Loading...
HomeMy WebLinkAboutApplication and WC wr�vr��ae��A ° d TOWN OF YARMOUTH BOARD OF HEALTH � - t� � APPLICATION FOR LICENSE/PBRMI'I'�tZ�l��� OCT 2 6 2U15 �� s * Please complete form and attach all necessarydocw�ents l�y ecemGe IS �Tii DF.:PT. Failure to do so will result in the return of your appl�cahon packet ESTABLISHMENTNAME:C/Y.1Erl'1'tnHZ�SEs �LC p 4�ND/Etilce CReAM TAXID• LOCATION ADDRESS: P R�uct�Q�r�adss $,y,y,okmavrH /YIA C/2 bb�f TEL.#: SZ�"��`�' 3 6�o MAILINGADDRESS: 323 1-E�'v�TH��' '� ScAks�Ar�'� NY los�3 E-MAIL ADDRESS: "nCa-llal e Veri a�n . rnet � ,1-f'cakaf ce- �ma11� �o� OWNERNAME: ���Y A� C.'+ HA�Y � \oS�PN �CA HALy CORPORATION NAME (IF APPLICABLE): CN,S E�Y-Tt`YzP !sr's J�.1�� MANAGER'SNAME: Rd�YA• CAHA�y pSr-Phs �'CA �^ ty TEL.#: ��F'�fs�`�2� /Y�"'� MAILINGADDRESS323 1--�enTHcoTs' aav ScAasaAce YY_y. 101�3 �4' Sro��84y� �oE) 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. -r.- --. _-- - -- - -__ — __ 2� Pool operators must list a minimum of two employees currently certified in standard First Aid and Communiry Cardiopulmonary Resuscitation (CPR), having one certified employee on premises at all times. Please list the employees below and attach copies of their cerhfications 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: (k'�(cwsen) 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 at[ach 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. �. I'I���-� A cnc�A�-y z. PERSON IN CHARGE: Each food�tablishment must have at least one Person In Charge (PIC) on site dwing hours of operation. � oSt"PH � �AHA'-Y 2 /�A��Y � . CRHAc:Y ALLERGEN CERTIFICATIONS: CF�c�a4t�) 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 DepaMment will not use past years' records. You must provide new copies and maintain a file at your establishment. ( 1. �/FrfeY � ' C�1F4A�.Y 2. ` OSrY�H � < �N�Ly 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# I z ..__.._-'.___ ._— .-.--- .--_.. ..- . . �L'�'Ti.''�`_i�rori�Ll V iTl��i�_ _. ._ ._ _ . . 111 1J � ._ . -.. .. - LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT N B&B $55 CABIN $55 MOTEL $I10 INN $55 CAMP $55 SWIMMINGPOOL$il0ea. LODGE $55 TRAILERPARK $105 WHIRLPOOL $IlOea. FOOD SERVICE: � ' LICENSE REQUIRED FEE PERMIT LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LO-100 SEATS $125 �y CONTINENTAL $35 NON-PROFIT $30 _>100 SEATS $200 �COMMON VIC. $60 �7�-�E`� _��D.KITCHEN $80 RETAIL SERVICE: � LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# � LICENSE REQUIRED FEE PERMIT# <50 sq.ft. $50 >25,000 sq ft. $285 VENDING-FOOD $25 =<ZS,OOOsq.ft. $150 �FROZENDESSERT $40 �� _TOBACCO $I10 � NAME CHANGE: $15 AMOUNT DUE _ $ 22S��O *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** 1 . . � ADMIIVISTRATION � ' 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 INSURANCE ', AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR ' CERT. OF INSURANCE ATTACHED � OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED ✓ Town of Yarmouth taates and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: ✓' NO YES ! MOTELS AND OTHER LODGING ESTABLISHMENTS ' 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 of residence I 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 �I 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 schedule 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 standazd plate count by a State certified lab, and submitted to the Health Department three (3) days priar 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: I 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.vannouth.