The URL can be used to link to this page

Home My WebLink AboutApplication and WC _ .. _ � TOWN OF YARMOUTH BOARD OF HEALTH ; APPLICATION FOR LICENSE/PERMIT-2011 �i';;u �� ` i *Please wmplete form and attach ap necessary documents by Dece ibe►�1 Bl�:::`'3 • � Failu�+e to do so wip result in the retum of your pa =-.� ;; , �.,, A a ESTABLISHMENT NAME: KC P;z7�Q �n c. ��u� p rn�tw.�s i a�� • � y, N �� ` LOCATiON ADDRESS: 2 ' W U. .c `S Gz� TEL . 4'O�- �/6� 2 I'� � MAII,INGADDRESS: D�r� rrY -e -5 ee Oz6% � OWNERNAME: rcLS:rn%r -e, z��- t— i4�1 c ' CORPORATION NAME(iF APPLICABLE): MANAGER'S NAME: _ rij � ` TEL.#: -/ MAILING ADDRESS: ? -P-/)" C%�� -e,t 26'ti � POOL CERT7FICATIONS: T6e pool supervisor must be certifted as a Pool Operator,as required by State law. Please list the designated Pool Operator(s)and attach a copy of the certiScation to this form. l. Z, Pool operators must list a minunum of two employees currenUy certified in basic water safety,standard Fitst Aid and Commumty Cazdiopulmonary Resuscitation(CPR). Please list these employces below and attach copies of empio.yee certifications to this form.T6e Healt6 Depar�ent wtll 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 -CERTIF'ICATIONS: 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 5ervice Establislunents,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 tile at your establishment 1.�� /TJ�I�I�� l7`l7 S�!� 2, PERSON IN CHARGE: Each food establishment must have at least one Peison In Charge(PI�)on site during hours of operarion. I. _�, HEIhfLICH 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 h�ained in anti-cholang 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 busiuess. 1. Z 3. q, RESTAURANT SEATIlVG: TOTAL# �.oncnvc: OFFICE USE dNLY LICENSE REQU[ItED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&B S55 �CABW a55 _MOTEL S55 _INN S55 _CAMP S35 _SWIMMINGPOOL 580� _IADGE S55 _1RA[[,gRPARK $105 _A+f{IItL1'OpL S80ea. FOOD SERVICE: Lt ENSE REQU[RED FEE PERhIIT# llCENSE REQUIRED FEE PFRMIT# L[CENSE REQUIRF,D FEE PERMIT# 0.100SEA75 S85 _CON7[NENTAy $39 _NON-PROFIT S30 _>100SEA15 5160 _COMMONVIC. S60 _WHOLESALE $BO [e�rnn,ssev�ca: —a�s�n.�TcxEx aso LICENSE REQU[ltED F&E pgRM1'p q LICENSE REQUIREp FEE PERMiT# LICENSE REQU[RED FEE PERMIT p _tS0 sq.ft. S50 _>25,000 sq.R. S225 ,_VENDING-FOOD S25 _Q5,000 sq.R S80 _FROZIN DFS3ERT S40 _TOBACCO S95 x,�scx.uvcE: ais AMOUNTDUE = S S5 `� ••»•pLEASE TURN OVER AND COMPLETS 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 petmit to operate a business if a person or company does not heve a Certificate of Worker's Compensation Insurenoe. THE ATTACHED STATE WORKER'S COMPENSAI'ION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR CERT. OF IN5URANCE ATTACHED f-es OR WORKER'S COMP.AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth ta�ces and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO 1H01'ELS AND OTHER LODGING ESTABLISH1t�NTS TRANSIENT OCC[JPANCY: For purposes of the limitations of Motel or Hotel use,Tcansient occupancy shall be limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hobel 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 thiriy(30)days,and an aggegate of not more than ninety(90)days within any six(6)month period. Use of a guest unit as a residence or dwelling unit shell not be considered transient. Occupancy that is subject to the collection of Roam Occupancy Excise, as defrned in M.G.L. c. 64G or 830 CMR 64G,as amended,shatl