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Home My WebLink AboutApplication and WC � � � �.. .. .- , /;) , T ` _ _.-�+�- , �� / Irr�Cj.' _Y(/��I�;, VQ�7`�v�..7 -- � �' ► TOWN OF YARMOUTH BOARD OF HEALTH - � ��t��-�. s,�a-noN ave. � '� � �� APPLICATION FOR LICENSE/PERM i °�. �� .. ��'� �,, -�1 * Please complete form and attach all necessary docu��s ecembe 75 � �l S . Failure to do so will result in the return of you�.��pli�tion packe . --------- --- �--- � ESTABLISHMENT NAME: '�c�n K,� ` �D n.J�'i TAX ID: �- LOCATION ADDRESS: f �o� 1/ r,/�/ S . t TEL.#: Q ' 8 ' �l�d/ MAILING ADDRESS: Srtc}'on � / ' �/ d E-MAIL ADDRESS: I � J � OWNER NAME: " c 2 t CORPORATION NAME (IF PLICAB E): ��-�►'dn /kt/'Py�� ne n ��'S L(�(.. ' MANAGER'S NAME: �C c��'�� 7'a n 6� T�L•#: �'b k ' �5 � " 84D� MAILING ADDRES S: �1�i b� �I'''��l'�'�_1�JC�'4 i�� 1 a/n�n:/� 11�,�- O 26G� 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. ', � . - — - ------ � _ - -- ---- . ----_ 1. 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. �,(i�tn �,ne,t 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. L 2. PERSON 1N CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1,,��.�__----�.a_.�_ --_�—.r�,__ __ 2. __ _ _ ___ ___ :_ ALLERGEN CERTIFICATIONS: All food service establishments are 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. ' 1. �-.` �1�✓ti�, �U n� 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. 1�c�,�G� �Un.-g 2. 3. 4. RESTAURANT SEATING: TOTAL# �.� ---------__ ,.-�`uT��.fli�� _ _ _--- -- _ _ _-- _ _ — LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $110 INN $55 CAMP $55 SWIMMING POOL$110ea. LODGE $55 TRAILER PARK $105 _WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED PEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# ( 0-100 SEATS $125 ��Q�O CONTINENTAL $35 NON-PROFIT $30 >100 SEATS $200 �COMMON VIC. $60 ��OSs _WHOLESALE $80 — —RESID.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 -<z5,000 sq.ft. $150 —FROZEN DESSERT $40 TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE _ $ �8S•OO *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** t 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 � CERT. OF INSURANCE ATTACHED `� ° OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED � E Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK � APPROPRIATELY IF PAID: / ; YES �/ NO � . MOTELS AND OTHER LODGING ESTABL.ISHMENTS r TRANSIENT OCCUPANCY: For u oses of the limitations of Motel or Hotel use Transient occu anc shall be � P rP � P Y � 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 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 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. ! i 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 cont�ct 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.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 Board of Health. OUTDOOR COOKING: Outdoor cooking,preparation,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 3 L IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 15, 2015. ; I 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 PLAN. DATE: �0 t �a �� SIGNATURE: �� C,r�wC'�� - PRINT NAME&TITLE: !