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Home My WebLink AboutApplication and WCf � I � TOWN OF YARMOUTH BOARD OF HEALTH R� � � , �� APPLICATION FOR LICEN E/PERMIT_-2 1 p�'J� .��, �- NUV �; 7 ZU15 * Please complete form and attach all ne €ary documen s. y c ber IS 2015. Failure to do so will result in the�ek'urn your appliCahgn c 98EALTH DEPT. , � _ �, . .� ;u �. E5TABLISHMENT NAME• �.v4r l�7ay 6c...�L TAX ID• LOCATION ADDRESS: $ I �: ,vyr G'aLo. r�.o�M �,�� M.l TEL#• 774 S3o 3� 7/f MAILING ADDRESS: A I ��(J CiLLL�s yLM_.ro0 9N' dQf T /N� 02G hf E-MAIL ADDRESS: co/•v •�751�d..r+o�,-o n �o 09VNER NAME: .a .- �.�� cJ y T,e�. CORPORATION NAME (IF APPLICABLE): iNsr o �� I.vc MANAGER'SNAME: C1�-%rfo�h� Q';�u: � TEL.#: 7g�B�9 ��t� MAILING ADDRESS:�'c' Cs;/,Fs., L..� ��.�+�� .4,s ms�3� 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 certification to this form. ', j--- ---______ _ _ 2. Pool operators must list a minimum of two employees currently certified in standard First Aid and Community Cazdiopulmonary 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 will not use past years' records. You must provide new copies and maintain a file 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 will not use past years' recards. You must provide new copies and maintain a Sle at your establishment. �l�- ' �-I'� . 1. , , .uQ.s-� 2. �-- PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. �Lv-i i .1ta..-:' 2. 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 file at your establishment. 1.�/�LJ lVli {�Gf I� Z. 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.� K�.•r 6lli'u�r: 2. v 3. 4. RESTAURANT SEATING: TOTAL# ( '7 �.- __ _ OFEIC'F, iTCF.pNLY__ __ - - -- ----- --- � LODGING: - LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&B $55 CABIN $55 MOTEL $110 _INN $55 CAMP $55 SWIMMINGPOOL$IlOea _LODGE $55 =TRAILERPARK $105 _WH[RLPOOL $110ea. FOOD SERVICE: � LICSNSEREQUIRED FEE PERMIT# LICENSEREQUIRED FEE PERMIT# WCENSEREQUIRED FEE PERMIT# 0-100 SEATS $]25 CONTINENTAL . $35 NON-PROFIT $30 - =>100 SEATS $200 �(f �COMMON VIC. $60 �� =WHOLESALE $80 RETAIL SERVICE: —RESID.KITCHEN $80 � LICENSEq REQU[RED FEE PERMIT# LICENSE REQUfRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# ` =<25,000 sq.ft. $$50 �25,000 sq ft. $285 VENDING-FOOD $25 _FROZEN DESSERT $40 _TOBACCO $I 10 NAME CHANGE: $15 AMOUNT DUE _ $ 260.00 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** ADMINISTRATION � � Under Chapter 152,Section 25C,Subsection 6,the Town of Yazmouth is now required to hold issuance ar 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 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. 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 shall be limited to the temporary and short term occupancy,ordinarity 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 thir[y(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 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 schedu►e the inspection three(3) days prior to opening. PLEASE NOTE: People are NOT allowed to sit in 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 contacf 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.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 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,prepazation,or display of any food product by a retail or food service establishment is prohibited. ,__ i 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 15, 2015. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE AN. DATE:�Ii/� SIGNATURE: � PRINT NAME & TITLE: G o�� R�'s' c:Fl PPo�A Rev. 10/01/IS � . � � The Commonwealth ofMassachusetts Department of Industrial Accidents Office of Investigations ' I Congress Street, Suite 100 Boston, MA 021I4-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Aunlicant Information Please Print Legiblv Business/Organization Name: (�1;,��r ;/�-� Address: ( Ki �s f �i rG i.� � } City/State/Zip: u-.v, ,-�' 7.