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� �`�� TOWN OF YARMOUTH BOARD OF HEAI,TH _ ,
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APPLICATION FOR LICENSE/PERAIIT`-2013 ` � _�`'
* Please complete form and attach all necessary c�ocilfi�ient's b %Dec mb�� �2��]1�
Failure to do so will result in the return of your application acket. ���
HEALTti DEPT.
ESTABLISHMENT NAME: �Io ml Z�.v s i ZZ Q T ID: 1 - ZS �Z 7
LOCATION ADDRESS: 23 T W I,,,;�{-,c� /�a.�l� Smli. ?�armou-1� TEL.#: 5U�'- 39`/- 6�8
MAILINGADDRESS: ThO�teG r/Y Ci�c � ,z �e ./� 0261/
OWNER NAME: lLi'Q�s! �%r ,D a h u -e t�'
co�o�Tiorr NaME �iF aPPLicaaLE>: ,�c Pi zao_ ln c .
MANAGER'S NAME: TEL.#: 5 oa'—S6/—/S�A/
MAILING ADDRESS: 6S Thnr k�i cr�Y Ci r�/�- � S v..�c �-r� o�6Y9
,�� .
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated
Pon1 nn,:xaiar!s� and attacl-�a copy of the certif c�tion to tris form.
L 2.
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.
1. Z.
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 Estabiishments, 105 CD�IR 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.
�. � yr�S ���G /C'� uchiz� 2. I ri SC��o_ G�^-j ur0
PEKSvi�iiQ C.iiAKiic: - - - _
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
�. � � r�s j�v, J(,c,,,� c%� 2. l� ri s �/� ,�.� u ��
HEIMLICH CERTIFICATIONS:
Ail 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-choking procedures belaw and
attach copies of employee certifications to this form. The Health DepaMment 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�t LICENSE REQUIRED FEE PERMIT#
_B&B $55 _C.vBIN $SS _MOTEL $55
INN $SS CAMP $55 _SWIMMiNG POOL $SOea.
_LODGE $55 _TRAILERPARK $]OS _WHIRLPOOL $80ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
�0-IOOSEATS $85 � I �O _CONTINENTAL $35 _NON-PROFIT $30
_>]00 SEATS $160 _COMMON VIC. $60 _WHOLESALE $80
RETAIL SERVICE: � —RESIU.K[TCHEN $80 —
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# [.ICENSE REQUIRED FEE PERMIT#
__<50 sq.ft. $50 _>25,000 sq.ft. $225 _VENDING-FOOD ^�25 _
<25,000 sq.ft. $80 _FROZEN DESSERT $40 TOBACCO $95
NAMECHANGE: $IS AMOUNTDUE _ $ gS•OO
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*****
I _'�
l
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 INSiJRANCE
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 renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES NO
MOTELS AI�ID OT��ER LODGING E;STA$��6�3ME#PS- ._ �---
TRANSIENT OCCUPANCY: For purposes of the limitations of Motei 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 thirly(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 ar
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 generaily 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 De�artment to schedule the inspection three(3)days
prior 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
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
obtamed 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 or revocation of your Frozen
Dessert Permit until the above terms have been met.
OUTSIDE CAFES:
Outside cafes(i e1 outdoor seating with waiter/waitr�s�service],must have prior appro�alfr4m���rd ofHealYh.__-___
OUTDOOR COOHING:
Outdoor cooking,prepazation,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 COMPLET�D RENEWAL APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 15, 2012.
ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, N�W
EQUIPMENT, ETC.), MUST B�REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY REQU A S E PLAN.
