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Home My WebLink AboutApplication and WC� of r W D TOWN OF YARMOUTH BOARD OF HEALTH 1�C5C�OMCD � � APPLICATION FOR LICENSE/PE� �' � �, � .... � �� .� ut�; �� 2U15 * Piease complete form and attach all necessary c�ocum s}�_�, c�mb:r 1 S 20�5. ' Failure to do so will result in the return oi�y6ur�pp�i ation pac t. HEALTH DEPT. E�TABLISHMENT NAME: uan Loi Co. , Inc dba Thuan Loi R��1�ID• LOCATIONADDRESS:1300 Main St Rt 28 S.Yarmouth MA 02664 TEL.#: � �98-5592 MAILING ADDRESS: 156 Sea Street Quincy MA 021 69 E-MAILADDRESS: trant81 @verizon.net OWNER NAME: CORPORATION NAME (IF APPLICABLE): Thuan Loi Co, .Inc MANAGER'S NAME: Tony Anh Tran (CEO) TEL.#: ( 617) 910-683 5 MAILING ADDRESS: Sea Street Quiney,MA 02169 PbOL 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 rnust 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_ Tony Anh Tran 2, PERSON 1N CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. -- i. '�t�:z� ln� ��:ri- _ _ � _, -� -- _ ALLERGEN CERTIFICATIONS: All fdod 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. 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. L 2. 3. 4. RESTAURANT SEATING: TOTAL# 23 ' _-- C��J��1V'L�f' -------- _-- ---------- LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $110 [NN $55 CAMP $55 SWIMMING POOL$110ea. _LODGE $55 —TRAILER PARK $105 WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �0-100 SEATS $125 6��0 CONTINENTAL $35 NON-PROFIT $30 >100 SEATS $200 �COMMON VIC. $60 ��-� —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 =<25,000 sq.ft. $150 _FROZEN DESSERT $40 TOBACCO $110 NAME CHANGE: $ts AMOUNT DUE = $ /S 5•OO *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** i �1 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 1NSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK k APPROPRIATELY IF PAID: S YES X NO j � 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,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 f 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 axe 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. ' - f 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 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 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 Board of Health. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishtnent 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 PLAN. � DATE: 12/'(�9 i 2015 SIGNATURE: � PRINT NAME&TITLE: �ONY _ANH TRAN Rev. ]0/O1/15 � � The Commonwealth of Massachusetts _ Department of Indccstrial Accidents � - Office of Investigations ' I Cong7ess Streei, Suite 100 , Boston, MA 02114-2017 . www.mass.gov/dia '' Workers' Compensation Insurance Affidavit: General Businesses �� Applicant Information Please Print Le�iblv Business/Organization Name: Thuan Loi Company. , Inc dba Thuan Loi Restaurant Address: 1300 Main Street Rt 28 ' City/Sta.te/Zip: S.Yarmouth,MA 02664 Phone#: C 508) 398-5592 ' Are you an employer?Check the appropriate boz: Business Type(required): ' 1.� I am a employer with �2 employees (full and/ 5. ❑Retail '� __ or part-time).* 6. [�RestaurantlBaz/Eating Esta.blishment 'r _ _ --- -- - --_ - --- - 2. I am a sole proprietor or partnership and have no �. � Office and/or Sales(incL real estate,auto,etc.) i employees working for me in any capacrty. ' [No workers' comp.insurance required] 8• ❑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.� Manufacturing '! no employees. [No workers' comp. insurance required]* 1 L�Health Care ' 4.