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 Deparhnent. 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 Board of Health. 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 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 PLA . � DATE: �� � ' ��0� ZQ � � SIGNATURE: Q � ' PRINTNAME & TITLE: f1n�Y A � ANA�y �os�l'H F` AHA�r Otur(�Rs� Rev. 10/OIAS ��, ` � t� The Commonwealth ofMassachusetts I . � Department oflndustrial Accidents Office of Investigatdons � 1 Congress Streef, Suite 100 Boston,MA 02114-2017 ' www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses ', A licant Information Please Print Le 'bl � `'/LEAM Business/Organization Name: ��� �K����S r's ��.0 6A ,�i-o�^a�t 5 1 ce Address: "I � B�ov r t 2� �v����rfG E City/State/Zip: �o.y/lRMouTH ,! ��� OZ�� `f Phone#: .5��-G �`1- 3 � ! o Ar,�e y �n employer?Check e a propriate bos: Business Type(required): 1.LI 1 loyer with �� � employees(full and/ 5. ❑ Retail �_�e s 6. []�RestaurantBaz/Eating Establishment -- -- - --- --- - ', 2. I am a so e propnetor or partne�p and fiave no 7, � Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. g. �Non-profit [No workers' comp.insurance required] 3.❑ We aze a corporarion and its officers have exercised 9. ❑ Entertainment their right of exempfion per c. 152, §1(4), and we have 10.0 Manufacturing no employees. [No workers' comp. insurance required]* 11.❑ Health Care 4.❑ We aze a non-profit organization, staffed by volunteers, with no em lo ees. o workers' comp. insurance req.] 12.0 Other P Y LI`I *Any applicant that checks box#I must also fill out the section below showiag their workers'compensation policy mformation. **If the cotporate officers have e�mpted themselves,but the corporafion has other employees,a workers'compensation policy is required�d such an organization should check box#I. I am an employer that is providing workers'eompensation insuran�far my emp[oyees. Be[ow is the policy information. �' �--, InsuranceCompanyName: � RVr'tr(1S �./f'��N �"�'�' oMPnrcy dF Mr'YLiCA � Insurer'sAddress: C(o �oGFlCS + G(�,qy /fSuRArrCe: rl(�r�`��Y `f 3'T OU'1� �3�� c�riisr�iz�P: �d u �-i-r ���l�t i s �� � 2GG a � o�f oz � � Polic #or Self-ins. Lic.# � ����S Q� ����-�^ ''� Expiration Date: ' ' r , + 'on a e showin the oli number and expu�ahon date). i Attach a copy of the workers compensation policy declarah p g ( g p �Y a Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalfies of a i _ — , - - i fine up to $1,500.00 and/or one-year imprisonment�as wetl as civ#T pe�ties in the form of a S3'OP W(3RI£ORDERsn a- ne of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwazded to the Office of Investigations of the DIA for insurance coverage verification. � I do hereby certify,under the pains and pe 'es ofper,/'ury thal the informafion provided above is true and correM. � � � l.ad�. Date: 0 CT• ��O :L 0 1� � Si ature: I /� �[ � CtLL q i`{-�Ea'C1-�'2� CI'/�r,cY> • "� ��{-'C���'��1� ,�oSrPH Phone#: OfficiaL use on[y. Do not write in this area,to be comp[eted by city or town offuiaL 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 �.. ,-__��_ . . TRAVELERS J� woRKeRs co�a�ws,anaa AMU EMPLOYERS IIABItITY POW6Y TYPE AR' INFORMATION.PAGE WC 00 00 O7 ( A) : POLICYNUMBER: (6hR16-5690104-0-15) RENEWAL AF (6HU6-5890104-0-14) INSt1RERt TFf TRAVELERS II�EM[dITY COAPANV OF :AI�RIGA f. NCCI CO CODE: 13439 INSURED: PRODUCER: CNJ ENTERPRISES LLC ROt�RS & C�2AY INS AGENCY 323 I-EATHCOTE ROAD 434 RDUTE 734 SCARSDALE NY 10583 SOUTH DEFNIS MA Qp660 In3Ured i3 A LIMI7ED LIABILITY CW�pANY Otfier work p{aces and iderrtiFicatian numbazs ara shpwn in ths scheduls(sj attsched. 