HomeMy WebLinkAboutApplications, WC and Licenses ����YA�� TOWN OF YARMOUTH
� ; °
0(� � '"3 ll46 ROUTE 28 SOUTH YARMOUTH MASSACHUSETTS 02664-4451
` MATTACMEES � �
� h��Ap01111Tt0�bfl'� Telephone (508) 398-2231,Ext. 241 — Fax (508) 760-3472
-n
B O ,ARD OF HEALTH
To: 2009 Yarmouth Board of Health License/Permit Holder ��''� "'� �J��!�
� � ,„, ,,�,, „ �
From: Yarmouth Health Department ` + �'3 � " ��
6--�cy��.u��-� �y��..i.
Re: T�Identification Numbers
Date: June 15, 2009
'The Massachusetts Department of Revenue requires that the Health Department furnish to them
detailed information regarding all permits and licenses that we issue. One of the required details
is to provide a t� identification number, whether it be an establishment's Federal Employer
Identification Number(FEIN)or, in the case of an individual's license, a Social Security Number
(SSl�. This information will be used by the Health Department purely for administrative
purposes only.
Since you did not enter this information on your business application, would you please fill out
the information below and return this letter as soon as possible to:
Yarmouth Health Department
1146 Route 28
South Yarmouth, MA 02664
Thank you for your anticipated compliance. If you have any questions regarding this matter,
please do not hesitate to call. The office hours are Monday to Friday, 8:30 a.m, to 4:30 p.m. The
telephone number is (508) 398-2231, ext. 241.
Establishment: Inside Scoop LLC FEIN or SSN: �".`� " o���(,j ►J
Location Address: 519 Route 28 West Yarmouth MA
Signature:
Print: ��U� �UK� Title: �c�✓�e►r�1�1C'Yl'l-�E't�
� Printed on
( Recycled
� y Paper
,c�,
� .k .�;
':w � � � ► TOWN OF YARMOUTH BOARD O�,HE2�L'�'�' ,, ����tj[�D
� � APPLICATION FOR LICENSE/P"ERMIT�Ztl� • �
q--� t;R�'� MAY � �; �.009
* Please complete form and attach a11 necessary documents by Dz ece� ber I S 2008.
Failure to do so will result in the return of your applicahon p �{���`[�{ ��PT.
NAME OF ESTABLISHMENT: �w �'�eE �'G�� �,� � TEL. #
LOCATION ADDRESS: s� r� �r.:v
MAILING ADDRESS: - �
OWNER NAME: �— �� L� ti - TAX ID FEIN or SSN :
CORRORATION NAME (IF APPLICABLE): 2 1 �,
MANAGER'S NAME: � „ �. TEL. # O - S"� -7�j�',S"
MAILING ADDRESS: ..5�
POOL CERTIFICATIONS:
The pool supervisor must be certi�ed as a Pool Operator,as required by State law. Please list the designated
Pool Operator(s) and attach a copy of the cei-tification to this form.
1. /�� 2.
Pool operators must list a minimum of two employees cuxi ently certified in basic water safety,standard First Aid and
Community Cardiopulmonary Resuscitatian(CPR}: Please list these employees below and attach copies of employee
certifications to this form. The Health Department fvill not use past years' records. Yau must provide new
copies and maintain a Cle at your place of business.
1. � 2.
3. 4.
FOOD PROTECTION MANAGERS - CERTIFICATIONS:
All food service establislunents are requued 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 applicatian. The Health Department will not use past years'records.
You must pravide new copies and maintain a file at your establishment.
1. � -►1, ✓�'� � �t-•^i,�s 2.
PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
1. �-�t_ ��-.� 2.
HEIMLICH CERTIFICATIONS:
All food service establishments with 25 seats or more must have at least one employee trained in the Heunlich
Maneuver on the premises at a11 times. Please list your einployees nained 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 y�ur place of business.
1. 2.
3. 4.
RESTAURANT SEATING: TOTAL#
OFFICE USE ONLY
� LODGING:
LICENSE REQUIRED FEE PER.MIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT??
B&B S55 CABIN $55 MOTEL �55
INN S55 CAMP $55 SWIl�IMING POOL �80ea.
