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Home My WebLink AboutApplication and WC TOWN OF YARMOUTH BOARD OF HEALTH �, APPLICATION FOR LICENSE/PERMIT-2017 •� *Please compiete form and attach all necessary documents by December 16.2�16. Failure to do so will result in the return of your applicarion packet. ESTABLISHMENTNAME: A 1 E �J " D^� 9� LOCATI�NADDRESS: � "I }�, o� TEL.#: o$ 39'4-9+,5,35 ' MAILING ADDRESS: �. . E-MAIL ADDRESS:---�q n Co1��D�o�Ih a i rCDl�n OWNERNAME: `r"ED Dlr,�fit��PdUi.nS CORPORATION NAME(IF APPLICABLE): D�� FQO�S T-+�J G MANAGER'S NAME: Q lS o u vS TEL.#• �,0 0 ^403,5 MAILING ADDRESS: P.�1• Oo�C' 1��t� ^ Sm. u�m o i.�h � l'yi +4 O L 6'�l- P RTIFICATIONS: �— The pool su ' r must be certified as a Pool Operator,as required by State law. Please lis iE�gnated Pool Operator(s)att eopy of the certification to this form. i. z. � � m � � Pool operators must list a minimum of two em 1 'fied in standard First Aid and Community � �.� Cardiopulmonary Resuscitarion(CPR), ' one certified emp o wa��remises at all times. Please list the = .A m employees below and attach co ' eir certifications to this form.The� epartment will not use past C7 , ,v � years'records. You m ovide new copies and maintain a fde at your place siness. � � rn i. a. v 3. - 4. FOOD PROT`ECTION MANAGERS-CER"TIFICATIONS: �'� Ali 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. � � Pleast attach copies of cerkification to this applicatian. The Health Department wilI not use past years'records. ,� You must provide new copies and maintain a file at your establishment ,�.. �� i.__ �aniel Ch�is�}-oPou�oS 2. Abja�,1 J�4'Wse� — � � PERSON IN CHARGE: '� Each food establishment must have at least one Petson In Charge(PIC)on site during hours of operation. �,,� i. Rose �o un Es1 f�{��n�rr� �c��i. ��rE� �N�ISTo Po�l�o s �'= a.� 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(Gx3)(a). Please attach copies of certification to this applicatiott. The Health Department will not use past years'records. You must prnvide new copies�nd maintain a file at yonr establishment �. �Ar��e ( C�r�s�PDu�oS 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 emplopees trained in anti-cholang procedures below and attach copies of employee certifications to this form. The Heaith Department will not use past years'records. You must provide new copies and maintain a file at your place of 6usiness. 1. �l�/4 2, 3. 4. RESTAURANT SEATING: TOTAL# pt'7 _ OFFICE USE ONLY LODGWG: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �B S55 CAB[N $55 MOTEL $110 —� S55 CAMP S55 —SWIMMINGPOOL3110ea _IADGE s55 TRAILERPARK S105 _WIIIRLPOOL SilOea FOOD SERVICE: LI ENSE REQUIItED FEE PE LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _0-100SEATS SI25 �tt7�I�l CONTINENTAL S35 NON-PROFIT $30 >L00 SEATS $200 �COMMON VIC. a60 �S —WHOLESALE $80 RETAIL SERVICE: —RESID.KITCHEN S� LiCENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICBNSE REQUIRED FEE PERMI7'# <50sq R S50 >25,000 ft. 5285 VENDING-FOOD S25 =QS,OOOsq.R $I50 �FROZEN�ESSERT S40 �o� =TOBACCO a110 NAME CAANGE: S15 AMOITNT DUE _ $ �Z�•O D *"'•PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM**'•• ;I ._ . . .. . .. . .. . .. r ADMINISTRATION Under Chapter 152,Section 25C,Subsection 6,the Town of Yannouth is now required to hold issuance or reaewal 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 INSURANGE AFFIDAVTT MUST BE COMPLETED AND SIGNED,OR CERT.OF 1NSURANCE ATTACHED� OR WORKER'S COMP.AFFIDAVTf SIGNED AND ATTACHED Town of Yarmouth t�es and liens must be paid prior to renewal or issuance of your permits. P�EASE CHECK APPROPRTATELY IF PAID: YES NQ MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transiern 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 residemce elsewhere.Transient occupancy shatl generally refer to continuous occupancy of not more than thiriy(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,sha11 generally be considered Transient. POOLS POOL OPE1vING: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. 