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HomeMy WebLinkAboutApplication and WCi\ ��^° �� TOWN OF YARMOUTH BOARD OF HEALTH , �DoM«.�os P�2ZA . APPLICATION FOR LICENSE/PERMIT-20ll ' �' r�4z�4 i(�8 : ' _ * Please complete form and attach all necessary documenfs-by"December I S 2010. � Failure to do so will result in the return of your application pac cet. ESTABLISHMENT NAME: MIJI�`S i i� TAX ID: D 3 �D LOCATIONADDRESS: I,t,�i a4'!, S. ktmaKfit, TEL.#: � -3`)�/- (p(y MAILINGADDRESS: 1� S . Sc �4 � v OVVNER NAME: �,J CORPORATION NAME (IF APPLICABLE): ►�yVl �,�� � I K r, MANAGER'S NAME: �}n�-�-z Kac�v�-- TEL.#� MAILING ADDRESS: POOL CERTIFICATIONS: �J �{� The pool supervisor must be certified as a Pool Operator, as required by State law. Please list flie designated Pool Operator(s) and attacl� a copy of the certification to this forni. 1. 2. Pool operators must list a minimum of two employees cun�ently certified in basic water safety,standaz•d Fv�st Aid and Commuuity Caz�diopulmonaiy Resuscitatiou(CPR). Please list these employees below and attach copies ofemployee certifications to this foi7n. 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 seivice establislmients are requn-ed to have at least one fidl-tnne employee who is certified as a Food Protection Manager, as defuied 'ui the State Saiutary Code for Food Seivice Establisl�mevts, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past��ears' records. You must provide new copies and maintain a file at ��our establishment. 1. 2. PERSON IN CHARGE: Each iuod estaouslmient must ua-ve at least oi�e Pers�n:u Ci�arge (YIC) ou site dur'vig ;;auis of ope�atior.. 1. I�v,�-�- ��,otv��. z. r� PkppKs HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee ri•ained in the Heimlich Maneuver on the premises at all times. Piease list your employees tranied in anti-choknig procedures below and attach copies of employee certifications to this foim. The Health Department will not use past years' records. You must provide ne«� copies and maintain a file at��our place of business. I. 2. 3. 4. RESTAURANT SEATING: TOTAL #, OFFICE USE ONLY LODGI\G: LICENSE REQUIRED FEE PERbIIT i� LICENSL REQUIRED FEE PE&\IIT> LICENSE REQL?IRED FEE PER\qIT r —B�B S» _CABIN 555 il30TEL S55 _1NN S5� _CAYfP S» _-__-_.__.. SIi-L'�L��IING POOL S80ea. _LODGE S�5 _TRAII,ERPARK 5105 R$IRLPOOL S80ea. FOOD SER�'ICE: LICENSEREQLIRED FEE PERbII?= LiCENSEREQUIRED FEE PER\�IIT= LICENSEREQUIRED FEE PERbIII'= �0-100 SEATS S35 ���0� _CONTRVENTAL S35 NON-PROFIT S30 _>I00 SEATS 5160 _CO�T.vION VIC. 560 �bT-IOLESALE S80 RE7aII.SER�'ICE: —RESID.KIiCHEN S80 LICENSE REQUIRED FEE PE&�ilr r LICENSE REQUIRED FEE PE&�fIT# LICENSE REQUIRED FEE PER\".IT= _<50sq.1t. S50 _>'_S.00Osq.ft. S?�5 \'ENDING-FOOD S25 _Q�,OOOsq.ft. S30 _FROZENDESSERi S40 �IOBACCO 5)� �:��tE cxa�cE: sts AMOUNT DUE _ $ $5�00 ""*"pLEASE TtiR\O�'ER ASD CO\IPLETE O:HER SIDE OF FOR3I*x*** / ' � ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town ofYarmouth 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 AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED V OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your pernuts. PLEASE CHECK APPROPRIATELY IF PAID: YES� NO iiOiELS AivI3 tjTi3r`:�i.GDGiivi�E�1At�i.I�gIiVIENTS TRANSIENT OCCUPANCY: For purposes ofthe limitations ofMotel 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 ofresidence 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 wnsidered 