HomeMy WebLinkAboutApplication and WC � � a � TOWN OF YARMOUTH BOARD OF HEALTH ,�, . , �`; �
�, APPLICATION FOR LICENSE/PERMIT r- 0 V `
y�. aT,:r-'� � 1 r ''. j i
* Please complete form and attach all necessary d6a��in ' cem r I5� ZOl1. '
Failure to do so will result in the retum of}�ur cation pac t. NEALTH �EPT.
ESTABLISHMENT NAME• �G PIZta_ Tticornora�-eo�a�/6/a %a��S�: �/5-25'd°6�927
LOCATION ADDRESS: 2.�(.��-r-{-c peZ��� �oc.,�f4 Yc-rmau�l,,WA-TEL.#: 3d -39�/- 66P�
MAILING ADDRESS: 65 Thvrnb.e�� G- cle Sl� 026�!
OWNER NAME: � a i m i r Z u -c v
CORPORATIONNAME (IFAPPLICABLE): i2221uoor oro-� O_ pt�k. I�D' PiLZ2
MANAGER'S NAME: �YrOS I GLV�2 l�-c.�„ 2Y TEL.#: �"b8- 365- �/�87
MAII.INGADDRESS: �'S %fi,�rtt62-n-Y /�T^/� ��y ieG �� O�Y�
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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 certificati4n to this 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. 2.
3. 4.
FOOD PROTECTION MANAGERS - 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 application. The Health Department will not use past years'records.
You must provide new copies and maintain a file at your establishment.
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PExsorr nv c�cE:
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
1. 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 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#
_B&B $55 _CABIN $55 _MOTEL $55
_Iti1N $�5 _C.4A-iP $55 �S:'�'LtiSP:E:NCPQOi. Q30:;x.
_LODGE $55 _TRAILERPARK $105 _WHIRLPOOL $80ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUII2ED FEE PERM[T# LICENSE REQUIRED FEE PERMIT#
LO-100SEATS $SS a'D?7 _CONTINENTAL $35 NON-PROFIT $30
_>]00SEATS $160 _COMMONVIC. $60 WHOLESAL.E $80
RETAII.SERVICE: —RESID.KITCHEN $80
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_<50 sq.ft. $50 _>25,000 sg.ft. $225 _VENDING-FOOD $25
_QS,WO�sy.ft. $80 _FROZLNDESSERT $40 � _TOBACCO $95
NnNCE c�uvcE: $is AMOUNT DUE _ $ 85• 00
•*"**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. TFIE ATTACHED STATE WORKER'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGPtED, OR
CERT. OF INSURAI`TCE ATTACHED
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth tases and liens must be paid prior to renewal or issuance of your permits. PI.EASE CHECK
APPROPRIATELY IF PAID:
YES NO
Mt3TEL� AND 6THER LODGING ESTAi3LISHNYENT�
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 customazily 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 OPEIVING: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
pnor to opening.PLEASE NOTE:People aze NOT allowed to sit in the pool area until the pool has been inspected
and opened.
POOL WAT�R TESTING: The water must be tested for pseudomonas,total coliform and standazd 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 Yazmouth 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.yazmouth.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.e.,outdo9r seating with waiter/waitress servicej,must have prior aflpmval frnm the Bnard of Health.
OUTDOOR COOKING:
Outdoor cooking,prepazation,or display of any food product by a retail or food service establishment is prolubited.
NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN
TE� COMPLETED RENEWAL APPLICATION(S) AND REQUII2ED FEE(S) BY DECEMBER 15, 2011.
Ai.T, RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT,ETCJ, MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY RE E A E PLAN.
DATE: I� '2 I I 2-� �I SIGNATURE:
PRINT NAME& TITLE:� Q���,Y �z��-�J . f"r� 5�
Rev.10/25/ll
� The Commonwealth of Massachusetts
Deparnnent oj/ndustria/AcciJents
NAfaNiw�tllM�
* 600 Washingtoe Sfreet, 7`�Flaor
' ' Boston,Mass. 02111
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❑ I�a homeowcer performing all wodc myself.
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�f I am an employer providing wodcecs'compeasation for my employees woticiog on this job.
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WORKERS COMPENSATION AND EMPLOYERS' �IABILTY
INSURANCE POLICY---- INFORMATION PAGE
INSURER: POLICYNO: WL115956A
NORFOLK & DSDIiAM MUTUAL FIRE INSURANCE COMPANY
222 AMES STRBET NEW BUSINESS
DEDHF►i+f, MA 02026 NCCI Company No: 21059
Account No:
FEIN: 45-2586927
ITEM 1. NAMED iNSURED AND MAILING ADDRESS: AGENT NAME AND ADDRESS:
RC PIZZA INCORPORATBD DBA DOMINO'S PIZZA A. DAVID RISMAN INSURANCE
65 THORNBERRY CIRCLE AGCY
MASHPEB MA 02649 6$9 FSLLSWAY
MSDFORD, MA 02155
AGENT NO.: 20722
LEGAL ENTITY: CORP�RATION
OTHER WORKPLACES NOT SHOWN ABOVE: (See Workers Compensation Classification Schedule)
ITEM 2. POLICY PERIOD: From: 09/12/2011 To: 09/12/2012
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: $ 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;
SHB ENDORSBMENT 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 will be determined by our Manuals of Rules, Classifications, Rates and
Rating Plans. All information required on the Workers Compensation Classification Schedule is subject to
verification and change by audit.
Total Estimated
Minimum Premium: $ 470 Annual Premium: $ 25, 250
Audit Period: ANNUAL Additional/Retum Premium:
Comments : ,
Issued At: � ��
!� �� " ��-�
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Date:0 9/2 Q/2 011 Countersigned by ��,�',�,.ee��-: ' �c-�-��—
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WC 00 00 01 A Copyright 1987 National Council on Compensation Insurance
INSURED COPY