The URL can be used to link to this page

Home My WebLink AboutApplication and WC �..s._-.._ . . . . � f ._-�� . . ._ ... � ^� TOWN OF YARMOUTH BOARD OF HEALTH € .,f � �� APPLICATION FOR LICENSE/PE�0,�4, � � ,. J�q �� ,� * Please complete form and attach all necessary ents by :I�rce e�r 13 �Q�3 � Failure to do so will result in the retum of yo � L�i��a c k e�-- , .�':_— � ESTABLISHMENTNAME: orn: vs �zz�. - L 'i2ZC� � D• - LOCATIONADDRESS: ��"/ 5��/� �V2. /ai'//�Oct/�i� �1� 9Z6F`1 TEL.#: 50 -,3b1-/y�j Ma�,irrG aDDxEss: 6 S �horn�-errY��. M,�-s� a-ee . �sA �z6 v 9 E-MAILADDRESS: ��,rJ�SC��,oa�,� 9mr,i,l . ��rr� OWNERNAME:�LrRSirrJ% r /,}�hul2� co�o�TroN rra� �iF arrLicaBLE�: ,�c �;z z r 1n � MANAGER'SNAME: ��brr�ini� �r�5�-ot/ TEL.#: S08-Z�D -y7,6U MAILINGADDRESS: 6'S T/iC�n,(,-erTY" Gir. sl��.�� . ,L.�i�?3 pZ6�19 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: 2. ' — Pool operators must list a minimum of two employees currently certified in basic water safety, standazd irst Aid and Communiry Cardiopulmonary Resuscitation(CPR),having one certified employee on premises at a11 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£►le at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one fuli-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. , i. �� h r�0�i r �r�'i 5 �V a. '�Gz m l �' �/ �.e, �D , K PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. 2. ALLERGEN CERTIFICATIONS: All food service establishments are required to have at least one full-time 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 copies and maintain a file at your establishment. i.�,� b ��m; r l�-ri s f� � 2. � - �-�-r`� 1� v ` . 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-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. 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT k B&B $55 CABIN $55 MOTEL $55 INN $55 CAMP $55 SWIMMINGPOOL $80ea. _LODGE $55 TRAILERPARK $105 WHIRLPOOL $SOea. FOOD SERVICE: LJCENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# I 0-]00 SEATS $85 _CONTINENTAL $35 NON-PROFIT $30 _>I00 SEATS $160 �COMMON VTC. $60 —WHOLESALE $80 —RESID.KITCHEN $SO RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <SO sq.ft. $50 >25,000 sq.ft. $225 VENDING-FOOD $25 =<25,000 sq.ft. $80 _FROZEN DESSERT $40 TOBACCO $95 NAMECHANGE: $15 AMOiTNTDUE _ $ {��'j.0� ***•"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 AFFIDAVTT 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 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, 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 Depar�ment prior to opening. Contact the Health Department to schedule the inspection three (3) days prior to opening.PLEASE NOTE:People are NOT allowed to sit in the pool area until the pool has been inspected and opened. POOL WATER TE5TING: 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 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 Health Department to schedule the inspection three (3) days prior 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 Department, Downloadable Forms. FROZEN DESSERTS: Frozen desserts must be tested by a State certified lab priar 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: Outside cafes (i.e., outdoor seating with waiter/waitress service), must have prior approval from the Boazd of Health. 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 13, 2013. 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 REQU A SIT LAN. DATE: JP�//��ZO/y' SIGNATURE: �^� 1 / ,p PRINT NAME&TITLE: L�ra-5�m��' � �u(-U/ V /_-�� Rev. 10/08/]3 • � The Commonwealth ofMassachusetts DepaKment of Industrial Accidents � O�ce oflnvestigations ' 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Leaiblv Business/OrganizationName: ,�C /'%ZZQ .Zi�t- �,�jQ �pl�� j��2 Address:��'Y cS?