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Home My WebLink AboutApplication and WC �a� y; u L� _ �/^� � TOWN OF YARMOUTH BOARD OF HEALTH V APPLICATION FOR LICENSE/P�124' 1 OCT � 7 ZO15 � �"'' * Please complete form and attach all necessary��u ' e� ' r S 2015. Failure to do so will result in the return�fyo p i$c a et. � � �F�T ESTABLISHMENTNAME: So�-�-� Yarm�u-W� Da�±� Queen TAXID• LOCATION ADDRESS: q�1 2ou+c 28 TEL.#: (So8) 394-9 5 3.S MAILINGADDRESS: 9�7 Ro:��FC ag E-MAILADDRESS: oluncdr��e hv�mail• curn _ OWNERNAME: ?fcC D�macv� ulns CORPORATION NAME (IF APPLICABLE): Dara foeds� =nc � MANAGER'S NAME: Dan Chris�pau lo s TEL.#:(508) 39 H-9 53 S MAILINGADDRESS: P o Box Ilan So. yarmu��-H � rY1A Oc2664 POOL CERTIFICATIONS: The pool supervisor must be certiCed 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. _ _ _ - L _ - - - _ Pool operators must list a minimum of two employees currently certified in standard First Aid and Community Cardiopulmonary 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. 1. 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' records. You must provide new copies and maintain a file at your establishment. 1. �aniel Chrrs�apoulos 2. l�s � kobes PERSON IN CHARGE: Each food establishment must have at least one Person In Chazge (PIC) on site during hours of operation. _ t. _ _ �o.s � �o l m e5 _— - - -- 2. - - --Tf—o�ra n�na.__ �is c, l l ' - _ ALLERGEN CERTIFICATIONS: All food service establishments aze required to have at least one full-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. i. �4nie1 Chris-�ovaulos 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# a �{ __ _ _ _— — — ----OFF�E`E-�33�-6N�- - _ LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUtRED FEE PERMIT# L[CENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $110 INN $55 CAMP $55 SWIMMING POOL$ll0ea. _LODGE $55 _TRAILER PARK $105 _WHIRLPOOL $110ea. FOOD SERVICE: � LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERM[T# �0-IOOSEATS $125 �1L�05a CONTINENTAL $35 NON-PROFIT $30 >l00 SEATS $200 1COMMON VIC. $60 _,�S _WHOLESALE $80 — —RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT k <50 sq.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 � <25,000 sq.ft. $I50 �FROZEN DESSERT $40 �7[--O Z _TOBACCO $110 NAMECHANGE: $t5 � AMOUNTDUE _ $ 2ZS.0� *****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. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE � AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR i CERT. OF INSURANCE ATTACHED ✓ OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED I Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK I APPROPRIATELY IF PAID: ! YES � NO ��I MOTELS AND OTHER LODGING ESTABLISHMENTS I TRANSIENT OCCUPANCY: For purposes of the limitations of Motel ar Hotel use,Transient occupancy sha11 be � limited to the temporary and short term occupancy,ordinarily 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 sha11 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. I 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 standard plate count by a State certified lab, and submitted to the Health Department three (3) days prior to opening, and quarterly � thereafter. II 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 Yannouth 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.vannouth.ma.us under Health Deparhnent, 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. Failwe 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 of Health. i OUTDOOR COOHING: Outdoor cooking,prepazation,or display of any food product by a retail or food service establishment is prohibited. j 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 SIT PLAN. � DATE: /d��J�5 SIGNATURE: PRINT NAME & TITLE: /)1Gn¢zaina a,f/ne� �anre! ��.ris�/upa,c�us Rev. 10/Ol/IS '��'�., INFORMATION PA6E RENEWAL AGREErffi1T Insurer: PRODUCER: Agent# 9999 MA Retail Merchants WC Gioup Inc. Cove Risk Services, LLC PO Sox 859222-9222 PO Box 859222-9222 Braintree. MA 02185 Braintree, MA 02185 (Carrier Code: 34355) Carrier Policy �: 014005030237115 Carrier Prior Policy �: 014005030237114 1. The Insured: Dara Eoods. Inc. South Yarmouth Dairy Queen Mailing Address: 917 Main Street Rte 28 South Yarmouth, MA 02664 Fein: Other workplaces not shown above: Type of Business: Corporation NO OTHIIt WORKPLACES FOR THIS POLICY Risk ID: 2. The policy period is from 12:01 a.m. on 1/O1/2015 to 12:01 a.m. on 1/O1/2016 at the insuzed's mailing address. 3. 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 Tr�o of the policy applies to work in each state listed in Item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident $ 100.000 each accident Bodily Injury by Disease $ 500.000 policy limit Bodily Injury by Disease $ 100,000 each employee C. Other States Insurance: D. This policy includes these endorsements and schedules: WCOOOOOOB(07/11) WC000310(04/84) WC000414(07/90) WC000422A(09/08) WC200301(04/84) WC200302(OS/86) WC200303B(07/99) WC200405(06/O1) WC200601(06/92) 4. The premium for this policp will be determined by out Manuals of Rules, Classifications. Rates and Rating Plans. All information required below is subject to verification and change by audit. Classifications Code Premium Basis Rate Per Estimated No. Total Estimated $100 of Annual Annual Remuneration Remuneration Premium SEE SCHEDULE OF OPERATIONS Total Estimated Annual Premium $ 1,852.00 Minimum Premium $ 219.00 Expense Constant .00 Deposit Premium .