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Home My WebLink AboutApplication and WC _ LRys�p a.-r _, TOWN OF YARMOUTH BOARD OF HE�,i,TH ��r �D APPLICATIOPI FOR LICENSE2,��-2�� °`Please complete form and attach all�►eces�do�by m l��1 3� �d0�9 Failure to do so will result in th�re�"urc��f�ybw applicatxon �i n utr� • NAMEOFESTA$LISHMENT: Fx�.�s�D� Q��o27 TEL. # �'1�-St�C.q LOCATION ADDRESS: 2'7� 2fi �k MAILING ADDRESS: w , i�Q- vV1 A o2.�v73 OWNERNAME: TAX ID (FEIN or SSNI: CORPORATION NAME (IF APPLICABLE): "Tn+-��s {-}us�,-�-c I�d-.� I N� MANAGER'S NAME: (�d S Qo ez.e•nsli-i TEL. # 9l�-Sb t.9 MAILINGADDRESS: Caw.e POOL CERTIFICATIONS: - The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated - - -�ool-0perator(s)-and attach a copy of the certificarion to this form. __ ____ _ _ L c�ra aMPS 11�-qu� 2. Pool operators must list a minunum 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 maintafn a �le at your place of business. 1, clu,N,es Tk�c�k 2. Man�sz P�c4k 3. 4. FOOD PROTECTION�fANAGERS - CERTIFICATIONS: All food service establishments aze 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 applicarion. The Health Department will not use past years' records. You must provide new copies and maintain a file at your estab6shment. 1. l�W b ara 4j inna n e l�� 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Chazge (PIC) on site during hours of operation. 1. Fra�nk v�ru��¢�n 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 tunes. Please list your enployees trained in anti-chokwg procedures below and attach copies of employee certificarions to ttris form. The Health Departroent will not use past years' records. You must provide new copies and maintain a file at your place ot business. L @.A�Jn.el P��-c.kel 2. 3. ^ 4• RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FE£ PERMI7# LICENSE REQUIRED FEE PERMIT# B&H $55 � CABIN $55 ,�MOTEL S55 # �0-O�(o �1NN $55 _ _CAMP $55 2 SWIMIvIlNG POOL $80ea. N• �_ ��2yS LODGE $55 _TRAII.ER PARK $105 I WI3IRLPOOL S80ea. �t o�6t O FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQLJIRED FEE PERMIT# LICENSE REQUIIiED FEE PERMTI# �0-100 SEATS S85 '� IO _(xj�j 1.CONTINENTAL $35 �l0-b�j �NON-PROFIT $30 >1005EATS $160 I COMMONVIC. $60 � �-6 � _WHOLESALE $80 RETAII.SERVICE: —RESID.KITCHEN S80 LICENSE REQUIItED FEE PERMI'I N LICENSE REQUIItED FEE PERA9T# LICENSE REQLJIRED FEE PERMIT# ,_<SOsq.ft. 850 _>25,OOOsq.ft. 5225 _VENDING-FOOD S25 . _QS,OOOsq.ft. S80 _FROZENDESSERT $40 �TOBACCO $55 xnMECSntveE: sis AMOUNTDUE _ $ '{-75.Oa '•""•PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM•""*" -_ _ _ _ _ ADMIl�TISTRATION � � Under Chapter 152, Section 25C, Subsection 6,the Town of Yazmouth is now required to hold issuance or renewal of any license or pemut to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE A7"1'ACHED STA1'E WORKER'S COMPENSATION INSURANCE . AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACI�D � OR WORKER'S COMI'. AFFIDAVIT SIGNED AND ATTACHED Town of Yaimouth t�es and liens must be paid prior to renewal or issuance of your pernuts. PLEASE CHECK APPROPRIATELY IF PAID: YES ✓ NO MOTELS AND OTHER LODGING ESTABLLSHMENTS TI2ANSIENT OCCUPANCl': For purposes ofthe limitarions of Motel or Hotel use,Transient occupancy shall be limited to the temporary and short term occupancy, ordinarilq and customarily associated with motel and hotel use. Transient occupants must have and be able to demonstrate that they maintain a principal place ofrevdence elsewhere. Transient occupancy shall generally refer to cominuous 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 noY be considered transient. Occupancy that is subject to the collection of Room Occupancy Excise, as defitted 