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Home My WebLink AboutApplication and WC a�� , � � TOWN OF YARMOUTH BOARD OF HEALTH D�` ,' � ��'� I APPLICATION FOR LICENSE/PE�JVI��'Y2D 6 , w�� 0 �'"" * Please complete form and attach all necessary�curn��t � 'y � DEPT. �I ' Failure to do so will result in the return of your application pa . i� ESTABLISHMENT NAME: ' c TAX ID: ' LOCATION ADDRESS: /D� �r.�/�V' Sr- O2..T Z�3 TEL.#: I-S��-3�� 9�� MAILING ADDRESS: S� �-''� ', E-MAILADDRESS: �G- 1.�L"l �C L.L � ' ��--%Foro � h OWNER NAME: �-- 1�2G'n .�' � ZZ-�GLty ' CORPORATION NAME (IF APPLICABLE): .�"-'i ' 1VTANAGER'S NAME: TEL.#: ; MAILING ADDRESS: '. POOL CERTIFICATIONS: . The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pcsol Operator(s) and attach a copy of the certification to this form. - - ----- ---- , Pool operators must list a minimum of two e loyees currently certified in standard First Aid and Community Cardiopulmonary Resuscitation (CPR), h mg one certified employee on premises at all times. Please list the employees below and attach copies of t ir certifications to this form. The Health Department will not use past years' records. You must provide ew copies and maintain a file at your place of business. 1.' 2. i 3. 4. i FbOD 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. ��1��'' d'' ..� ?f�l2Z�'��G�- 2 PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. _ __.1 ' _ _ : _ �. v� 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.,-�� L' l� •� f.��7��'Ct/l � 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. a��`z��D /L �U Z?.L',�-t c.✓.� 2. C� v!i'�'� �. IO r� 2��-L`/,� , 3. � 4. i i RESTAURANT SEATING: TOTAL# j�c> � . . . . - �3'Y'7�iT�3Y:��T'r�L�TiT- . . --. . ----._ '�II LODGING: LICENSE RE2UIRED FEE PERMIT# LICENSE RE�UIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# i B&B $55 CABIN� $55 MOTEL $110 — - � INN $55 CAMP $55 SWIMMING POOL$110ea. � _LODGE $55 _TRAILER PARK $105 WHIRLPOOL $1 l0ea. ' FOOD SERVICE: LICENSE REQUIRED FEE ��I�T#'t LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �0-100 SEATS $125 ��=�—i—�y� CONTINENTAL $35 NON-PROFIT $30 j >100 SEATS $200 �COMMON V1C. $60 �g� =WHOLESALE $80 I —RESID.KITCHEN $80 RETAIL SERVICE: LICENSfi 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: $is AMOUNT DUE _ $ I S�.Op f **,��* *�*** � PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM � i � - . � 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 �._ Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES � NO ! 1 MOTELS AND OTHER LODGING ESTABLISHMENTS i � 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. �j 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 i 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 �I 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 �I thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of I 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 fortns 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,preparation,or display of any food product by a retail or food service establishment is prohibited. NO�'ICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETtJRN 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 COMMENCEME T. RENOVATIONS MAY RE UIRE A SITE LAN. � DATE: f� l� �S SIGNATURE. � � PRINT NAME & TITLE: /�� .�l2Ze�/�' `'�n Rev. 10/Ol/IS I � � ` � The Commonwealth of Massachusetts � ' _ Department of Industrial Accidents � � Office of Investigations " I Congress Street, Suite I00 _ Boston,MA 02114-2017 , www.mass.gov/dia ' Workers' Compensation Insurance Affidavit: General Businesses : Applicant Information Please Print Legiblv ' Business/Organization Name: ��G- �Cj (��1�/�% �- �vf�� Address: f D 7�P �✓t dE�� f �Z( Z� City/State/Zip:�-/� �i�-�-� v T� �- � Phone#: � r �� r �� " �� d Are you an employer?Check the appropriate boz: Business Type(required): ; � 1.�am a employer with��employees(full and/ 5. ❑Retail or part-time).