HomeMy WebLinkAboutApplication and WC `= o��i�
'a TOWN OF YARMOUTH BOA,RI�_OF�EALT�I
k� � APPLICATION FOR LICENS�� P�'•= Q�d ; ,_v I � �Q13
* Please complete form and attach all nece�sary #��� �c
Failure to do so will result in the return of your applicat '
ESTABLISHMENT NAME: �'IyJ ' G S 'ZZ�- ID: .'S�—=-`��v� ' ' 7
LocaTiort aDD�ss: � U; h ;+� 'S f�� �h .5 YQ�mou�l, a1/� �266�L.#: .so�-.s-6i/r�/
MAILING ADDRESS:��-Thornbc��� Ci����.ee ,�r/� 026'h'9
E-�,ADD�ss: .�r_ dzhu.l�✓� �amc�s�. r,e-f _
OWNERNAME: �'rQsimir Dz ec, � Y
CORPORATION NAME (IF APPLICABLE : KG �/�22 Q . LrIG.
MANAGER'S NAME: i n_ u e� 2 ic TEL.#: .3'p —6 /— ZOo2
MAILINGADDRESS: �ST�h�rtih�rry G'r� Q l�Sl�.T � v2.�'�/%
POOL CERTIFICATIONS:
The pool supervisor must be certiGed 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. Z•
Pool operators must list a minimum of two employees currently certified in basic water safety, standazd First Aid and
Community Cardiopulmonary 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 wilt not use past
years' records. You must provide new copies and maintain a Tile at your place of business.
l. 2•
3. 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 wi11 not use past years' records. You must
provide new copies and maintain a file at your establishment.
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PERSON IN CHARGE:
Each food establishment must have at least one Person In Chazge (PIC) on site during hours of operation.
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ALLERGEN CERTIFICATIONS:
All food service establishments are required to have at least one fixll-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 tle at your establishment.
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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 a11 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.
l. 2•
3. 4.
RESTAURANT SEATING: TOTAL# NA
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
� B&B $55 CABIN $55 MOTEL $55,
—ID1N $55 CAMP $55 _SWIMMING POOL $80ea
LODGE $55 _1RAILER PARK $105 _WHIRLPOOL $80ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERN�IT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
1 0-100 SEATS $85 f`f-f� —CONTINENTAI, $35 NON-PROFIT $30
—>100 SEATS $160 _COMMON VIC. $60 =��DEKITCHEN $80
RETAIL SERVICE:
LICENSE REQUIRED FEE PERMIT# UCENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
<50 sq.ft. $50 >25,000 sq.ft. 5225 =TOBACCO FOOD $95
—<25,000 sq.ft. $80 —FROZEN DESSERT $40
NAME CHANGE: $15 AMOUNT DUE _ $ ��� GC'
***•'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 ar 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 taxes and liens must be paid prior to renewai 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 sha11 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 sha11
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 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 sit in the pool azea 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 Heaith 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.
_ - - FOC"iD SEt�VIC�
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 Yannouth 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.yarmouth.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 ar 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 31. 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., PAIN'I'ING, NEW
EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO
COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
DATE: Iz�//�Z�/j SIGNATURE:
PRINT NAME& TITLE: Q m�r //Z�uI�(/ �G$� Z/7�
x��. ioiosns
• � The Commoxweatdh oj'Mrrssnchusetls
Depordnettt oflndustrialAccid�ttJs
O„�ice oJlnvestigattorrs
600 Washington 5treet
. Bostoh,MA 02111
www mass gov/dia
Workers' Compensation Insurance�dxvit: General Bnsinesses
Anplicant Information Please Print Lesib�
Business/Organization Name: �G �j Z 2�L 1 n�. a��� �D/n j n p ,S / /Z Z GL
Address: ,�,� %�j p��'1�-e I'rY Gj rc-�-e
City/state/Zip: �o_S�t .eC D26y�/' Phone#: S��~�6/-/�/�'�
Are ou an e�pbyer?Cheek the appropriste baz: Basiness Type(requtran:
1.�f 1 am a employer with /�� employ�s(fuU and! 5. Q Rdail
or part-timej.' 6. Q RestauraatlBaz/Eating Esfablishment
2.❑ I em a sole proprietor or permership and have no 7. 0 Qffice and/or Sales('i�L reffi estaza,suto,etc.}
employaes wurking for me in anY capaciry• 8. �Noo-profit
[No worken'comp.insurance requiredJ
3.❑ We are a corpoTarion and its officers hava ezetcised 9. �Entertainmant
their right of exem�ion}xr c.i52,§1(4�and we k�ave 10.�Manufecturing
no employees.jNo workers'comp.insu�ance required)' i L.Q H�ith Care
4.❑ We are a non-profit or�niarion,ataffed by wluoteers,
wit6 no employees.[No wod�'comp.insu�ace req.] 12.0 Other
•Any epplieaot that olrecks box OI must dso tifl aut tAesaSion helow showing tlidr vrorkas'e�pamdm poliry inPoimatiun.