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 pnor to opening. PLEASE NOTE: People aze NOT allowed to sit m the pool area until the pool has been inspected and opened. POOL WATER T'ESTING: 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. �(3f?;CLGSfPf�:�very i,utdoorin ground swimming pool must be cirained oi covere�within seven(7) days of closing. FOOD SERVICE SEASONAL FOOD SERVICE OPENING: All food service establishments must be ins�ected by the Health Department prior to opening. Please contact the Health Department to schedule the inspechon 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.varmouth.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 Pernut 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 ofHealth. OUTDOOR COOKING: 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. TT IS YOUR RESPONSIBILTI'Y TO RE"TURN THE COMPLETED RENEWAL APPLICATION(S) AND REQUIItED FEE(S)BY DECEMBER I5, 2010. ALL RENOVATIONS TO ANY FOOD ESTABLIS�IMENT, MOTEL OR POOL (i.e, PAINTING, NEW EQUIPli-�'NT,�TC.), MUST BE REPORTED TO P�APPROVED BY THE BOARD OF HEALTH PRIOR TO COb�IME�'�EMENT. RENOVATIONS MAY RCES J�I .E A,�T� PLAN. DATE: � IU SIGNATURE: � ��- PRINT NAIvi£&TITLE: �rt� �,�'C•✓y �r�f ic�ivF� to oc, to - _ E he Co:r.r�eon:c�eat:& afl�lass�cizarseits � __ ,7eparbrtentoj`Indus2�'i¢l9cride�rts . - l�fTiceoffnuestfoatfons -= 600 GT'ashiizgtan Street, T-h Floor -- Boston,hless. 02IZI --- R`ork^rs' Compensation Insurance Affida��t-Gene:al Businesses Anolicant informafion: Please PRINT 1 "blv name� � �1�� r 1�7.J address: 'S UG.SSI✓P �. citv ��7✓«-�'� staie: IV'� zin: dw�Q� nhone# ��'-��O -� /G / worY,site location(fiill zddress): ❑ I a:�t a sole proprietor and have no one Business Type: ❑Retail❑RestauruzdBavEating Establishment worl�ng in any eapacity. ❑Office Q Salu(including Real Estate,Au[os etc.) [�'I am an employer with �� employezs(full&part ume}. [�]'Ot6er i ZZ� ✓e� -/z. -e - c�^-�"- Q I am an employer providing workers'compensation for my employees workin�on this jo . comox±±vname: � � i 7)�1t ��'IL�� r address: I C� ��AS..S)✓1 L✓�• citv: �Gl��{ � VVt(� ���V ohono#: /��' 37� � 7�-��/ insuranceco. ��!l�lr'C'FJ' I1f���Y1 �y�ul�<� ��11. l.�`- oolicv� � UlI�„��z� ❑ I am a sole proprietor and 6ave hired the independent co�tractors listed belou•�vho have the followine workers' �� compeasation polices: comoanv oame: - address: citv p6one�: insurance co. oolin��' com anv name- addrecc: ciN: ohone�`� IiLSU�'A�CC CO. OOt1Cv'r� Attac6additlonafsheetlfnecessarp- � - - � ' .. � . � - �� Failure to secvre caverage as required under Sec[ion 25A ofMGL li2 can lcad to Ne imposidon ofcriminal pe�al5es of a nne up[o SI,500.00 anNar one years'imprisunment as well as civil penaltles in the form of a STOP WORK QRDER and a fine of 5700.00 a day against me. 1 undersrand that a ropy of this s[a[ement may be forwarded[o the 011ice of Investiga[ions ofthe DI4 for coverage veriHcation_ I do nere3��cerriJ}!{cider t trss and psnalties oj perjury that the iuf�rmation provide�l nbove is(rue andyrorrecL � ��/ //�ZO�d Sienatzre 7�� ..� Date P;n.nsme�J��f'L.� 'none#�/ � d (/ .,..,..a..;se oa., do ac:a�;.e,r�t�s ere�.o bz tumpk.ed br ci.,�or.ur:u a�i.tfai cin•or rowo: permiNiceose� ❑Buiding Department �Licensing Baard ❑dreck ifimmediate response is required ❑Selec!meo's Of6re ❑He21[F.Dw�rimen[ contact person: phone c: �Othe� .e �acseoi.'oo31 , . 