❑ We are 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#I. ; I am an employer that is providing workers'compensation insurance for my employees Below is the policy inforntation. ' Insurance Company Name: Twin City Fire Ins Co Insurer's Address: One Park Place, 300S State St 7th Floor City/State/Zip: Syracuse, NY 13202 Policy#or Self-ins. Lic. # Q 8 WECLB 7 5 9 3 Expiration Date: �g�� ' Attach a copy of the workers' compensation policy declaration page(showing the policy number and ezpiration date). � Failure to secure coyerage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a , __ - _ __ __ __ . , -- fine up to$1,500.00 and/or one-year imprisonment,as well as civiTpenalties in the form of a STOP WORK ORDER and a fine � of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of � 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: Date: 12 0 9 2 015 Phone#: ( 508) 398-5592 Official use only. Do not write in this area,to be completed by eity or town officiaL j i ; 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 Client#: 42064 ACORD,,, CERTIFICATE �F LIABILITY INSURANCE �RE DATE(MMlDDIYYYY) � � 7HIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ON�Y AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED ��02/2015 ; BEIOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. BY THE POLICIES _- IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed.If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). ' PRODUCER HUB International New England couTacr , �NnMe: Christopher Hedetniemi PHONE �� --- 265 Orleans Road - — — _ -- �aic,N�o eXq 508-945 0446 Fnx _ __ North Chatham, MA 02650 E.^"A�� -- ��n�c,r,o�: 508-945-9136 'ADDRESS: � � �-�-�� . � 508 945-0446 --"" _--- INSURER(S)qFFORDiNG COVERAGE � NAIC a� ' INSURED INSURER A:Ca(�ItOI I17(�g(pnljy CO�p0�8t1017 �- Thuan Loi Co, Inc. DBA wsuReRs:Twin City Fire Insurance Co 29459 ' Thuan Loi Restaurant ;�NsuReR c: — ; 156 Sea Street iNsuaeR o: --- ' QUIf1Cy, MA 02169 INSURERE: �� COVERAGES INSURER F • - CERTIFlCATE NUMBER: TNIS IS TO CERTIFY THAT THE POLIGES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED N ME'D BOV�EnBFOR�HE POLICV PERIOD + INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH PO�ICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR _._. __ -._. .. . � _____._______._...._______.__ LTR__ _ TYPE Of INSURANCE ADDL SUBR ----"--�'— ��-----�----�pOUCY EFF ppUCY EXP INSRIWV� POLICYNUMBER �� A GENERALLIABIUTY � _1MMIOD/YYYY MM/D�NYYY�_ LfMITS�� CP0254543901 ----- X COMMERCIAL GENERA�LIA8I�ITY _ O6I�4IZO�rJ OG/�4IZO�G EACH OCCURRENCE $��QQQ OQ� ;. I __ �DAMA�E T RENTED � � �� --- ___ �CLAIMS-MADE �OCCUR PREMISES Ea occurrence� $�OO OOO . �� i --- � � MED EXP(Any one person) S 5,00� '�� ...---- --------.._.__._.._. �----... __._. . . __ PERSONAL 8 ADV INJURY S�,OOO�OOO GEN'L AGGREGATE LIMiT APPUES PER: I GENERAL AGGREGATE S Z,OOO,OOO � - X POLICY PR�- ❑ i I PRODUCTS-COMP/OPAGG SZ�OOO�OOO _ '� —____I_�I JE T LOC $ ____ �. AUTOMOBILE LIABILITY � �— '� COMBINED SINGIE LIMIT ANY qUTO � � �Ea accidenU 5 � � � ALL OWNED — SCHEDULED � I :80DILY INJURY(Per person) S �'�� ' AUTOS AUTOS I I BODILY INJURY(Per accident) S I11RED AUTOS NON-OWNED . , _ . _ � AUTOS PROPERTYDAMAGE $ �� -�-�" ' .. I Per accidenQ ... ,...., _— - ____ __ � . .. —�� ---...--...___ ._----� �------._..__.-------- UMBRELIA LIAB I .. .....------------.- .- . ___---.___._._ . _ --- ;OCCUR EACH OCCURRENCE S � � EXCESS LIAB ._.._. ___ � ..... . _ �CLAIMS_MADEI AGGREGATE S � ._ --- - _ _ DED '� RETENTION$ -�- �� '. B WORKERS COMPENSATION � Q$WECLB7593 09/17/2015 09117/2016 X � _ I � AND EMPLOYERS'UABI�ITY ' ! WC STATU- OTH- � ANY PROPRIETOR/PARTNERIEXECU7IVE Y�N ' � � I TQRY�._jM1T$ E� __ __ _ � OfFiCERiMEMBEREXCLUDED7 a N!q �- . IE.LEACHACCIDENT S'IOO�OOO__ � (Mandatory in NH) � - u yes,describe under I E.L.OISEASE-EA EMPLOYEE 5��,�0� DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY IIMIT $SOO,OOO A Liquor Liability � CP0254543901 06/14/2015 06l14/2016 500 ea000 occurence I � I - — -- - � �4Q,000 ann aggregate i DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICIES(Attach ACORD 101,Additlonal Remarks Schedule,If more space is requlred) ; CERTIFICATE HOLDER CANCELlATION Town of Yarmouth SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Rt ZH THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED W ACCORDANCE WITH THE POLICY PROVISIONS. West Yarmouth, MA 02673 AUTHORIZED REPRESENTATIVE �dib. O 7988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 of 1 The ACORD narne and logo arQ registered marks of ACORD #S1488840/M1474689 CH004