�� (,�, �'� Y-t�lJi G. . ��M�r'�. �� I Rev. 10/O 1/I S � I II ! � The Commonwealth ofMassachusetts . Department of Ind�cstrial Accidents Office of Investigations � ' 1 Congress Street, Suite I00 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses . Applicant Information Please Print Le�iblv Business/Organization Name:�j��IG j., �on�� Address: "��J �6 Sr�i �i 6Q �r/ City/State/Zip: 2 H Phone#: �G�� _�� 'UO l Ar you an employer?Che k the appropriate boz: Business Type(required): 1.,,�I am a employer with�_employees(full and/ 5. ❑Retail or part-time).* ' � �- 6. �'gstauraaltBar/Eating Establishment ___ - - 2.�I I am a sole proprietor or partners�iip a.nd have no �, � Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers' comp.insurance required] g• ❑Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment their right of exemption 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 employees. [No workers' comp. insurance req.] 12.❑ Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. , **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#1. ', I am an employer that is providing workers'compensation insurance for my employees Below is the policy information. ' Insurance Company Name: m� (�,,e�Ya�� IY��✓vl��r S W(i (s/6 U / =n�, Insurer's Address: Q� Q d� $�i� `3. �� 1�tZ , City/State/Zip: 13((a,�n��(.G M 1� D �I �S� Policy#or Self-ins. Lic.# o b�l D o S 0 3�6 6 '� J I,'S` Expira.tion Date: 6 Attach a copy of the workers' compensation policy declaration page(showing the policy number an ezpiration date). ' Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of crimina.l penalties of a —___ - - __ �- - - - - � � P Y P � P I fine u to$1,500.00 ancl/or one- ear im nsonmen as welTas civil enal�ies in the�orm o�a Sg`0��t3�anc�a n-- - of up to$250.00 a day against the violator. Be advised that a copy of this sta.tement may be forwarded to the Office of 'I Investigations of the DIA for insurance coverage verification. I do hereby certify,under the pains and penalties of perjury that the information provided above is true and correct. Si ature: ��►G i.,_�,e,.�� i Date: l0 1 ��1 � lt� Phone#: �G�' �5 f� � �O d � Official use only. Do not write in this area,to be completed by city or town officiaL ; 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 � ; � ; INFORMATION PAGE RENEWAL AGREEMENT i i � Insurer: PRODUCER: Agent�k 542 � MA Retail Merchants WC Group Inc. Rogers & Gray Insurance Agency, In � PO Box 859222-9222 434 Route 134 � Braintree, MA 02185 South Dennis, MA 026b0 � (Carrier Code: 34355) Carrier Policy ��: 014005032604115 a Carrier Prior Policy ��: 014005032604114 i j : • j 1. The Insured: Z Donut Company, Inc. �f Mailing Address: 436B Station Ave i South Yarmouth, MA 02664 Fein: Other workplaces not shown above: Type of Business: Corporation ' SEE SCHEDULE OF OPERATIONS Risk ID: 2. The policy period is from 12:01 a.m. on i�oi/ao1� to 12c01 a.m. on ` 1/O1/2016 + at the insured's mailing address. � ' 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: i MA I i B. Employers Liability Insurance: Part Two of the policy applies to work in each j state listed in Item 3.A. The limits of our liability under Part �ao are: Bodily Injury by Accident $ 1,OQ0,000 each accident Bodily Injury by Disease $ 1,000,000 policy limit Bodily Injury by Disease $ 1.000,000 each employee C. Other States Insurance: D. This policy includes these endorsements and schedules: WC040000B{07/11) WC000308 WC000310(04/84) WC000406A(08/95) WC000414(07/90) WC000422A(09/08) WC200301(04/84) WC200302(05/86) WC2�0303B(07/99) WC200405(06/Ol) WC200b01(06/92) 4. The premium for this policy will be determined by our 