«•If the curponte of6mrs have amopkd�ra*.but Nroapentim 6as o�aupbfas,a wakm'canpaaazion po[icp ia reqiemd and mch m
organimUon s6ould d�edc box SL �
I am an emplayer 16at is provlding/wl�or`kers'compens/rufon insur'm/rce fn/r my employees. Be[ow 1s the polfcy lxformatlon.
Insurance Company Name: ND t-fv/X.�,O-e�I�lG/n �uc T� ��e 1�5/-�/"a�r� �o�+-z/JD�1 J�
T—
InsureYs Address: Z 2 2 �)'Y)t S .���
csry/state/zip:_��c�f�GL m
Policy#or Self-ins.Lic.# W�IJ39SE Expiration Date: 2 21��
Attach a copy of the workers'compensation poltcy declaration page(showtng t6e policy number and eapiratton date).
Failure to secure coverage as required under Section 25A of MGL a 152 cea lesd ro the imposiaon of criminal penatHes of a
fine up to$1,500.00 and/ar o�year imprisonment,as well as ci�nl Qeoaities in the fonn of a ST'OP WORK ORDER and a fine
of up ro S150.00 a day againstthe violator. Be advised that a copy of this slatement may be focwyarded W the Office of
Investlgatidas of the DIA for i�surance coverage verificati�.
I do hueby certtfy,an tht pa7ns peaaltles ojpe{�uy thpt the Informntton provlded above is true aru(correct
s� na : /2 ZD
Pl ne � QO ' —/`�
O}j'Pclal use only,. Do nat wrtte!a thls area,io be cmnptded by rify or town o,(/1cla/.
City or Town: �A-2h+��TT} Permit/I,icense#
Iss ircleooe):
. Baard o[Hea th Building Department 3.Citylfown Clerk 4.Liceosiag Board 5.Selectme¢'s Office
Other
Conmct Person: Phone#: 5U B 35B-o73�3 I 7G I���
� warw.maa.gov/dia
``�� CERTIFICATE OF LIABILITY INSURANCE �Zi5i2o1"3"'
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BV THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER�S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy�ies) must be endorsed. N SUBROGA710N IS WAIVED,subject to
the terms and conditions of the policy,certain policies may require an endorsement. A sWtement on this certificate tloes not confer rights to the
certificate holder in lieu of such entlorsement(s�.
PROOUCER CONTACT
NHME:
Risman Insurance Agency, Inc. PHonE . 781.396.2116 aC N�:�81.395.2300
689 Fellsway AODH�ESS:
Medford, MA 02155 CRODUMER�' p_
Michele $dSCld INSUREWS�AFFORUINGCOVERAGE NAIC#
INSURED INSURERANOLFOZIC S Dedham Mutual Ins Co
iNsuaerseArbella Protection Inaurance C
KC Pizza Incorporated iNsuaeacAmerican Safety Indemnit Co.
65 Thornberry Circle INSURERD:
INSURER E:
Mashpee MA 02649 INSURERF:
COVERAGES CERTIFICATENUMBERPomino's Pizza REVISIONNUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANV REQUIREMENT, TERM OR CONDITION OF ANV CONTRACT OR OTHER DOCUMENT IMTH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLIGES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDI710NS OF SUCH POLIGES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR; rypEOFINSURANCE A�LSUBR POLICVEFF POLICVE%P ��MITS
LTR�. MSR WVD POLICY NUMBER MMIOOIYVYY MMIDOIYYYY
GENERALUABIUTY 1182654A 09/12/2013 9/12/2014 EqCHOCCURRENCE $ 1�0�����0
X COMMERCIAL GENERAL LIABILITV PREM SES Ea occurte�wa $ SO�OOO
A CLAIMS-MADE �OCCUR I i MEO EXP(Any one person) E 5�OOO
� PERSONAL 8 PDV INJURV S S�OOO�OOO
� GENERAL AGGREGATE E 2�000�000
GEN'LAGGREGATELIMITAPPLIESPER: PRODUCTS-COMPIOPAGG $ 2�000�000
POLICV PEo- LOC §
AUTOMOBILE LIABILITV j 3020005865 09/12/2013 09/12/2014 COMBINEDSINGLE LIMIT $ 1���0�D00