geaera}ty be considered Transiem. POOLS POOL OPENfiIG:All swimming,wading and wlvrlpools wluch have been closed for the seasoe must be insnected by the Health artmentpnor to opemng. Contact the Health Department to schedule the inspection thtee(3)dayspn or to opening. P ASE NOTE: People are NOT aliowed to sit m the pool area until Uie pool has been inspected and opened. POOL WA'I'LR TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab,and submitted to the Health Depaztment three(3)days prior to opening,and quartetly thereafter. POOL C205INC: Every outdoor in ground swimming pool must be dcained or covered within seven ('� days of closing. _ FOOD SERVLCE SEASONAL FOOD SERVICE OPENING: All food service establislunents must be inspexted by the Heaitfi Departrnent prior to opening. Pleasc cantact the Health Department to schedule the inspection three(3)days prior to opening. CATERING POLICt': Anyone who caters wittrin the Town of Yarmouth must notify the Yarmouth Health Department by filv' �g the required Temporazy Food Service Application form 72 hours prior to the catered event 1'hese forms can be obtained at the Heakh Departrnent, or from the Town's website at www.varmoutfi.me.us under Health Department, DownIoadable Forms. F1t07.EN D�S5ER�'S: Frozen desserts must be tested by a State certified iab prior to opening and monthly thereafter, with sample results submitted to the Health Department. Failure to do so wiil result in the suspension or revocation ofyour Frozen Dessert Permit until the above terrns have been met. OUTSIDE CAF�`S: Outside cafes(i.e., outdoor seating with waitet/waitress service),must have prior approval from the Boazd of Health. OUTDOOR COOKINC: Outdoor cooking,preparaHon,ar display of any food product by a retail or food service establishment is prohibited. NOTICE: Permits nm annually from January 1 to December 31. IT IS YOUR RESPONSIBILTfY TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15,2010. AI,L RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIl'MENT,ETC.),NNST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCfiN�1VT. RENOVATIONS MAY REf�UIRE A STI'E PLAN. DATE: (`��5 2-D�� SIGNATURE:_ � PRIlVTNAME &T1TLE: � ��f c-yT �z� �-eri �/�-e 5i�G-4 � neV.o�mvi i ,�C �, Zc�O �� >_ �rJ Lt�-r�Lw�S �i 2?� ACOR�, CERTIFICATE OF LIABILITY INSURANCE °"'�"�'°°'"'"° 08/16/2011 ��R 781.396.2116 FAX 781.395.2300 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Ri s�ren Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 689 FC115Wa HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR Y ALTER THE COVERAGE AFPORDED BY THE POLJCIES BELOW. Medford, Mp 02155 Michele Sarcia lNSURERSAPFORDINGCOVERAGE NAIC# n�wr�o KC Pizza Zncorporated dba Domirros Pizza �Nsua�an Norfolk & Dedham Mutual Ins Co 23965 65 Thornberry Circle wsuneRe: Arbella Protection Insurance t Mashpee, MA 02649 INSURERC: INSURER D' INSUftER E: COVERAGES THE POLICIES OF INSURANCE LIS7ED BELOW HAVE BEEN ISSUED TO THE INSURED NAMEDABOVE FOR THE POLICY PERIOD INDICATED.NOTMTHSTANDING ANV REQUIREMENT,TERM OR CONDI710N OF ANY CONTRACT OR OTHER DOCUMENT WfTH RESPECT TO NMICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLIqES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CANOfT10NS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CWMS. �LIR N8 TVPEOFINSUMNCE POIJCYNUYBER OR7E DAIE � WYIS OENERALWIBILIIY TBD O9�IZ�ZOZI OS�LZ�ZO�.2 EACHOCCURRENCE S ].