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Home My WebLink AboutApplicaiton and WC � _ �A`l51 D��0 2-T TOWN OF YARMOUTH BOARD OF HEALTT3 _ _ � �_i�� APPLICATION FOR LICEl�TSE/PERMIT- 2011� ` ~ " Please complete form and attach all necessary docum�i�De�cemb 15 201 U. =- ;:::u Failure to do so will result in the return of your 2pplicatro�2 pac t. > i��1LT,'r;33��''T. ESTABLISHMENT NAME: Rxc C�cQ Q.esoi'�' `' TAX ID: - ' LOCATION ADDRESS: Z2 �a�rT� ZY TEL.#: Sa8 -'7lS -5��9 MAILINGADDRESS: � • YFt¢-W�+�� a2�"1'i OWNER NAME: CORPORATION NAME (IF APPLICABLE): L�k��s 1-4-ns0�� '�, I nc c- _ MANAGER'S NAME: (Lv�Q S�� z¢n sl�i P TEL.#: S 4�� MAILING ADDRESS: Sc..w�- 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. _ Cli c��w. Ikae�k 2. Pool operators must list a m'viimum of two employees cunently certified in basic water safety,standazd First Aid a�id Commwiity Cardiopulmonary Resuscitation(CPR). Please list these empioyees below and attach copies ofemployee certifications to tlus form. The Health Department will not use past years' records. You must provide new copies and maintain a tile at your place of business. (1� .,��,,,n ilwr� I� � 1'y1 a2iN�� Pacak `� 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establislunents u-e requu•ed to have at least one full-time employee who is cei�tified as a Food Protection Manager, as defuied 'ui the State Sauitary Code for Food Seivice Establislunents, 105 CMR 590.000. Please attach copies of cei7ification to this application. The Health Department will not use past�-ears'records. You must provide new copies and maintain a file at your establishment. � govlovv-q S�r✓Lo,e[.��i 2. PERSON IN CHARGE; _____ _-__- _ __ _ _ - -- - --___ --- -- -_ _ ' Each food estabuslunent must have at least one Person In Charge (PIC) on site during hours of operatiou. � ��Av��c W'rrrGv� 2. HEIMLICH CERTIFICATIONS: All food seivice establishments with 25 seats or more must have at least one employee h•ained 'ui the Heimlich Maneuver on the premises at all times. Please list yom� employees tranied in anti-choking procedures below and attach copies of employee certifications to this forni. The Health Department wilt not use past years' records. You must provide new copies and maintain a file at your place of business. � rvtL[r�JS7 1'QCa�c. 2, 3. 4, RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LODGI\G: � LICENSE REQUIRED FEE PER'�III'# LICENSE REQUIItED FEE PERD4Ii= LICENSE REQUIRED FEE PER�SIT g _B&B S55 _CABIN 555 � \40TEL S55 ((�'O10 �611 –0?A --_INN � S55 _cqNrP S55 2ccr�lbL�IiNr,pppLCROea. .�,F11–n21 � � _LODGE 555 _I'RAII.ERPARK 5105 I «'FIIRLPOOL SSOea. 'I�'��'�L FOOD SER�'ICE: �' LICENSE REQUIRED FEE PERMII'# LICENSE REQUIRED FEE PER\4II'# LICENSE REQUIRED FEE PER�41T= I I 0-]00 SEAI'S S85 � (�b �CONTINENTAL 535 �'II�U3 _NON-PROFII' S30 _>I00 SEAl'S 5160 I C01�L�fON VIC. S60 I� �6� �LI-IOLESALE S80 RE7.1IL SER\7CE: —RESID.RIICHEN S80 LICENSE REQIDRED FEE PERVIIT# LICENSE REQUIRED FEE PER\31I'z LICENSE REQUIRED FEE PER��IIT< _<SOsq.B. S50 >25,OOOsq.ft. S?25 VENDING-FOOD S25 _<25,000 sq.ft. S80 _FROZEN DESSERI' S40 iOBACCO S» � �:��cE ctia�cE: sis AMOUNT DUE = S �}"�5•00 � *"***PLEASE'ILR\OVER A�D CO�iPLEtE O'IHER S[DE OF FOR�f*"*"* �_ _ � I ADMINISTRATION , I Ilnder Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal I 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 COMPENSAITON INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED � OR WORKER'S COMI'. 