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Home My WebLink AboutApplication and WCI � �'� TOWN OF YARMOUTH BOARD OF HEAL i ' APPLICATION FOR LICENSE/PERMI'P-201 �" ��? i � �� a, '�� b�� ,�,. � _ �"Please complete forn►and attach a11 necessary documents : "r 2 . �� .�; ` � , � Failure to do so will resutt in the return of your appli n et� � c ��`� Z [ f�5 � CAPE COD FARMS . � O ESTABLISHMENT NAME: _ � nrn; LOCATION ADDRESS: 25z n�wN sr,RT 28,WEST YARMOUTH,MA 02873 �L.#: Spg'�7g.3�g (� MAILING ADDRESS: 16�ST MAIN ST,WESTBOROUGH,MA 01581 � � � OWNER NAME: �dHNNY KAYROUZ,KHALIL NAOUM ;"I W ('p J CORPORATIQN NAME(IF APPLICABLE): �►PE COD FARMS II LLC MANAGER'S NAME: KHA��L NAOUM TEL.#: �e-�3�-s�ao MAII,MG ADDRESS: Zs�Ma"sr,RT 28,WEST YARMOUTH,MA 02873 POOL CERTIFICATIONS: The pool snpervisor must be certiiBied as a Pool Operator,as required by State law. Please list the designate�i Pool Operator{s)and attach a capy of the certification to this form. 1. 2. Pool operators must list a minimum of two emplo ees currently certifiad in basic water safety,stan.dard First Aid and Community Cardiopulmonary Resuscitation�CPR). Please list these employee.s below and attach copies of employee certifications to this form. The Health Department will not use past years' records. Yom m�st provide new copies and maintaia a file at yoar place of business. . 1. 2. 3. 4. FOOD PROTECTION MANAGERS-CERTIFIGATIONS: All food service establishmegts are required to have at least one fitll-ti�ne 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 att�ch copies of certification to this application. The Health Department will not nse past years'records. Yoa must provide new copies and maiutain a file at your establishment 1. 2. PERSON IN CHARGB: ' Each food establishment must have a#least one Person In Chazge(PIC)on site during houis of operation. 1. 2. HEIlviLICH CERTIFICATIONS: Ali food service establishments with 25 seats or mare must have at least oae employee trained in the�Ieimlich Maneuver on the premises at all times. Please list your employees:trained in anti-choking procedures below and attacfi copies of employ�certifications to this form. The Heslth Department will not use past years'records. Yom m�et provide new copiea and maintain a file at your place of,business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: - LICENSE REQUIltFA FSE PERMIT# LICEN3E REQUIRED FEE PERMIT# LICENSE REQUIRED FEE FERMIT# B&B SSS CABIN SSi _MO'CEL SSS _1NN S54 CAMP S55 �.SWIMMiNG POOL S80ea. _LODGE SSS TRAILER PARK SIOS �WHtRLPOOL S80es. FOOD SERVICE: L[CENSE REQUIRED FEE PERMIT# LICBNSS REQUIRBD FEE PERMTf# LICENSE REQUIRED FEE PERMIT H • 0-100 SEA7'S S85 ._CONfINE1TfAL S33 NON-PROFIT S30 >100 SEATS S160 COMMOM VIG $60 _WHOLESALE S80 RETAII.SERVICE:. —RESID.KITCHEN SSO LICENSE REQUIRED.FEE PERMiT N LICENSE REQUIRED'FEE PERA�IIT# LICEN3E REQUIRED FEE PERMiT# <SO sq.R SSO >25,000 sq.ft. 5225 VENUING-FOOD S25 ,��,,�� G25.000 sq.R. S80 •��I' •t;�� _.FROZEN DESSER.T S40 LTOBACCO S95 - 1 77�1,�� NAME CHAi�iGE: S15 AMOUNT DUE = S � �� C�' r�r��epLEAgg TURN OVER AND COMPI.E'I'E OY'HER SIDE OF FORMr�a'+ � � � ✓ ' �, ,�. ` , ' ADMI1vISTRATION � Under Chapter 152,Section 25C,Subs�tion 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 