttR-�n.��+� V� k o2�� OWNER NAME: CORPORATION NAME (IF APPLICABLE): c�u �'c N,-,�� Q�-�a.l� t.� � � ' MANAGER'SNAME: 12od S2ocze�clu TEL.#: �oQ -�IS-Sbtp� MAILINGADDRESS: 2zs 2uuZ� Z5' W YA-2�o�R1-E ✓V�A o2c�,-l ; POOL CERTIFICATIONS: The pool supervisor must be certified 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. J lw� � 1r�.0 k- 2. Gtir,S C�ru.,e�S � Pool operators must list a minimum of two employees currently certified in basic water safety, standard 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 file at your place of business. � I� �GI/L1�(� �4!'uIL 1. d lw� tl•<. �,1.� _ 2. — 3. r �f s C��ls 4. — FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are 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. l. �JG.r�-iw*� ��w�o�nt �� i 2. �- _ �zFr?g!�?.?�?rriT!�RGEi-- _ — - - - -- -- - ._ Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. 1�� 4r V1f rr�rc�- 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 employees trained in anti-chokmg 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. lM �r �� S� .ac.c,�k 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# � B&B $55 _CABIN $55 ( MOTEL $55 ��z��j2' INN $55 CAMP $55 z SWIMMING POOL $80ea=�fL?� - I LODGE $55 _TRAILERPARK $105 I WMRLPOOL $80ea. �(� FOOD SERVICE: �I LTCENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# I 0-100 SEATS $85 ��3-a'tS �CONTINENTAL $35 _��`F� _NON-PROFIT $30 >100 SEATS $160 �COMMON VIC. $60 13-Q3r° _�OLESALE $80 -- RETAIL SERVICE: —RESID.KITCHEN $80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PEIL'v1IT# <50 sq.ft. $50 >25,000 sq.ft. $225 _VENDING-FOOD $25 . �a25,000sq.ft. $80 —FROZENDESSERT $40 _TOBACCO E95 __ NAMECHANGE: $15 AMOUNT DUE _ $ 475 •00 *****PLEASE 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 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 taaces and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES *� NO MOTELS AND OTHER LODGIN� ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes ofthe limitations ofMotel or Hotel use,Transient occupancy shall be limited to the temparary 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 thiriy(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 I� 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 far the season must be inspected by the Health Department prior to opening. Contact the Health Department to schedule the inspection three(3)days ', I' pnar to opening. PLEASE NOTE: People aze NOT allowed to sit m the pool area until the pool has been inspected ' � and opened. ', PGOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standazd plate count b� a State certified lab, and submitted to the Health Department three (3) days prior to opening, and quarterly I� tYiereafter. f POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of i , closing. � FOOD SERVICE ' I 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 priar 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.varmouth.ma.us under Health Departsnent, j 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. OUTSIDE CAFES: Ou1�id_e c�'es(i.e.,atttdQor seating�xith waiter/suaitress serviael,m�as1 have pri�ra}�}�rov 1 frnm h RoartlQfI3ealth ___- __ OUTDOOR COOHING: 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 3 L IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 15, 2012. 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 COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ' DATE: � I • �2 . �2 SIGNATURE: ��2— PRINT NAME & TITLE: R–�D Zl�c-2 e�e(�( Gi vLt , Rev. 10/09/12 . , —L._._ . WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE Associated Industries of Massachusetts Mutual Insurance Company 54 Third Avenue, Burlington, Massachusetts 01803 - (800)876-2765 NCCI N026758 POLICY NO. yyryQ g003721012012 PRIOR NO. W(�g003721 0120 7 1 ITEM 1. The insured Travis Hospitaliry inc.dba Bayside Resort Hotei � Mail Address: R�28 West Yartnouth MA 02673 225 Main Street � S[reet No. Town or Ciry County State Zip Code FEIN � ❑Individual ❑Partnership �Corporation OJointVenture �Association ❑Other � Otherworkplaces notshown above: . - 2. The policy period is from 04l01/2012 to 04/01/2013 12:01 a.m.standard time at the insured's mailing address. 3. A. Workers Compensation Insurence:Part One of the policy applies to the Workers Compensation Law of the states listed here; MA B. Employers Liability Insurence:Part Two of the policy appiies to work in each state listed in item 3.A. The limits of our liabiliry under Part Two a2: Bodily Injury by Accident$ 500.000 each accident � Bodiy Injury by Disease $ 500.000 oolicy limit � Bodily Injury by Disease $ 500.000 each employee C. Other States Insurance:Coverage Replaced By Endorsement WC 20 03 O6A D. This policy includes these endorsements and schedules:SEE SCHEDULE � 4. The premium for this policy will be detertnined by our Manuals of Rules,Classifications,Rates and Rating plans. � All infortnation required below is subjed to verification and change by audR. Class�cations Premium Basis Rates Cotle Estimetetl Per$700 Estimeted No. Tatel Mnual � IN Mnual Rertwneretion Remareretion Premium � INTRA 362922 SEE E ENSION OF INFORMATI N PAGE Minimum premium$ 231.00 Total Estimated Annual Premium $ 15,144.00 As indicated interim adjustmeMs of premium shall be made: Deposit Premium $ 4,028.00 ❑ Annually ❑ SemiAnnuaily ❑ Quarterly � Monthly � MA Assessment Chg. $16,404.64x 5.9000% $�8�� l_.�-� This policy,including all endorsements,is hereby countersigned by 02/09/2012 AuthaizeE Sipne4ue Date GOV GOV KIND PLACING CLAIM NAME SAFETY Eastern Insurence Group LLC STATE CLASS AUDIT OFFICE OFFICE CHECK GROUP �233 West Centrei Street . MA 9052 S 804 0500 Natick,MA 01760 WC 00 00 01 A Q-11) InGutlas copynghtetl matenal of the Nelionel Council on Cwnpensation Insurence, used with its permission. '