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 RemunPrati nn ��TM��ri�r--�----- ^ . � ,,,. � � , i � I ii C � i I '' ' PAGE: �1 ! �i jSCHEDULE OF OPERATIONS FOR: ! � � ��' Car�ier Policy #: 014005032&04115 ' � Z �onut Company, Inc. ; 43�B Station Ave , Fein: ! �! , : i� South Yarmouth, MA 02654 � � , DIV� #: 04004 E/L Number: 0000000001 , � � � � OTHER WORKPLACES: Br�ewster ponuts, LLC Fein: ; � 9 'Lower Rd NJ Taxpayer ID#:000230635 Brewster, MA 02631 Eff date: 01/01/15 SIC:5812 Mailing: DIV #: 00003 � 436B Station Ave E/L Number: 0000000001 South Yarmouth, MA 026b4 Chatham Donuts, LLC I Fein: i 1563 Rte 28 NJ Taxpa�rer ID#:000230635 � Chatham, MA 02669 Eff date. 01/01/15 � SIC:5812 , Mailing: DIV #: 00009 ' 436B Station Ave E/L Number: 0040000001 � South Yarmouth, MA 026&4 �� Harwich Donuts, LLC Fein: 175 Rte 137 NJ Taxpayer ID#:000230635 � East Harwich, MA 02645 Eff date': 01/01/15 ; � SIC:5812 � ', � Mailing: DIV #: 00005 � 436B Station Ave E/L Numb�r: 0000000001 i ' South Yarmouth, MA 026b4 ( � Fein: � � Zogra�os Donuts, Inc. ' Rte 137 NJ Taxpa�rer ID#:400230635 , ' Harwich, MA 02645 Eff date': 01/0�/15 SIC:5812' � Mailing: DIV #• OOOQ2 436B Station Ave E/L Number: 000'0000001 � South Yarmouth, MA 02654 , j � j Pleasa��nt Lake Donuts, LLC Fein',: ', j 173 Pl�easant Lake Drive NJ Taxpayer ID#�000230635 ; i Harwi�h, MA 02646 Eff date: 01/01;/15 , ' SIC:5812 Mailing: DIV #: 00008 436B Station Ave E/L Number: 0000000001 � South Yarmouth, MA 02664 i ! 1 1 1 , i I i a � ; SCHEDt.7LE OF OPERATIONS FOR: ; � PAGE: 2 � Z Donut �ompany, Inc. C�rrie�- Policy #: 014005032604115 � 436B Station Ave ; ; Fein: ; � � South Ya;rmouth, MA 02&64 � ' � + � DIV #: 00000 E/L Number: 0000000001 � � i ; OTHER WO�RKPLACES: Zografos Donuts, Inc. Fein: 481 Route 28 NJ Taxpayer ID#: 400230535 � Harwichport, MA 02646 Eff date: 01/01/15 � SIC:5812 � DIV #: 00002 E/L Number: 04�0000003 a ( Dennis Donuts, Inc. Fein: Rte 5A NJ Taxpayer ID#:000230635 North Eastham, MA 02651 Eff date: 01/01/15 SIC:5812 i Mailing: � DIV #: 00004 436B Station Ave E/L Number: OOOOQ00001 South Yarmouth, MA 02664 I Zografos Donuts, Inc. Fein: � Orleans Market Place NJ Taxpayer ID#:000230635 ; Rte 6A Eff date: 01/01/15 � Orleans, MA 02�53 SIC:5812 � DIV #: 00402 E/L Number: 0000040002 � ; Patriot Square Dionuts, LLC Fein: 6 Enterprise Ro�d r NJ Taxpayer ID#: 000230635 South Dennis, MA 02660 , Eff date: 41/01/15 SIC:5812 Mailing: , DIV #: 00007 43&B Station Ave E/L Number: 0000040001 South Yarmouth, MA 02664 Dennis Donuts, Inc. Fein: South Dennis, MA 02660, , Eff date: 01/01/15 ; SIC:5812 '; � DIV #: 00004 ' ' E/L NumbEr: 0000000004 � ! � � � � SCH�DULE �OF OPERATIONS FOR: I PAGE: 3 , � Z Donu� Com�hany, Inc. Carrier Policy #: 014005032504115 � �436B S�atio� Ave gein: j South �armouth, MA 02564 , � DIV #: 00000' E/L Number: 0000004001 � OTHER WORKPLACES: Z Donut Company, Inc. 436 Station Ave NJ Taxpayer ID#:000230635 � South Yarmouth, MA 026&4 Eff date: 01/01/15 SIC:5812 DIV #: 00400 E/L Number: 0000040401 Station Avenue Donuts, LLC Fein: 436 Station Ave NJ Taxpayer ID#: 000230b35 South Yarmouth, MA 02564 Eff date: 01/01/15 SIC:5812 � DIV #: 00001 � E/L Number: 0040000001 i Wellfleet Donuts, LLC Fein: 2396 State Highway NJ Taxpayer ID#: 000230635 Wellfleet, MA 02657 Eff date: 01/01/15 i SIC:5812 Mailing: DIV #: 00006 ' 436B Station Ave EJL Number: 0000000001 � South Yarmouth, MA 026b4 �,II � ; WC 00 00 01 A