WORI�R'S COMPENSATION INSURANCE A�FIDAViT MU3T BE COMPLETED AND SIGNED,OR CERT.OF INSURANCE ATTACHED X OR WORKER'S COMP.AFFIDAVIT SIGNED AND ATTACHED X Town of Yarmouth ta�ces and liens must be paid ptior to renewal or issuance of your permits. PLEASE CI�CK APPROPRIATELY IF PAID: YES X NO MOTELS ANR OTHER LODGING ESTA.BLISHMENTS TRA�NSIENT OCCUPANCY: For purposes of the fimitations of Motel or Hotel use,'Fransieat occupaucy shall be limited to the temporazy and short term occupancy,ordinarily and customarily associated with motel and hotel use. Transient occupants must have aad be able to demonstrate that they mainntain a principal place of residence elsewhere.Transient occugancy shati generally refer to continuous occupancy of aot more than tluriy(30)days,aad an aggregate of not more than ninety(90)days within any six(�month period. Use of a guest unit as a residence or dwelling unit shail not be considered ttansient. Occupaa.cy that is subject to the collecdon of Room Occupancy Excise,as defined in M.G.L.c.64G or 830 CMR 64G,as amended,shall generally be considered Transient P�OLS POOL OPENING:All swimming,wading aud whirlpools wluch have be�n ciosed for the season must be' by the Health Det�artinentpnor to opening. Contact the Health Department to schedule the inspection thtee(�� pnor to opening:PLEASE NOTE:People are NOT ailowed to sit m the pool area un61 the pool has been inspected and opened. POOL WATER TESTING: The water must be tested far pseudomonas,total coliform and standard plate count by a State certified lab,and submitted to the Health Department tl�ree(3)days prior to opening,and quarterly therea�ter. POOL CLOSING:Every ouWoor 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 itispected tsy the Heatth Ue�r�ent prior to opening. Please contact tlie Health Departmeirt to schedule the inspecrion three(3)days prior to openin$. CATERING POLICY: � Anyone who caters witaain the Town of Yarmouth must notify the Yarmouth Health Department by filing the re�uiue�Temporary Food Service Application form 72 hours prior to the catered even� These forms can be obtatned at the Health Department,ar from the Town's website at www.�armouth.ma.us under Health Deparhnent, Downtoadable Forms. FROZEN DESSERTS: Frozen desserts must be tested by a State certified lab prior to opening aad monthly thereafter,with sample results submitted to the Health Department. Failure W do so will resiilt in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAF�S: Outside cafes(i.e.,outdoor seating with waiter/waitress servic�),must have prior approval from the Board of Health. OUTDOOR COOI�NG: Outdoor cooking,preparation,or display of any food product by a retail ar food service establishment is prohit►ited. NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RET[JRN Tf�COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15,2012. ALL RENOVATIONS TO ANY FOOD ESTABi�ISHMENT, MOTEL OR POOL ('i.e., PAIIVTING, NEW EQUIPMENT,ETC.),NNST BE REPORTED TO AND APPROYED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: °�2013 SIGNATURE: �,�� PRINT NAME 8G TITI.E:�.wHNNY KAYROVZ x�.