I , (Ea amitlent)
ANY AUTO BODILV INJURV(Per person) $
B iALLOVVNEDAUT05 I BODILYINJURV(Peraccitlanp $
X �.SCHEDULEOAUTOS PROPERTV DAMAGE
X HIREOAUTOS (PeracciCent) $
X NON-OWNEOAUTOS $
S
UMBRELLA LIAB 7C OCCUR 1105967A 09/12/2013 09/12/2014 �CH OCCURRENCE $ 2.�00�0��
EXCE55 LIAB CLAIMS-MADE AGGREGATE E 2�OOO�OOO
DEDUCTIBLE ! $
�S � X RETENTION $ 10 �e� � I$
A WORKERSCOMPENSATON 115956A � 9/12/2013 9/12/2014 `NCSTATII- OTH-
ANDEMPLOYERS'LIABILITY ��N
ANV PROPRIETOR/PAftTNERIEXECUTNE . � E.L EACH ACCIDENT $ SOO OOO
OFFICERIMEMBEREXCWDE�9 �:,N�A
(MantlatorylnNH) � ELDISEASE-EAEMPLOVE $ SOO OOO
Ify es,descnCe untler '� �
DESCRIPTION OF OPERATIONS Lelow I EL.DISEASE-POLICV LIMIT $ SOO OOO
C Excess Auto Liability 158sxsixso247o1 09/12/2013 09/12/201G 2�000,000
OESCRIPTION OF OPERATONS I LOCAl10N5/VEHICLES (AHach ACORD 101,AtlEltlonal RemaMs Sc1�eAule,H more apace Is requireE)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANV OF TNE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION �A7E 7HEREOF, N07ICE WILL BE DELIVERED IN
TOwR Of Yarmouth� MA ACCORDANCE WITH THE POLICV PROVISIONS.
AUTHORQED REPRESENTAl1VE
Michele Sarcia/MJS
�� � � >�
ACORD 25(2009/09) O 1968-2009 ACORD CORPORATION. All rights reserved.
INS025 tzoosoe� The ACORD name and logo are registered marks of ACORD
• WORKERS COMPENSATION AND ENIPLOYERS LIABILTY
• INSURANCE POL�Y—INFORMATION PAGE
INSURER: �U�NO: 9iS115956A
NORBOLiC & DSDHAM MOTIIAL BIRB SN3IIRANCH CODIPANY
asa au�s sTxsgr xffiaswar.
DBDSAM, MA 02026 NCCI Company No: a1Q59
Accourd No: g63006110
FEIN: 45-258692T
ITEM 1. NAMED INSURED AND MAILiNG ADDRESS: AGENT NAME AND ADDRESS:
KC PIZZA INCORPOPATBD DBA M�tINO'S PIZZA A. DAVID PIS1tAN INSIIRAPCS
65 THORNBSRRY CIRCLS AC3CY
MASHPSE MA 02649 684 FSLLSOPl�Y
MEDFORD, MA OZ155
AGEN'f NO.: 20722
LEGAL ENTITY: CORPORATION
OTHER WORKPLACES NOT SHOWN A80VE: (See W�kers Campensatlon Classification Sc�edule)
ITEM2. POLiCYPERIOD: From: 09/12/2013 To� 09/12/2014
EffecGve 12:01 A.M. Standard Time at tlie Insured's mailing address.
REM 3. COYERAGH:
A Workers Compensation Insurance: Part One of ihe policy applies to tlie Workers Compensa6on Law of the
states listed here:
b�
B.Empbyers'Liability Insurance: Part Twa of the policy applies to work in each srdte listed�ttem 3A. The limits
of liability under Part Two are:
BodilylnjurybyAcxident: S SOd, 000 Qa�hacadeM
Bodily lnjury by Disease: $ 500,000 Po�kY���
Bodily Injury by Disease: S 500,000 ���P�°Y�
C. Other States insurance: Part Three af the poiicy appfi�to Uie states, 'rf any,listed here:
SBB FIJDORSSMSNT WC a0 03 06 8
� D. This Pdicy indudes these Endorsements and Sc�edules:
See Schedule of Fams and Endorsements.
ITEM 4. PREMIUM: The premium for this Pdicy witl be determined by our Manua�of Rules,Ciassifications, Rates and
Rating Pians. Ail infortr�atlon r�equir�ed a�the Worke�s Compensation Classification Schedule is subject�
verification and c�ange by audit.
Totat EslimaUed
MinimumPremium: $ 470 AnnualPremium: � 2g,�13
Audit Period: �p,�, Addilional!Retum Premium:
Commerrts :
Issued At:
��� 08/65/2013 Cauntersi�ed by
WC 00 00 01 A CopyrfyM tse]wnonal couna�an compsnsaUon u�wwram�s
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