* 6. estaurantlBar/Eating Establishment ' :� I am a so e propnetor or p ers ip and ave no �, � Office and/or Sa1es(incL real estate,auto,etc.) �' employees working for me in any capacity. , � [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]* 11.0 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 informaLion. . **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organizafion 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: ; Insurer's Address: City/State/Zip: ; I Policy#or Self-ins.Lic.# Expiration Date: � Attach a copy of the workers' compensation policy declaration page(showing the policy nnmber and ezpiration date). � - -____ Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a � fine up to�I,�OUA�and/or one-year impnsonmen,as�w�T as civi p`1 enai�e�in-th�f�n�f�a�T`@��j@R� - � 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,un r the pains a d penal ' s ofperjury that the information provided above is true and correct. , Si ature: � ��'�2� �� s� Date: Phone#: 1 ` �� /CC> ��6 � �; 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 ` I � .,. - ,, ..._-------- :?'� �.'� � P�y onl�ne:�ww tE�e�artfcrd.carn/senric�center ;,� #;'�=� For BiBing Questions and Address Changes Call: 1-866-467-8730 E �' 7 a.m. to 7 p.m. Central Time (Mon—Fri) THE � ' HARTFORD �'�� Bil�ing COm}�any: Report Claims 24 hours a day: 1-800-327-3636 �` Hartford �ire lnsurance Company gilf date; 12t07t�5 Billing Account#: 14269605 Cu�e€�t Ba1a�c�- $�71 Sfl Min�rnu� E3ue•$'!68 Sl1 C3ue�ate: 12�27!'IS =_��{��.� �.#'^�e t�� u�ent Balance or no fess than the Minimum Due. By pay[ng the Current Balance in full,you can avoid future _� ��c�P�=:�ssec=ata�with administering your payment plan. If your payment is not received by the due date,a late fee of$30.00 will �� _:_��s��. ' N��ecf Insured: ALFRED VOZZELLA DBA BIG AL'S =�`;;;�r F;c��nt: CHPtGP�1CN iNSURANCE AGENCY ltdC • For Certificates of Insurance, Policy Changes or Coverage q�estions call: 1-508-771-1660 � A�CC3U1��SU�tlWIARY ' t1VIPflRTANT'MES�iAGES • Previous Account Balance $887.00 � Payments &Adjustments -$315.50 Premium Activity $0.00 , � New Fee(s} $0.00 ' � � Account Ba(ance $571.50 ' � � '�l�ANSAt�'I'FE�[��A�LS�sin�e a�r�a�t'bill) ' = :Trans�ctic�r� Pay�nenis( Pre�st�m t=ee � r . . , � d3a#� - ' Tra�sact�on{3escrip#�ax� Palicy#k Po#icy'F�e Ad�stments; hcEiiiity > Activity: � = 'F1t14."!5 Fayment-Thank Yvu -3285.50 sS t�S!:45 t�ate Fec Reverse�i -530.00 � 7OTAE:S: -3315.50; �II.AQ 5�:� � � — , : � � � ' — � _.._.�_ ,.�.�_.r__ __ .;_.____._ _ _ � � Thank you for selecting The Hartford, We appreciate your business. .... ......... •----,. ..-••,- --..... ......... ........ ......... ........ ......., ........; ......... . : ........ ........ ...••-•- --....,. ........ .....,, ...... , . :' �'lease,de�ac#�here and�sert v�i��our pa�en�. Wr�tte Cf�Q acc��r�t nt�r�tb��c�n��e c�teck and ntat�e,payable to The Ha�for: , Check below and complete Account reverse side to req�est: Number: 14269505 ; Payrrrien�Uue Rat� ;;; 1 )15 ❑ Address Changes ' Amount Gure�n#$alan�e �nirnui'�pue Enclosed: $571.50 $168.50 ' Mail Payments To: ' The Hartford ' P O Box 660916 6944 � Dallas, TX 75266-0916 ALFRED VOZZELLA DBA BIG AL'S � BREAKFAST AND LUNCH �IIrI�i��i��i�11iIII��I��iI��IIiI��i�I�,�ilii�Hi�lh��ilil�� 1076 ROUTE 28 ; SOUTH YARMOUTH, MA 02664 '; G, . - � ��' ; � �' � � ��`��-�- 081426960547084400�00000168500000�057150810000 ' � � 71445405 12/07/15 20 OS 14269605 02 NU : ___— ----. ---- ! __. __ _--- __ _.__� _--- _ I _t '` ; �'I�it`�E�.