�`e� �,Fivt uR- �r�� City/State/Zip: �4�f�/nOLc�li, �/II� OZ66`/Phone #: .5bd'��'j/— ��lC�� Are you an employer? Check the appropriate boz: Business Type(required): 1.� I am a employer with �� employees(full and/ 5. Retail or paR-time).* 6. �RestaurantBaz/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7. � Office and/or Sales(incl.real estate, auto, etc.) employees working for me in any capacity. [No workers' comp. insurance required] 8� ❑Non-profit 3.❑ We aze a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4),and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]* 11.❑ Health Caze 4.❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.❑ Other 'My applicant that checks box#1 must also fill out the section below showing their workers'compensation policy infotmation. **If the coryorate officecs have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#L � � I am an emp[oyer that is providing workers'comp�en/sa/tion insurance for my employees. Below is the policy information. InsuranceCompanyName: /�D��//7Ct/'� /��tc,O� �j�e 1�� u/'p--/JG� �`i7y �/ � Insurer's Address: 2 2 2, f—j ��,5 S � City/State/Zip: %/-Zd�l�/�'J , �jy �Z ��Ij Policy#or Self-ins.Lic. # '�f/� ��J 7 J�,�/7 Expiration Date: Attach a copy of the workers' compensafion policy declaraHon page(showing the policy number and eapiration date). Failure to secure coverage as required under Section 25A of MGL a 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or o�e-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwazded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify,un the pain and pena[ties ofperjury that the information provided above is true and correM. Si ature: Date: � /��Z�� Phone#: Jr� � �6�—��/(�� Official use only. Do not write in this area,to be completed by city or town officiaL City or Town: y�-p�0�� Permit/License# I 'rcle one): 1. Board of Health 2. uilding Department 3. City/Town Clerk 4.Licensing Board 5. Selectmen's Office 6. er Contact Person: Phone#:_S�9-34 8—ZZ31 1C /Z�� www.mass.gov/dia ' WORKERS COMPENSATION AND EMPLOYERS' LIABILTY INSURANCE POLICY---INFORMATION PAGE INSURER: POLICY NO: p�115956A NORFOLK & DEDHAM MUTUAL FIRB INSURANCB COMPANY 222 AMES STRSHT RLNSWAL , D$DHAM, MA 02026 NCCI Company No: 21059 Account No: g63006110 FEIN: ITEM 1. NAMED INSURED AMD MAILING ADDRESS: AGENT NAME AND ADDRESS: RC PIZZA INCORPORATFsD DBA DOMINO' S PIZZA A. DAVID RISMAN INSURANCS 65 THORNBERRY CIRCLI3 AGCY MASHPEE MA 02649 689 FSLLSWAY MEDFORD, MA 02155 AGENT NO.: 2 0 7 2 2 LEGAL ENTITY: CORPORATION OTHER WORKPLACES NOT SHOWN ABOVE: (See Workers Compensation Classification Schedule) ITEM 2. POLICY PERIOD: From: 09/12/2014 To: 09/12/2015 Effective 12:01 A.M. Standard Time at the Insured's mailing address. ITEM 3. COVERAGE: 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 appiies to work in each state listed in Item 3.A. The limits of liability under Part Two are: Bodily Injury byAccident: $ 500, 000 each accident Bodily Injury by Disease: $ 500, 000 policy limit Bodily Injury by Disease: $ 500, 000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: SEE ENDORSSMENT WC 20 03 06 B D. This Policy includes these Endorsements and Schedules: See Schedule of Forms and Endorsements. ITEM 4. PREMIUM: The premium for this Policy wili be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required on the Workers Compensation Classification Schedule is subject to ve�fication and change by audit. Total Estimated Minimum Premium: $ 486 Annual Premium: $ 39, 971 Audit Period: ANNUAL Additional/Retum Premium: Comments : Issued At: Date: 08/OS/2014 Countersigned by WC 00 00 01�A Copyright 1987 National Council on Compensation Insurence ' INSURED COPV