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 three(3)days prior to opening,and quarterly therea.fter. POOL CLOSING:Every outdoor in ground swimming pool must be drained or covered witlun seven(7)days of closing. FOOD SERVICE SEASONAL FOOD SERVICE OPEMNG: Atl 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 openuig. CATERING POLICY: Anyone who caters within the Town of Yarmouth must norify the Yatmoukh Health Department by filing the reqwred Temporary Food Service Apptication form 72 hours prior to the catered event. These forms can be obtained ai 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 Fmzen Dessert Permit until the above terms have been met. OUTSIDE CAF�S: Outside cafes(i.e.,outdoor seating with waiterlwaitress 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 prnhibited. i � NOTICE:Permits run annuatly from January 1 to December 31. iT IS YOUR RESPONSIBILITY TO RETUI2N ; THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 16,2016. ! ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAIIVTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR ' TO CO�NCEMENT. RENOVATTONS MAY REQi�RE A CI7'E PL i/7// DATE: I6�oZ��/�7 SIGNATURE: Cl(i(� PRINT NAME&TITLE: �Ql�i l tt Qu�oS t�.toiiuie __— --_ _-- ----- _— _ --- _-- _ —___— __ INEORMATION PAGE RENEWAL AGREEMEIVT Insurer: PRODUCER: Agent# 9999 MA Retail Merchants WC Group Inc. Cove Risk Services, LLC PO Box 859222-9222 PO Box 859222-9222 Braintree, MA 02185 Braintree, MA 0218� (Carrier Code: 34355) Carrier Policy ��: 014005030237116 Carrier Prior Policy �: 01400�t33Q237115 l. The Insured: Dara Foods. Inc. South Yarmouth Dairy Queen Mailing Address: 917 Main Street Rte 28 South Yarmouth, MA OZbb4 Fein: 043�40794 Other workplaces not shown above: �pe of Business: Corporation NO OTHER WORKPLACES FOR '1�iIS POLICY Risk ID: 2. The policy period is from 12:01 a.m. on _ 1/01 2016 _ to 12:01 a.m. on i[O1/20ll at the insured's mailing address. 3. A. Workers Compensation Insurance: Part One of the policy applie� to the Worker� Compensation Law of the states listed here: MA B. Employers Liability Insurance: Fart �ao of the policy applies to work in each state listed in item 3.A. The limits of our liability under Part �o are: Bodily Injury by Accident $________100.Od0______ each accident Bodily Injury by Disease $_ _ 500,000 __ _ _ policy limit Bodily Inj ury by Disease $_ ___ _l00,00Q__ __ each employee C. Other States Insurance: D. This policy includes these endorsements and schedules: WCOOOOOOC(O1/15) WC00031Q(Q4/84) WCO�Q414(07/90) WC000422B(Ol/15) WC2003Q1(04/84) WC2003d2(05/86) WC200303B(07/99) WC200306B(05/13) WC200405{Q6/O1) WC200601A(Q7108) 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 verificatian and change by audit. Classifications Code Premium Basis Rate Per Estimated No_ Total Estimated $100 of Annual Annual Remuneratian Remuneration Premium SEE SCHEDULE OF OPERATIONS Total Estimated Annual Prem�.um $ 1,852.00 Minimum Premium $ 219.00 Expense Constant .00 Deposit Premium ,