��P'��1�€�L�R�� TTTE � I;�RTFORD 000251 ALFRED VOZZELLA DBA BIG AL'S BREAKFAST AND LUNCH 1076 ROUTE 28 SOUTH YARMOUTH, MA 02664 Policy Number Audit Period Report Due Date AUDIT ID 08 WEC CP0867 11/07/2014—11l07120'!5 01/12/2016 9817023 N � o Producer Name&Code CHAGNON iNSURANCE AGENCY INC 08 084400 The required information to audit your policy can be easily input via our secure website by following these steps: � •Access The Hartford's Online Business Canter site at: www thehartford comJservic ceMer � • �og into the secure site using your User fD and Password.Once you've logged in,cUck on the Audit Tab. � Note:if you haven't yet registared,you may do so prior to compieting your audit;for security reasons,you wili need to have m the billing zip code associated to the poHcy in order to register. o • Enter your policy number- p8 WEC CP0867 N • Enter the following Audit ID- 9817023 • Compiete the on-line questionnaire as it pertains to the following: ALFRED VOZZELLA DBA BiG AL'S BREAKFAST AND LUN • Prior to submitting your audit,you will be provided with instructions on how to upload or fax any required supporting documentation. If you choose not to utilize our website,you may compiete this form,remember to sign the report and iist your telephone number and emaii address.You can send fhe completed foRn to: The Hartford-Premium Audit Department,P.O.BOX 14175,LEXINGTON,KY 40512-9917 or fax via (866) 868-6153.If you need assistance while compieti�g tt�e form contact us: By phone (840)447-7649 Mon-Fri 8am-6pm EST When your policy was issued the insurance premium was based on estimated payroils.Now that the policy is expiring,please provide your � aoival payroll amounts so that we can adjust the premium to reflect your actuai payroil activiry for the audit period shown above. �� Failure to submit the requested information by the due date shown above witt result in an increase to premium. , �� ' � 1.Please provide a detaiied description of your business operations(I.E.work performed,product manufactured or services provided) � � � '"�—�s� � � � � � � � 2.Tell us about your legal entiiy: � ❑ I�dividual ❑Partnership ❑ LLC ❑ Corpo�ation ❑ Non-Profit ❑Other . � tf other,Please Specify � � 3.Provide gross payroils from your 4 most recent filed quarterly 941 or state unemployment tax retums. If using Federal Form 941 ' � the amounts should refiect Medicare wages � � Quarter,20— $ puarter,20_ $ ' � Quarter,20— $ Quarter,20_ $ � ATTACH A COPY OF THE TAX RETURNS OR THE EQUIVALENT USED TO FtLL IN THE TOTALS SHOWN AHOVE. � THE TAX RETURNS CAN BE ATTACNED TO THE FORM PROVIDEd OR UPLOADED SEPAHAT�I.Y IF YOU SUBMIT INFORMATION VIA THE WEBSITE. Page 1 of 3 � � NOTICE NOTICE ! � T4 TO �. EMPLOYEES EMPLOYEES . The Commonwealth of Massachusetts � DEPARTMENT OF lNDUSTRIAL ACCIDENTS � � � � 1 Congress Street, Suite 100, Boston, Massachusetts 02114-2017 -� 617-727-4900 — http:/lwww.state.ma.us/dia � As required by Massachusetts Generai Law, Chapter 152, Sections 21, 22, & 30, this wiii � give you notice that I (we) have provided for payment to our in jured employees under the � above mentioned chapter by insuring with: � w J � HARTFORD INSURANCE COMP�INY OF THE MIDWEST � NAME OF INSURANCE COMPANY � ONE PAR.K PLACE, 300 S. STATE ST. , 7TH FLOOR 0 �c cYRAC'T7�F, T�N 1 �� ADDRESS OF INSURANCE COMPANY '_ 08 WEC CP0867 _ 11/.07J15 �. POLICY NUMBER EFFECTIVE DATES '� ' PO BOX 355 � CHAGNON INSURANCE AGENCY INC W y�OUTH MA 02673 � - NAME OF INSURANCE AGENT ADDRESS PHONE : ALFRED VOZZELLA DBA BIG AL'S ' � � ' 1076 ROUTE 28 � _— — 50 TH YARMQUTH MA 02654 = EMPLOYER ADDRESS ' � . . ' � � = EMPLOYER'S WORKERS COMPENSATION OFFICER(IF ANY) DATE � _ = MEDICAL TREATMENT = The above named insurer is required in cases of personal injuries arising out of and in the course of = employment to furnish adequate and reasonabfe hospital and medical services in accordance with the = provisions of the Workers Compensation Act. A copy of the First Report of Injury must be given to the = injured employee. The employee may select his or her own physician. The reasonable cost of the services � provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably -' connected to the work related injury. In cases requiring hospital attention,employees are hereby not�ed that - the insurer has arranged for such attention at the � =- - NAME OF HOSPtTAL ADDRESS . TO BE P4STED BY EMPLOYER � Form WC 88 20 01 D Printed in U.S.A. ! . , I i _s_ , _ , i