�OOO X COMMERCIALGENERALLLABILITV pppq�u�� i SO� CIAIMS MA�E �OCCUR MED IXP(Nry One pemOn) $ S� A PERSONALBADVINJURY S I�QOO GENERAL AGGREGATE E Z��(IO� GEN'LAGGREGATELIMITAPPLIESPER' PRODUCTS-COMPIOPAGG S Z�Q�� POLICY jE7 LOC AVfOMOBLLEW1BILfIY TBD O9�ZZ�ZOI1 O9�ZZ�ZOZI COMBMEDSINCaLELIMfT ANYAUTO (EaarriGanl) : 1�� ALL ONMFD Atf�0.5 BODILV INJURV 5 B SCHEDULEOAUTOS (P�ce��) X HIREDAUTOS BODILYINJURV 5 X NON-0NMFDAUTOS �Pg��) PROPERT/OAMAGE s (Peraooaen9 GARAGELIABIIlTY AUTOONLY-EAACCIDENT E ANYAUTO OTMERTHAN EAACC f AUTOONLV: AGXi S EXCE33/UYBRELL11IJ11&l1TY EACHOCCURRQJCE f OCCUR �ClAIMS MA�E AG('iREGATE f S �EDUCTIBIE : RETENTION f S worae�caevewsnnow TBD 09/12/2011 09/12/2012 X IWDEMPLOYERS'W�LfiY TORYLIMR$ ER ANYPROPRIEfOR/PAR7IJERIE7(ECUTIVEr� ELEACHACCIOFM f SOO� A OFFICERIMEMBEREXCLUDED? LJ (MantlnorylnNN) ELDISEASE-EAEMPLOY S S�.O ttyes,aesaiee um�r SPECIALPROVISIONSDebw ELDISFASE-POLICYLWR S SOO OTHER DESCRIP1qN OF OPERp7qtL41 LOCIITHINS I VEHClESI EXCLU&ONS MDED BY F.NOORSEIFM/SPECNLPNOYI90N$ bove coverages apply to following Domino's Pizza Locations: 34S Falmouth Rd. Hyannis, MA, 80 Route 130, Sandwich, MA, 23 Whites Path, South Yarnouth, MA, 16 Main St., Mest Harxich, MA, 87 Teaticket Hgwy, East Falmouth, MA & 40 Industry Rd., Marston Mills, MA CERTIFICATE HOLDER CANCELLATION s�+ann urc or n��eovE oecwem aoir�Es ae w�ce.�o e�ors�txe owrunox onren�e�oF.�ssuxc�nvrueioewwwRrora� _nnrswmr� rancE ro rne cemnure xanm wuEo To n'e�r.eur Fawne ro 0o so sxui KC Pizza Ineorporated ��'+*��uroxn�iN�nocrtswaExrsore 65 Thornberry Circle nern�sa+rwmr�s. Mashpee, MA 02649 ��o�+TATME — �...iE...p��a.�:. Michele Sarcia ]5 ACORD 25(2009/07) �79�-2009 ACORO CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD � � The Commonwe alth ofMassachusetts Department oflndastria[Accidents N�IeIN� 600 Washington Street, f"Floor Boston,Masc 02l11 Workera'CompensaHoa Iroannce ARidavk: gaildiu�/Plembiep,/Ekctrical Contraetors ��: �rQs�m i r l� z h u -2 U a�s: �5 Th o�v�1�=e rr_y _ C;r-c,l�e �� S �t t� sm«: � �;o: OZG y�o�� 50�—S6/—/y�'/ work site location(full addressl: ❑ [am a lwmeowner per('ocm�ng all wo�ic myself. Pro�ect Type: ❑New ConsWr.tion QRemodel ❑ I am a sole proprietor az�d have no one wodcing in any capxtty. ❑Building Addition �g [am an employer providing workers compensatioo for my employees working on this job. �m�,....��: KG �i Z2 a i� c d b o ,Do n�`� 's Pi 2 Z� ��,: Z3 i l.0 la ' -�-.� ' ��-1, ��: 5'�r.c-�t, lQ-�rn �u �� .�M ,�0�-39� 6�d'� �.m,.�ro. ��o IK�+% �o�l/�m ��-1 �. T,8�–_____— ❑ [am a sole pr 'etor.geaersl eo�trx[or,or homeowner(circle on�)and have hired the contracto�s listed below who have Ihe following workers'compensation polices: co�wav une• addraa• city: p`�� ieseasee ee. � tommsv w....• , ad�ar �: Wa�e M imeuee co, �� .m.+srrrrrr....� FaBve b scve owntde u`eqdrd��dv Stelfa�2SA sf MCL I52 eu lud b IYe ispdtlH�f oi�ral . . .. . . °r 7�+�'�r6aewnt a wd as dH peuHb la t6c t�af a ST01 WORK ORDBA aW�Eu d31Bl.N�i d��f�me�p b fI�M.M aWIK npy ef t�6 WteoeW my Ae fwn�NM b t!e Oeke af i�ef He DIA Rr c�ver�e verl6ntln. ��e. 1 sedashW th�t• . /dn 6ereby cntlfy rnler Me tu awd p !dv ojperjwry(h�Me fajorwoNow provl/ed aborc L*trre m�d comce Sig�utme Date � �� 2�i�/ Print name ro � � Z-(i(�-� .-c/V Phone k J'��SEI�'—�/� e1Bclai ux oWy do eW wrk<1�[his�rei fa he coaPkfe�DY d1Y or 4wo oHicid �. . . . �. .. Nty ar tawu• PermiMkeme N ❑thedt Himmt��!refpeme 6 rtqdred �� ' �Sd�c�e�1(M6cc ceWt[persea: P��M' QIIe1H D�ardest lm4�d s.p�xom� ❑(�v