2. The policy period is from oa-02-i s to 04-02-16 12:01 A.M. at fhe insured's maMing address. 3. A. WORKEAS COMPENSATION INSURANCE: Part One of the policy:appl�s to the Workers � Compensation Caw ofthe state(s),iisted here: �� MA ' �� � , � 8. EMPLOYERS LlABILITY INSURANCE: Part Two of Yhe poHCy ap�t�to work in eaCh state itsted in i � Rem 3.A. The ilmits of ourliabqfty under Part Two are: � Bodily 1nJury by Acciderrt: S 50000o Each Aceiderrt , ,� BodNy injury by Disease: S 500000 Pd1cy Limit �, � BodGy Mjury by Disease: 3 50�00o Each Employee. : . . .__ �_ � C. OTHER STATES INSURANCE: Part Three of ihe pdiey appties to the states, ff any,iisted here: ' � COVERAGE REPLACED BY EhDORSEMENT WC 20 03 06A , � � � � s � = D. This policy indudes these endorsemerrts and schedules: � SEE LISTING OF E(�ORSEMENTS - fiXTENSION bP IF�O PAGE � , B � 4. The premium for this pdicy will be determined by pur Manuals of RWes, Class'rfications, Rates and Rating ' = Plans. All requlr� irtformation is sut�ect to verificatbn and change by audft to be mada A�IALLY. DATE OF ISSUE: 03-09-15 WC ` Sr ASSI(�1: MA OFFICE: OR�ANDQ II�US AFF 161 � - � � �� �� � � � � � � � � � � PqAI]IICER: ROGERS & (aY2AY INS AfENCY ��'"^' f �� � �� ' , TR/CYECER5,�4 WORKERS COMPENSA7'!ON � AND . EMPLf3YERS LIA8ILITY POLICY 7YPE AR fNFORIuIATiON PACaE WC 00 00 01( Aj : POLICY:NUMBER: (6Hu6-5690104-0-15) GLASSIFICAT►ON SCHEDUtE: pREMWM BASIS ESTpMATED RATES ESTINfATED TOTAL QNPtlJI4L ' PER$100 OF ANNUAt CLASSIFICATIQNS CODE NU REMUNERATION RENlUNERATION PREMIUM ` SEE-EXTEt�ifM! OF' II�ORMATION PAGE - SCFEDULE(S) . SIG-CODE: 5812 NAICS: 722511 ---------------------'- TOT/AE ESTIM/ITED AM0.lAL STAFDARD PREMIl�1 g' STAI�ARD _ . ' PREMIUM DISCDUNT` ryp�: 0900-20 EXPENSE'CDNSTAN7 25p 'fERRORISM � : t TOTAL ESTIMATED PREMIUM 4gg, T.4XE5 At�D SURCHARGES �p ; i DEPOSIT /iMOUNT DUE 508MP AIR tWCIP} � Minimum Premium: $gt 9 : ENPLDVERS IIABILITY MINIMUM: $50 ST ASSIGNc, MA DATE 0F ISSUE: 03-09-15 wC OFFICE: ORLARAo IPDUS AFF-461 ': PRDDUCER: RflGERS & t92�1Y INS AG'ENGY 237XR ' ��s ca�Er�s�n°" TR�1tlELERS J� : f,�r��s w�urr Poucv EXTEN.SIOPi � i�a �nc;�-sc►�oucE wc o0 00 oi ( a) POLICY NUMBER: (�''6901 oa-o-15} ` ANV OF AFERICA 13439-►AA INSURER: TF� TRAVELERS INDEMdITY C� IN$URED'S w+►'� : C� ENTERPRISES LtC RATE Bll�EAU ID: 000974767 pftEMIIAArBASiS RA.�S ESTIMATE� ESTIMA'fED PER S1D0 � a�A� �T�RA�� REMIR�IERATION PREMIUM, GOD� CLASSIFICAtION LOGkTIIN+I 001 01 FEIN ' ENTITY CA 001 � ENTERPRISES LLC 328 ROUTE 28� 02664 173 5 ���TM5812 NAICS: 722511 y5� 1 .i5 SIC �° 90T9 RESTAtR2ANT t�� � '_ � �_ , � � # = 9 � ia�� .. . � �: . . . . . . . . . � . t � � . ._ . � � . . ; � _ a� . . . � . . . . � . . . . � � � . _� � � . . ... . - –'_'_�__ . i �-- . . . . .. . . . . . . ... �'��_–_ ; �.�. . . . . . -.__'_.'__' . . , — . .. ___�.-_'_ � � --------------------------------�EASED 4IMIT5�9807) $ ' 4g 9848) N[M1E � � ��FpR INCREASE� ���IFI�PREMItmA 20 LOSS CONSTAMT 223 � �RIT RATING/EX�ERIENCE �' AL �T�ARD PREMI� 250 = TOTAI ESTIMATED �ENSE CONSTANTt0900) y .� 0.0300 TERR�ORTitUST F4tJND 5Q8 � 5_80% M1�+ � SPECIAL FtA�D '508 � TOTAL E$TIMATED PREMIUMI ; � DEPOSIT AMa1NT DUE SCNEDUI.E NO: 1 OF LAST ST ASSIta�i: � DATE OF ISSUE: 03-09-�5 � _ - ' . o�+- �. . � . . �, �,: - --: `_ . � . '. .� . .