�a�nz � � , : i. • I • � � The Commonwealth of Massachusetts Department of Industr�al Accidents Off�ce of Investigat�tons 1 Congress Street,Suite 10� Boston,MA 02114-2017 www mass gov/dia Workers' Compensation Insurance Affidavit: General Businesses Apulicant Information PIease Print Legibiv Business/Organiza.tion Name: CAPE COD FARMS Ad�SS: 16 EAST MAIN ST City/State/Zip: WESTBOROUGH,MA 01581 Phone#: 508-878-7664 Are you an emptoyer?Check the agpropriate boz: Bnsiness Type(r�uired): l.� I am a employer with 5 employees(full and/ 5. �]Retail � or part-time).* .6. Q.RestaurantBar/Eatmg F.�tablisbment 2.❑ I am a sole proprietor oz partnership�cl have no �, []Office and/or Sales(incl.real estate,auto,etc:). employees working far me in any capacity. [No workers'comp.insurance required] 8. ❑Non-profit 3.❑ We are a carporation and its officers have exercised 9. ❑Entertainment their right of exemption per c. 152,§1(4),and we have 10.0 Manufacturing no employees.[Na workers'comp.insurance requiredJ* 11.0 Heatth Care 4.❑ We are a a�-profit organization,staffed by volunteers, with no employees.[No workers'comp.insurance req.] 12.�Other *Any appticant that cl�cks box#1 must aiso fill out the s�xtion below showing iheir workers'compensation policy infom�atioa ••If the corporate off'icers have acempud the�etvaa,bnt the corporation has oth�employees,a workers'compensation policy is reqnired and such an organiza6oa should cl�ck bmc#1. I am an enrployer that�s provid�iig workers'compensatton insurance for my employees. Below is the pol�cy informatron. insarance Company Natne: TRAVELERS Insurer's Address: ONE TOWER SQUARE • City/State/Zip: HARTFORD,MA 06183 Policy#or Self-ins.Lic.# �EUB-9A47405-7-12 Expirat�ion Date: 12-27-2013 Attach a copy of the workers'compensation policy declaration page(showing the poticy namber and expiration date� Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a Sne up to 51,500:00 andlar one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to 5250.00 a day agaiast the vioiator. Be advised that a copy of this statement may be foiwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certijy,under the ains and penalh'�s of perjury that the infornratioa provlded above�S true and correc� . 06/03/2013 Pho11e#: 508-87&7664 O,�'"icial use only. Do not wrlte�n th�s a�ea,to be completed by city or town o,,Q�iciaL City or Towu• YL1�1�0tT(�4 Permit/License# �ss ' (circle one): .Board of Heatth Z.Building I�partment 3.CitylTown Clerk 4.Licensing Board S.Selectmen's Oftice Contact Person: Phone#: 6�D8-34B��-3 (� �� www.mass.gov/dia I ; � � - � ' • � TRAVELERS,�, WORKERS COMPENSATION AND l'-`� ' H�ARTFo�R �obias EMPLOYERS IIABILiIY POLICY . TYPE V INFORMATION PAGE WC 00�01 ( A) PQLICYNUMBER: (IEUB-9A47405-7-12) CLASSIFICATION SCHEDULE: PREMIUM BASIS ESTIMATED RATES ESTIMATED TOTAL ANNUAL PER s100 OF ANNUAI. CLASSIFICATIOMS CODE NO REMUNERATION REMUNERATION PREMIUM SEE EXTENSION OF It�OF2MATI0N PA(� - SCHEDULE(S) SIC-CODE: 65t 2 ------------------------------------------------------------------------------------ STAt�ARD TOTAL ESTIMATED At�IUAL STANDARD PREMItJhA $ 867 PREMIt�A DISCOI�dT NONE 0900-20 EXPENSE CONSTANT 250 ,�"'� TERRDRISM 17 TOTAL ESTIMATED-PRE�MIUM-� 1134 TAXES AI� SURCHARf�ES 36 DEPOSIT ANfOUNT Dt� i 170 Minimum Premium: $238 �- DA7E OF ISSUE: 11-16-1 a �c