� Phone#: '►�4 33 0 3/ 'I 4 Ar,e�y/ou an employer? Check the appropriate bos: Business Type(required): 1.LI I am a employer with �8 employees (full and/ 5. ❑ Retail � or part-time).* 6. [�]R stauranUBaz/Eating Establislunent — — -_ _ 2. I am a so e rp opnetor or partnership and have no �, � Office and/or Sales (incl.real estate,auto,etc.) employees working for me in any capacity. [No workers' comp. insurance required] $• ❑Non-profit 3.❑ We aze a corporarion and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4),and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]' 4.❑ We aze a non-profit organizarion, staffed by volunteers, 11.❑ Health Caze with no employees. [No workers' comp. insurance req.] 12.� Other 'Any applicant that checks box#1 must also fill out the section below showing the'u workers'compensa[ion policy infoimztioa. ••If the cotpore[e office:s have exempted themselves,but the corporation has other employees,a workets'compensarion policy is required and such an orgatizarion should check box#1. I am an emplayer that is prov7�iding workers'compensation insurance for my employee^s. Below is thepolicy information. Insurance Company Name: psr��,r�S r:�_ .,� •.4 , �,•�� f�u�•c �nJ_ �e Insurer's Address: !�. D- �y .S'��¢3 Ciry/State/Zip: /"1 r�r� ��iv 5•1�4.��j' - A t 4 3 Policy# or Self-ins. Lic. # 1.� C- 20 _20- a o�'�o o - o o Expiration Date: 4�24�]o r t� Attach a copy of the workers' compensation poficy declaration page(showing the policy nnmber and ezpiration date). Failure to secure coverage as required under Section 25A of MGL a 152 can lead to the imposifion of criminal penalties of a fine up to$I;30G:1�0 ari�i one=yeaz impnsonment,as well as civil penalries in the Torm of a STOP WORK ORI7ER and a�`ine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be fonvarded to the Office of Invesrigations of the DIA for insurance coverage verification. I do hereby cert�,under the pains enalties ofperjury that the information provided above is true and correct. Si atur • Date: i/ � i� Phone#: �s� � 3 7 .ro�s z 9� Official use only. Do not write in this area,to be completed by city or town offtcial City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2. Building Department 3. City/Town Clerk 4.Licensing Board 5. Selectmen's Office 6.Other Contact Person• Phone#• www.mass.gov/dia Berkley Massachusetts Workers'Compensation Insurance Pian AcafGa Ir�surence Corrpeny NCCI Canler Code 33391 Atlministered by BerkleyAssigned Risk Seniws ASSIGNED R�I(SERVICES P.O.Box 58143,MfnneapoAs,Minneaota 5545&0149 � Phone(605)945-2144 Faz(8g6)2758118 TOR Free(80p)834-0589 www.be�kleyassignedrisk.com pollcysenicea�be�kleyrisk.com INFORMATION PAGE Renewal Of No. New 1.The Insured: Normal A/R Policy Number.WG20-20-005600-00 � Kings Way Grille Inc Risk ID:1084521 � 81 Kings Circuft Yarmouth Port,MA 02675 - � Tax ID#: � Date of Mailing:4/29/2015 . � �,_,Individual �Partnership � OMer wakpiaces not shown above: X❑Coryoretion �O�er See Schedule 2 The po�icy perlod is hom 12:01 a.m.4l24/2015 to 12.�01 a.m.q/$q/2016 at the lnsureds mailing eddress. 3A.Workere'Compensatbn Inamance:Part One of tha poicy appfies(o�he Workew'Compensation Law of tha states Iisted hare: MA B.Employers Liability Insu�snca:part Two of the policy appltes M work In each state Iisted in itam 3.A . The Nmfts W our liebility unCer Parl Two are: BodpY�nJury By Acddent � - $500,000 each aocident. BodOy Injury By Dlsease 5500,000 po0cy IImIL BodOy Injury By Diseese f500,000 each empbyee. C.Other Sietea Insurence:paK TAree of(he pdky app�f��q�e states,B any,listed here: COVERAGE KEPLACFD BY ENDORgEMENT WC 2p-03A6 B) D.Thls poNcy includes these endorsemeMa and achedules: , WC000310 WC000403 WC OOP904 WC00 0414 WC200q01 WC2004p5 WC200607A WC20080q WC990001A YVC9gpg016 WC200301 WC200302A WC200303� WC2003066 WC200307 4.The premfum fa fAis policy will be tletartnined py our Aqanuals of Rules,Classiflcetions,Rates and RaNng Plans. All Infortnalbn roquired below is subject to verificatlon antl changa by audq. PREMIUM BASIS RATES ENTRIES IN THIS ITEM,EXCEPTAS SPECIFICALLY PROVIDED ES7IMATED TOTAL pER 5100 OF CODE ELSEWFIERE IN THIS CONTRACT DO NOT ry�pp�pypNypF ESiMAATED ANNUAL REMUNERATION REMUNERATION NO. ANNUAL THE OTHER PROVISIONS OF THIS POLICY, pR�� See Schedule °8�P`��"" s+,zos.oa ncreased Umlls 1.01 512.00 ncreasatl Limlts NNnimum Minimum Premium: $268.00 ubJaet Pramlum �•� odlfled Premlum S7,2b8.00 Standard Ptemfum s�,�.