LODGE S55 TRAILERPARK $105 WHIRLPOOL $8dea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LIGENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERNIIT#
�0-100 SEATS �85 ��S _CONTINENTAL $35 NON-PROFTI S30
>100 SEATS 5160 COMMON VIC. �60 WHOLESALE �80
RETAIL SERVICE: —RESID.KITCHEN �80
LICENSE REQUIRED FEE PERI�IIT#. LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_<�0 sq.ft. ��0 _>25,000 sq.ft. $225 VENDING-FOOD �25 �
_<25,OOOsq.ft. S80 �LFROZENDESSERT �4Q �6�'d�� _TOBAGCO 5�5
�A��E cxA�rcE: sio AMOUNT DUE _ � ���
*�***PLEASE TUR'�OVER AND CO.VIPLETE OTHER SIDE OF FORi�'I'****
r
I• r,r
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 Yannouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES i/ NO
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 ofresidence 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 sha11 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 ins ected
by the Health Department prior to opening. Contact the Health De�artment to schedule the inspection five(�days
pnor to opening. PLEASE NOTE: People are NOT allowed to srt m the pool area until the pool has been inspected
and opened.
POOL WA1'ER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count
by a State certified lab, prior to opening, and quarterly thereafter.
POOL CLOSING: Every outdoor in ground swimming pool rnust be drained or covered within seven(7)days of
closing.
FOOD SERVICE
CATERING POLICY:
Anyone who caters within the Town of Yannouth 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.
FROZEN DESSERTS:
Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent 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 fromthe Board ofHealth.
OUTDOOR COOHING:
Outdoor cooking,preparation, or display of any food product by a retail or food service establishment is prohibited.
NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETtJRN
TI-�COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15, 2008.
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: s z�l o� SIGNATURE:
PRINT NAME&TITLE:�,��_- � �„ p
iojziros
Date: 5/28/2009 Time: 1�41 PM To: 9,1508-760-3472 Roqers 6 Gray Ins. Paqe: 002
' CERTIFICATE OF LIABILITY INSURANCE oATE(MM;28�og
Producer THIS CERTIFICATE IS ISSUED AS A MATTER OF
INFORMATION ONLY AND CONFERS NO RIGHTS lJ?C�N THE
First Cardinal Corp. GERTI�ICATE HOLDER, THIS CERTlFICATE DOES NOT
10 Bri6sh American Blvd. qMEND, EX�END OR ALTER THE COVERAGE AFFORDED BY `:
Latham,NY 12110-0141
THE POUCIES BELOW.
INSURERS AFFORDiNG COVERAGE NAlC i!
Insur�d INSURER A: MA Retail Merchants WC Group Inc. :
Inside 5coop,LLC I�ISURER B: �
20 Springer Lane
West Yarmouth,MA 02673 I�ISURER C:
i�suRER c:
I^JSURER E
COVERAGES
THE POLICIES OF INSURANCE USTED B£LOW HAVE BEEN lSSUED TO THE INSURED NAME+7 ABCVE FOR THE POIICY P£RIOD�NDICAT£O,NONNTHSTANOING i
' P.NY REQUIREMENT TERM OR CC�NDITIDN OF ANY CONTRNCT OR D's MER DOCUMENT VJI?H RESPECT TO VIMICH THIS CERTIFICATE NIT.Y BE 35SUED OR MAY i
PERTAIN THE IFJSURANCE AFFOROED BY 1NE POLICIES DESCRIBEDHEREIN IS SUBJECTTO ALl THE TERMS,EXCLUSIONS AND CONDiTiONS OF SUCH POUC�ES. ;
RGGREGATF LIMI7S SHOWN MAY HAVE SEEN REDWCEC BY PAIp CIAIMS,
� . F�:'iUC.•Y . . .,
�co-� E�ECTivE DR?E t��LICY EX?I:zATIGN
� iwSR tTz iwrto TYI''E OF INSURp.NCE V'OLICY MUMEEk UkJ�.1fti't') DA-E 45?NDDIVY) LIPAITS �
GENEFAI UABiL1TY F�.CH C�CCURRQrCE $
. CIJbAnAERGIAI GEtJER�_LIABIIITY FtRE DP,MAGE(Any one ti�e) $ -
� GU+Ii'15 MADE � CCCUR f.dEC EX?IAr,yone pzrsenJ $�
PEP.SONAI S hGV INJIIRY $
GHJERIU.AGGREGATE $
GENLAGr,REGAIELIMRThPFLI£SPER: PRO!'iU��S-GOiiFlQphGG $
PFfO- i
.. FOLI�� JEC� + L^vC
� AUTOMOBILEIIABiIiTY COM&f1E0 SAIGLE LIAiR $
ANY Ail7D (E�aa�7eat`
nLL O!tiWED AUTt7a , BODILY I:JJURY $
SY:W£DUtSD ALTOS (Par personj
HIRF.OFU�OS E3n[HI�'IV,IUR7 $
P�Id-G�YJf7ED hUTOS (P=r a:cic�tj
� PROPER7"CAMnGE $
rPe�axiccnY;
GARAGELIABI�ITY kUTOONIY-ERAC[I�ENT $
RI'dY AJTO O?HER THAN EA hCC $
� AUTO f.�Pll.Y �{GG $
EXCESS 1IA81lITY FJ�CH�JCCURRENCE $
. . . . .--- .. :
�CCUR n CLAlA1SMkDE kGGRE'�.4TE $ i
..... ..............................................................................:
�
� DEDUCtIP1= $
RETEMI•�N 8 $
WORKERS COMPENSATION ANO X N�'4TPTU- G?N•
� EMPLOYERS UABIL�IY TORY LIMITS EP,
' .�NYPROPRIETER�PPRTkEWEY,ECUTIVE E�:.EAGH.ACCIOEfJT $ �OO,OOO �
' � QFFiGER1MENEER'XGLUbEG?