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 wluch have been closed for the season must be inspected by the Health Depamnent prior to opening. Contact the Health Departmem to schedule the inspectiott three(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 cotiform and standard plate coum by a State certified lab, and submitted to the Health Department three (3) days prior to opening, and quartetly _ thereafter, POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(�days of closing. FOOD SERVICE CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Departmern by filing the required Temporary Food Service App&cation form 72 hours prior to the catered event. These forms can be obtained at the Health Department. FROZEN DESSERTS: - Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Peamit until the above tetms have been met. OUTSIDE CAFES: Outside cafes(i.e., outdoor seating with waiter/waitress service),must have prior approval&om the Board ofHeahh. OUTDOOR COOIQNG: Outdoor cooking,preparation,or display of any food product by a retail or food service establishmart is prohibited. NOTICE:Permits run annually from January 1 to December 31. TT IS YOUR RESPONSIBII.ITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15, 2009. ALL RENOVATIONS TO ANY FOOD ESTABLISI�vIENT, 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 REQUTRE A SITE PLAN. DATE: 1 I • �o , � q SIGNATURE: �— PRINT NAME&TITLE: 2o D G 2o cz C �nsl-r,� M4 2 09l25/09 • - WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE Associated Industries of Massachusetts Mutual Insurance Company Burlington, Massachusetts NCCI N026158 (800)876-2765 POLICY NO. WMZ 8003721012009 PRIOR NO. WMZ 8003721012008 ITEM 1. The Insured Trevis Hospitaltty Inc.dbe Bayside Resort Hotel Mailing Address: Rt 28 West Yartnouth MA 02673 225 Main Street (No. Street Torm or Ciry Counry S�ate Zip Cotle ❑ Individual ❑ Partriership � Coryoretion ❑ omar FEIN . Other workplaces not shown above: - 2. The policy period is from 04/Ot/2009 to 04/01/2010 �2;01 a.m.standard time at the insured's malling address. 3. A. Workers Compensation Insurance: Part One of the policy applies M tha Workers Compensation Law of the states listed here; MA B. Employers Liability Insurance: Part Two of the policy app8es to work in each state listed in item 3.A. ThelimitsofourllablllryunderPartTwoare: BodilylnjurybyAccident$ 500,000 eachaccident BodilylnjurybyDisease $ 500,000 policylimit BodilylnjurybyDisease $ 500,000 eachemployee C. Other Sffites Insurance:Coverege Replaced By Endorsement WC 20 03 06A D. This policy includes these endorsemen4s and schadules: SEE SCHEDULE 4. The premium for this policy wlil be detertnined by our Manuals of Rules,Clessifications,Rates and Ratlng plans. Ali infortnetlon required below is sub�ect to verificatlon and change by eudit. . Classificatlons Premium Basis Rates �e Eatlmatetl Per$100 Eslimeted � � Tofal Mnuel ot Annufll Remu�reretlon Remunerallon Premlum INTRA 362922 SEE E)(T NSION OF INFOR ATION PAGE Minimum premium$ 234.00 Total Estimated Annual Premium $ 13,716.00 As indicated,interim adjustments of premium shall be made: Deposit Premlum $ 3,661.00 ❑ Annually ❑ Semi Annually ❑ DuarteAy � Montldy MA Assessment Chg. $14,697.78 x 6.3000% $826.00 This policy,including all endorsements,is hereby countersigned by ��`-'�l�e-YXR 02/06/2009 ANhorizetl SlgnaNre D8[e GOV GOV KIND PLACING CLAIM NAME SAFEf'Y STATE CLASS AUDR OFFICE OFFICE CHECK GROUP Eastem Insurance C,roup LLC . MA 9052 804 0500 233 West Cen[ral S[reet WC 00 00 01 A(11-88) Natick,MA 01760 Inclutlea cap/rlphteC meterlel M Ihe Natbnal CounGl an Canpenaelbn Insurence. ' usetl wkh Its pertnlssion. A.I.M. Mutual 1989 2009 INSURANCE COMPANIES 20 Years of Faccellence in Service