� ence Cofrefant 57,258.00 artorlsm 5396.00 otel Esdmated Mnual Premlum �'� E92.00 �encv Name and Address �`�E�"re"� �os$ Et,sze.00 otal Fees&Premlum S70A0 HUB Intemadonal of New England LLC Net Deposk Premium Raqulred E1,69sAo 289 Ballardvale St#2 Premium Pald to pate E1,698.Oo Wilmington,MA 07887 otal Premtum Due (S1,s98.o0) So.00 DATE: �015 �� , Signature_ L.f'""'" ' , ��N„�c�aauawcw�Knmcomv�,.mnw�r.�mwwrwna�o.ev,+mn — Cennenu�kn 4wsance � WCi 98-�-0� Berkley Massachusetts Workers'Compensation Insurance Plan Acadie Insurence Canpany NCq Carder Code 33381 Administered by Berkley qssigned Risk Servicea ASSIGNED RISK SERVICES P.O.Box 59143,�nneapous,R�nneaoW 5545&0143 Phone(605)9452144 Faz(865)y75.g11 g ToN Free(600)634-4569 ww�r.berkleyassigrredrisk.com pulicyservicesQbarklayrisk.com INFORMATION SCHEDULE Renewal Ot No. New � 1.The insured: Po�. Normal A/R cy Number. WG20-20-005600-00 ' Kings Way Grllle Inc Risk 1D: 1084629 81 Kings Circuk . � Yarmouth Port,MA 02675 . Tax ID#: � Policy Perad: From:4/yq/pp15 � To:4/24/y016 � Endwsement Eff.Date:4/24ly015 Changes as set forth bebw are ha � Date of Mafling: 4/29l2015 reby made,with res d to the estimated remuneration,premium and/or rates. . PREMIUM BASIS RqTES ESTIMATEDTOTAL pER$100OF CLASS 4/2M2015 -M24l2016 ESTIMATED ANNUqLREMUNERATION REMUNERATIO CODE ANMIAL � - CLASSIF7CATION PREMIUM State: MA IMga Way GNlle Inc 81 Kings Clrcult � Yarmouth Port MA, 02676 $105,000 1.15 9079 RESTAURANT-NOC $� 208 MA Manual pr�nium $7208.00 Supplementary Disease b0.00 Wahrer M SWrogatbn Fador a0.� Number of WaWera � � $p� Increased limita 1.09 Increased Limits Minimum $�Z�� $38.00 Daductible Fador $0� SubJect premium � ExPaiience MotlificeUon $1�256.00 Mari1 RaWig $0.00 $0:00 Modifred Premium $1,258.00 Contrading Class Prem Adj pgm $�� StarMaN Premtum 87,258.00 SupplemeMal Disease Expusure 50.� ARAP Quelity Loss ManagemeM Prp $0.� Lo86 ConBtatM $�'� Expense Conslant $�'� Tetrorism $938.00 0.03 532.00 Shat Rete $O� � � MinYnum Premium AdjustmeM $p� FormarSelf Insured Cherge $0.00 7ote1 EsUmatedAnnual Premtum $��8� Paga 7 oi 2 WC990001A BG�I1IGy Massachusetts Workers'Compensation Insurance Pfan AcaCia lnsurenx Company NCCI Cerrler Code 33381 Adrrinistered by BerkleyAssigr�ed Risk Servkes AS5IGNEDRISKSERNCES P.O.Box59143,M'inrreapolis,Minnesoia 55459-0143 Phona(805)9452144 Fan(888)215-8118 Toll Free(800)694-4589 - `.�ww.befkleyasaignedriak.com pdicyservices�berkleyrisk.com INFORMATION SCHEDULE Renewal Of No. New �.rne insured: Normal A/R �y Number: wc-zo.zo-oossoo-oo Poli Rlsk!D: 1084529 Kings Way Grille Inc - 81 Kings Clrcult Tax ID#; Yartnouth Port,Mp 02675 . Policy Period: From: M2412015 To:4l24/2096 . � Endorsement Eff.Date:4/24/2015 �, Dale of Maiqng: 4/28/2015 � Changes as set forth be�ow are hereby made,wilh respect to tlie esGmated remuneraUon,premium and/or rates.� � DIAASses�neM . 1.058 $70.00 - Policy Summary 4/24/2015-4/24/2016 . Manual Premlum 51,20B.00 lncreased Limits 1.07 S7Y.00 � � Increasad�imlts Minimum ;�e� Subject Premium 51,268.00 � MotliFled Premium . 51.258.00 Standard premlum 57.26B.00 Expenae Constant �B� � Terrodsm o.03 y32.00 Tohl Estimated Mnual Premfum E1,828.00 DIAAssessment 1.068 $70.00 Total Fees&Premlum t7,898.00 Net Daposit Premfum Requirod � 57,698.00 Premlum Paid to Date (57,698.00) Refimtl E0.00 AII other tertns and wnditions of this policy remain unchanged. Aqencv Name and Address HUB Intemational of New England LLC 299 Ba1laMvale St#2 - Wilmington,MA 01887 Page 2 of 2 W�g9ppplA