N yes,desc�iC=��,:,� N� 014001059800109 5Y28109 1l01/10 E.._.DiSE4SE-EF EMPLOYEE
� S'PCCIPL Pf-tOYIStCNSbecw
$ 100,000 ;
� E.�_.qSFASE-POLICY L!M!T $ 500,000 i
O7HER
, LES'C�IPT�ON Cif GFERATiONrt LOCATi�NS/VEHICLES/EX.r,LU51UIV�ADDEU 8"EfJWkSEINB.T/SFECIAi Ff20VIS10�A
CERTIFICATE FiOLDER ax�rioraai.irist�RF,r� udk�Fe�tFtTFR: CANCELLATIQPJ
SHCULO ANY OF THE ABOVE QESCRIBED POLICIES 9E CANCELlEO BEFORE
Town of Yarmouth 1HE EXPIRATIONDATE THEREOF,THE ISSUING INSURERWILL ENDEAVOR TO ;
1146 Route 28 MAiL 35 OAYS WRiTTEN NOTICE TO 7NE CERTIFlCATE HOIpER NAMED
South Yarmouth,INA 02664-4492 TO 7HE LEFT.8UT FAfIURE TO DO 50 SHP.LL IMP0.5E NO oBLIGATION OR
LIA.BI LI TY OF,AMY KI ND UPaN TN E i NS URER.I7S/+GENTS OR
REPRESENtH?IVES.
AUTNORIZED REPRESENTATIVE
� � �
c /
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NUMBER: #09-185 FEE: $55.00
In accordance with regulations pmmulgated under authority of Chapter 94,Secrion 305A and Chapter
1 i l,Section 5 of the General Laws,a permit is hereby granted to:
. Arthur N. Luke, 519 Route 28, West Yarmouth, MA
Whose ptace of business is: Inside Scoop LLC
Type of business: Food Service
To operate a foad establishment in: Town of Yasmouth
� Permit expires: December 31, 2009 BOARD OF HEALTH: �felen S� �. C"t�ai�rinari
' sEnrnvc: z�ro :� .��caryyeo �lire C'�a 'wYrruui
n
i RESTtuc'rtoxs: Paper service only.Menu: Hot dogs,ice cream �` � �.Shl�tWl�/t r.rl ��
(saft serve&hard),pretzels,candy,cookies, J Qft�Q������'
', brownies,pizza slices(pr�cooked), � ` �t/t1`�
� soda,coffee,water.
June 4.2009
ruce Cc:Murphy,MPH . .,CHO
Director of Health
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
PERMIT NUMBER: #09-011 FEE: $40.00
This is to Certify that Arthur N.Luke d/b/a Inside Scoop LLC
519 Route 28,West Yarmouth,MA
IS HEREBY GRANTED A LICENSE
FOR TIiE MANUFACI'URING OF FROZEN DESSERTS
AND/OR ICE CREAM MIX
For the year commencing with March first 2409
This License is subject to the Rules and Regulations of the Massachusetts Department of Public Health Relative
to the Manufactunng of FROZEN DESSERTS and ICE CREAM MIX, to the Rules and ReguIations of the
Boazd of Health granting this License, and to the provision of the General Laws Chapter 94 as amended by
Chapter 373 ofthe Acts of 1934,and may be revoked or suspended in accordance with the provisions of Sectian
65J said Chapter.
BOARD OF HEALTH: .�fe�e�c S� J�..N. el�,r�xnu=n
*Regularion 105 CMR 561.009 requires � ��A�RA� �lC¢�.�Qln/riQlt
monthly plate count and coliform tests. 2���. SII'i,tltUUd¢R .r� �
J an.�u oK
��ian S
June 4.2009
Bce . y, , . .,
Director of Heal