OFFICE: PAYROLL 70A PRODUCER: AUT�IATIC DATA PROC INS XV770 COUNTERSIGI�D-AGENT � � ' : - ' TRAVELERS� WORKERS COMPENSATION ,,._� ONE TOWER SQ4JARE AND HARTFORD, cr obias EMPLOYERS LIABILIIY POLiCY TYPE V iNFORMATION PAGE WC 00 00 01 ( A) POLICY NUMBER: (IEUB-9A47405-7-12) REI�WAL OF (IEUB-9A47405-7-11 ) INSURER: TF�E TRAVELERS INDEh�IITY COF�ANY OF CONNECTICUT 1 NCCI CO CODE: 12637 INSURED: PRODUCER: CAPE COD FARM5 LLC AUTOMATIC DATA PROC TP15 16 EAST MAIN STREET 1 ADP BLVD MS 325 WE5TBOROUGH MA 01581 ROSELAI� N�1 07068 Insured� A LiM2TED �iABiLiTY COhIPANY Uther work places and ider�tfftcatton numbers are shown in the schedule(sj attached. 2. The pdicy period is from 12-27-12 to 12-27-13 1Z:01 A.M. at the tr�ured's ma�ir�g address. �_ 3. A. WORKERS COMPENSATION INSURANCE: Part�Jne of the pdicy appiies to ths Workers � Compensetion Law af the state(s)listed t�re: � � � _== � B. EMPLOYERS LIABIUTY INSURANCE: Part Two af the pdicy appii�to work in each state listed in �� item 3.A. The Nmks�cwr Itab�ity under Part Two are: � Bodiy Injury by Acciderrt: $ 100000 Each Accident o� Bod�y injury by D�ease: $ 500000 pdicy Limit ,� Bodiy InJury by D�ease: � 100000 Each Em�oyee � C. OTHER STATES fNSURANCE: Part Three of the pdicy applies to the states, if any,listed here: � AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA N� NIE MI NN � NI� MS MT NC NE I�i NJ M�1 NV NY OK OR PA RI SC SD TN TX UT VA VT WI � WV am' �� D. Th�policy indudes these er�dorserr�ents and schedules: �� o� SEE �ISTING OF Et�ORSENENTS - EXTENSIOIV OF INFO PAGE o� -� 4. The premium for this pdicy w�f be determined by our Manuals of Rules, qassificatior�, Rates and Ratfng � Plans. All required information is eul�jed to verificatbn and change by audit to be made AI�IAL�Y. � _.� --, D�►TE OF ISSUE: 11 -16-12 AK OFFICE: PAYROLL 70A PRODUCER: AUTOMATIC DATA PROC INS XV770 o�aei2 � . � � THE COMMONWEALTH OF MASSACIIUSETTS � TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #13-039 FEE: $95.00 � This is to Certify that Ca�e Cod Farm. II . . .dM/a a�e Cod F rm � 252 Route 28, West Yarmouth MA IS HEREBY GRANTED A LICENSE For _ SALE ANI� DTSTRTRiTTiON OF TOBA C'n PRn1�TTC'T� ; AS PER THE YARMOUTH BOARD OF HEALTH TOBACCO REGULATION This permit is granted in conformity with Article VI of the Sanitary Code of The Commonwealth of Massachusetts,and expires December 31.2013 unless sooner suspended or revoked. June 5.2013 BOARD OF HEALTH: J p�t�.[x l��te�� ftait ;��i�cd:13o��.lYL.1�., `?�ice �J• � , C!h'ccrac.�e� J. .��u�cuau� Bruce G. Murphy, ,R.S., CHO D'rector f ealth TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #13-056 FEE: $80.00 In accardance with regulations promulgated under authority of Chapter 94, Section 305A and Chapter ll 1,Section 5 of the General Laws,a permit is hereby granted to: Cape Cod Farms II LLC., 252 Route 28, West Yarmouth, MA Whose place of business is: Cape Cod Farms Type of business: Retail Food Service less than 25,000 sauare feet To operate a food establishment in: Town of Yarmouth Permit expires: December 31, 2013 BOARD OF HEALTH: J anc�ac l�aig�tecr�t, C.'�Cavcfnaft .�'��:13ao�.11R.1�., `?Iice �'ueQi�J. C!f'�a�Pe� J. ��aecua[� June 5,2013 Bruce,G. Murp y,MP , .5., CHO Director of Health