DATE: /2/OZ� ZD�L SIGNATURE:
PRINT NAME& TITLE: �c-!u-5/ mi7 �z�i ct��P�,! P�'-c.S�
Rev. 10/09/12 /
1
, � '� The Commonwea[th of Massachusetts
Department of Industrial Accidents
Office oflnvestigations
- 1 Congress Street, Suite 100
Boston,MA 02I14-2017 :
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Apnlicant Information Please Print Leeiblv
Business/OrganizationName: �omi��S �/ZZ�
Address:_ 2� w �M�-C S ��--� �
City/State/Zip: S��t �Q�-7»0� �����e#: s���3 9�/ -6���
Are you an employer?Cbecic thg appcopria[e box: _e Busin�ss Typ�(required�:_„_
1.� I am a employer with_ $P employees(full and/ 5. ❑ Retail
or part-time).* 6. ❑RestaurantBaz/Eating Establishment
2.❑ I am a sole proprietor or pazmership 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 a 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 na 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 poliry information.
*'If the corporate officers have exempted tMemselves,but[he colporation has other employees,a workers'compensa[ion policy is required and such an
organization should check box#1.
I am an emp[oyer that is providing workers'"comp/ensation insuranre for my employees. Be/ow is thepolicy informatioa
Insurance Company Name: /Yo/" % vz.ea �d � �Gz-
Insurer'sAddress: �ZL _ y1'ItS s�Y',C.P�L"
City/State/Zip:��(,Z.�'1'J /��/`7' Q2 OZ�
Policy�or Self-in;.Lic.',#_ �1 ����J 6�� _-___ ___ _ - - E�piraTic>r.Date: f7���2�ZOf�
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-yeaz 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 O�ce of
Invesrigations of the DIA for insurance wverage verification.
I do hereby certify,under the�and penalties of perjury that the injormarion provided above is true and correct.
Si ature: Date: Z 42 Z��2
Phone#: J� �J�6�/y�
Ojficial use only. Do not write in this area,to be completed by city or town o�cia[
�
City or Town: ��1Y�0 UT# Permit/License#
I o circle one):
1.Board of Health . Building Department 3. City/Town Clerk 4.Licensing Board 5. Selectmen's Office
Contact Person: Phone#:_�g-3�'jQ.��7L��Z[�`
� crvvw.ma;s.gc�/ais �
WORKERS COMPENSATION AND EMPLOYERS'LIABILTY
. INSURANCE POLICY----INFORMATtON PAGE
INSURER: POLICY NO: y1g115956A
NORFOLK & DEDHAM tdUTi3AL FIRS INSURANCE COMPANY
222 AMES STREBT Rg��'��
DEDHAM, MA 02026 NCCICompanyNa 21059
Account No:
FEIN: q5-2586427
ITEM 1. NAMED INSURED AND MAILING ADDRESS: AGENT NAME AND ADORESS:
KC PIZZA INCORPORATSD DBA DOMINO' S PIZZA A. DAVID RISMAN INS[7RAP7CS
65 THORNBERRY CIRCLI3 AGCY
MASHPEE MA 02649 689 FELLSWAY
MEDFORI}, 14iA 42155
AGENT NO.: 20722 -
LEGAL ENTITY: CORPORATION
OTHER WORKPLACES NOT SHOWN ABOVE: (See Workers Compensation Classification Scheduie)
ITEM 2. POLICY PERIOD: From: 09/12/2012 To: 09/12/2013
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 applies to work in each state listed in Item 3.A. The limits
of liability under Part Two are:
Bodily Injury by Accident: $ S OO, a a o each accident
Bodily Injury by Disease: � 500, OQO po�icy limit
Bodily Injury by Disease: $ 500, 000 each employee
C. Other States Insurance: Part Three of the policy appiies to the states, if any, listed here:
SSE ENDORSSMENT WC 20 03 06 A
D. This Policy includes these Endorsements and Schedules:
See Schedule of Forms and Endorsements.
ITEM 4. PREMIUM: The premium for this Policy wiil be determined by our Manuals of Rules, ClassiTications, Rates and
Rating Plans. All information required on the Workers Compensation Classification Schedule is subject to
verification and change by audit.
Totai Estimated
Minimum Premium: $ ,}7p Annual Premium: $ �q, g21
Audit Period: ANNi7AL Additional/Retum Premium:
Comments:
Issued At
Date: 0 8/0 2/2 012 Countersigned by
WC 00 00 01 A Copyright 1987 National Council on Compensation Insurance
INSURED COPY