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 iiTf3TELS ANID f3T�E^n.LS'i.i I3GI"�i i�'.ESTA&,�iSiiNii�:N i�s TRANSIENT OCCUPANCI': 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 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, shall generaliy 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 ttu�ee(3)days pnor to opening.PLEASE NOTE: People are NOT allowed to sit m 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 Uy 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. FOOD SERVICE SEASONAL FOOD SERVICE OPENING: All food service establishments must be inspected by the Health Department prior to opening. Please contact the l-[ealth Department to schedule the inspection three (3) days prior to opemng. CA1'ERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Departmem by filing the required T'emporary 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.yazmouth.ma.us under Health Department,Downloadable Forms. FROZEN DESSERTS: Prozen 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 Pernrit until the above terms have been met. OUTSIDE CAFES: Uutside cafes(i.e..outdo�s�ating with v�taiterlwaitress service), must have prior aoproval from the Board ofHealth. 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 31. IT IS YOUR RESPONSIBILITY TO RETURN TF� COMPLETED RENEWAL APPLICATION(S) AND REQUIltED FEE(S)BY DECF.MBER 15, 2010. ALL RENOVATIONS TO ANY FOOD ESTABLISHIVIENT, 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: 1 DI Z`J �� o SIGNATURE: PRINTNAME&TITLE: [�OD4(ioc�e..vtSl.�( l�v� i0'06'10 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE Associated Industries of Massachusetts Mutual Insurance Company Burlington, Massachusetts NCCI N026158 (800)876-2765 POLICYNO. WMZ8003721 0 7 2010 ITEM PRIOR NO. WMZ 8003721012009 ' 1. The Insured Travis Hospitality Inc.dba Bayside Resort Hotel �� Malling Address: Rt 28 West Yartnouth MA 02673 � 225 Main Street � � (No. Street Town w Cky Counry State Zp CaEa . ❑ Indivltlual ❑ Partnerehip � Corporatton ❑ Other FEIN Other workplaces not show�above: 2. The policy pedod is from��072010 to 04/Ot/2011 72;01 a.m.standard tlme at the insured's mailing address. 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensetion Law of the states listed here; � MA B. Employers Liability Insurance: Part Two of the policy applies to work in each state Iisted in item 3.A. ThelimftsofourliabilltyunderPartTwoare: BodilylnJurybyAccident $ 500, 000 eachaccident � BodilylnjurybyDisease $ 500,000 palicylimit BodilylnJurybyDisease $ 500,000 eachemployee C. Other States Insurance:Coverage Replaced By Endoreement WC 20 03 O6A D. This policy includes these endorsements and schedules: SEE SCHEDULE 4. The premium for this poiicy will be detertnined by our Manuals of Rules,ClassificaBons,Rates and Rating plans. Ail information required below is subject to veriflcation and change by audit. Classifications Premium Basis Rates �e Eatlme�e0 Per$100 Estlmated No. TotelMnuel M q�y� Hemureretbn RemunareUon Pramlum INTRA 362922 SEE EXT NSION OF INFOR ATION PAGE Minlmum premium$ 234.00 Total Estimated Annual Premium $ 14,693.00 As indicated,Interim adjustments of premium shall be made: Deposit Premium $ 3,859.00 ❑ Annually ❑ Semi Annuaily ❑ Quarterly � Monthly . MA Assessment Chg. � � ' $15,880.36 x 72000% $1,143.00 This policy,including alI endorsements,is hereby countersigned by ��p QD 02/16/2010 Authotlzetl Slgnaiure oa�e � GOV GOV KIND PLACING CLAIM NAME SAFETY STATE CLASS AUDIT OFFICE OFFICE CHECK GROUP Eastern Insurance Group LLC MA 9052 8 804 0500 233 Wes[Central Street WC 00 00 01 A(11•68) Na[ick,MA 01760 IncluOes copyriphletl malerlal of the Netbnal Council on CompansaGon Insurence, usetl wllh Ita parmlasbn.