10/27/2010 9:13 AM FROM: Risma� Risman Insurance TO: +1 (508) 8777611 PAGE: 002 OF 003 ACORD CERTIFICATE OF LIABILITY INSURANCE DATE�MMI�OA'ri1� io/z�/zoio PROOUCER (7g1)396-2116 FAX (781)395-2300 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION • Ri sman Insurance Agency, Inc. ONLV AND CONFERS NO RIGHTS UPON THE CERTIFICA7E HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR . 689 Fel l sway � ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Medford, � MA 02155 Michele Sarcia lNSURERSAFFORDINGCOVERAGE NAIC# iNsurs�o AM Pizza, Inc. . iNsur+een� Norfolk & Dedham Mutual Ins Co 23965 U6A: Domino's Pizza � wsuaeae: Arbella Protection Insurance C 384 Edgel l Road iNsuRea c . Framingham, MA 01701 � iNsuReea. INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWIhISTANDING ANY REQUIREMEM,TERM OR CONDITION OF ANY COMRACT OR O7HER DOCUMENT WI7H RESPECT TO WHICH 7HI5 CERTIFICATE MAV BE ISSUED OR MAV PERTAIN,iHE INSURANCE AFFORDED BYTHE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BV PAID CLAIMS. INSR �D' TypEOFINSURANCE POLICYNUM9ER OATEYEF�FECTIVE pO,L�YA'E'R�PIO TION LIMITS LTR NSR ceNe�uunnei�m � R0662751A �6��18��01� 06�28�2011 EACHOCCURRENCE $ 1�0�0�0� X COMMERQPL GENERPL LIPBILITY � . . . � . - . ' - PREMBES Ea occurzence $ SO�OO CV11MS I.NDE � OGCUR. � . � MED EXP(!vry we peRon) $ �S�OO q �� � . � PeRsowa s.�v ir�duRr s 1,000,00 . ._. .�. .... . ... ... . .- ...... _ GE�aa.AGGREw� $ 2,000,00 GEN'L AGGREWTE LU<IT APPLIES PER: � PROWCTS-WMP/OP AGG $ 2�OOO�OO � POLICY jEa LOC - AUTOMOBILELIFBILRY 009844��004 OG�1$�ZOZO� OG�ZR�ZOLI COMBWEDSINGLELIMIT .�Ea acutle�nl s 1�000�00 ANY P11T0 . . .. �PiLON?JED�lftO$ � � . . � BODILY'iNJURY $ B .' SCFEDL�kEUAUF09 . . _ . IPe�pers0�� . X� HI,RE6.41JT05`j,.;;� BODILV INJURY X.:..NOKOWNEDA1fI06 . . _ . .. _ ... . (Peraccider�t�.. . . $ . � PROPERTV DMMGE t ...._ _.___. .__ ... . _ . _. _.__. .... . ..... , _ . __... . .�Perecciaenq. . .. ._ , ...: _. __'_ "' __. _""'-_ ' '_..._ . . ___ . .._.._. MRF.9NLY-EAACCIDEM $ �GARAGELIABILRY._ .p. �...��„ .. -'�� ` PNVAUTO ' .. OTiERTFUW EAACC S .. . . . ., . .. . . . AUTO'ONLY�. AGG S EXCESS/UMBRELLPLIN61LrtV ��.�. ULOOSS49A OG�SS�ZQZU 06�18'�Z�ZL �EACHOCCURRENCE S Z�Q����Q X OCCUR � CL41M5 hNDE- .. .. . .. .. . �,�° . .. � . . AGGREGATE f . p . � s 2,000,00 DEDUCTIB�E � . � s RETENTION S S WORHERSCOMPENSATON.� .. . . � WEOBEH32A 06/18/2010 - 06/18/2011 : TaRvum�Ts ER ANDEMPLOVERS'LIA6ILITV � ' � . ANY PRAPRIETqWPARTryER/�%ECNIVE � � � � - E L.EACH ACCIDENT E SOO�OO A OFFlCER/MEFIBER E%CLUDE09 � � �Mantlafory In NH) . � � E L.DISEPSE-EA EMPLOVE $ SOO OO II yes,CesGnGe unGe[ _. � -� � - �- -�—. "' E L:DISEASE-P6LiCV LiMIT S SOO�OO SPECIALP,ROVISIQN$prypv ... -�-. , ':1� " � �' . • � .� � � OTHER� ., . .. . . . . DESCRIPTIONOFOPERATIONS/LOCAl10N5/VEHICLESIEXCLUSIONSM�E06VENDORSEMENT/SVECIALPROVIS16NS � . : . . �'��i'�'� - , .. . . . � . CERTIFICA7E.HOLDER � EANCELLAiION � � � � ' � � �� � SHOULO ANY OF T1E ABOVE�ESLRIOE�POUQES BE CANCELLED BEFORE TIE EXPIRRTON � � - � � � ';. � pATE THEF�EOF�THE I;SU�NG INS.URER WILL ENDEAVOR TO MAIL _ OAYS WRITTEN TOWII Of Ydf.7110UCIl � . _�� NOTICETOTHE�LERTFICATEHOLDERNAME�TOTHELEFT,BVfFAILURETODO503HALL Board of Heal th IMPOSE NO 08LIGATIoN OR LIABILT/OF ANV KINO UPON lHE INSURER,RS RGElf�S OR 1146 Route ZS � REPRESEMATIVES � Yarmouth, MA '02664 AUTHORITEDttEPRESENTATNE � ' Q � . �� ... . .. .. . . -. Michele��Sa�ci ; JS. . . � �1�� ACORD 25(2009/01) � - � OO 1988-2009 ACORD CORPORATION. All rights reserved � � The ACORD name and logo are registered marks�of ACORD� .