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Home My WebLink AboutApplication and WC r :. •� 12.�...0 ��C ' � TOWN OF YARMOUTH BO O E T �� 3 �� ` � � � APPLICATION FOR LICEN - ; 0 � „ � ;�.;� NUV 2 8 2016 * Please com lete form and attach all nec ' � �� mber 16 2016. p �' Failure to do so will result in the return of your application acls��-�H DEpT. ESTABLISHMENT NAME: TAX ID: �-�Ls�'�% 'Y LOCATION ADDRESS: dibla ROYAL TT RESTeUR�IN]'R G�11LE TEL.#: S��S'--3��-,2��'� ' MAILING ADDRESS: E-MAILADDRESS: Yarmouth pprt, MA n2675 ��`�'�l`p �'��-� '''`�°�`�'`� OWNER NAME: �j-�o��'�Cr�. ��L�-��r CORPORATION NAME (IF APPLICABLE): ' MANAGER'S NAME: � '' �-' � �,.,, �� IZl 2�io TEL.#: . MAILING ADDRESS: � _S ?6%. � �-r,, '� ' � - �-` � POOL 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. =: - -- —� _ _ Pool operators must 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 fle at your establishment. 1. 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. 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. 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# � OFFICE USE ONLY � LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $110 INN $55 CAMP $55 SWIMMING POOL$110ea. LODGE $55 TRAILER PARK $105 WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE P RMIT LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# l0-100 SEATS $125 �� CONTINENTAL $35 NON-PROFIT $30 >100 SEATS $200 TCOMMON 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 _Q5,000 sq.ft. $150 —FROZEN DESSERT $40 TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE _ $ (B�j.00 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** � �O�t�-I�f-d34Q-a3 , � � 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 t�es and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES\� NO � E 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. 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 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. � I 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 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 thereafter. � POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of � closing. � ; ___ __ --- - =---- - - - �_ _a � .___ _ __ . __. _ . . _.� __ _ _ .. � _ � FOOD SERVICE i 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. f i 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: Outc�oo�coo�cing,preparation;or display of any fQoc��rod�ct?�:et��er foo�se�ie-�€stablis�1�nent 3�rs�ibtte��---- -� 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 16, 2016. � ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW : EQUIPMENT,ETC.), MUST BE REPORTED TO AND A ROVED BY THE BO OF HEALTH PRIOR ' TO COMMEN EME T. RENOVATIONS MAY REQ SIT PL ATE: SIGNAT � J� �b URE: � �PRINT NAME & TITLE: � � )OL c� S� /��O Rev. 10/12/16 ' i � j � ` � The Commonwealth of Massachusetts ' _ Department of Indus�rial Accidents Office of Investigations ` 1 Congress Street, Suite I00 ' . Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses A licant Information II ING Please Print Le ibl � Business/Organization Name: dlbla ROYAL II RESTAURANT 8�GR �T�T�,�T�,��Route 6A) Address: Yarmouth Port, MA 02675 � City/Staxe/Zip: Phone#: �� 6��' -2-2-�� Are you an employer? Check the appropriate boz: Business Type(required): 1.❑ I am a employer with employees(full and/ 5. ❑ Retail or part-time).* 6. �RestaurantBar/Eating Establishment 2. I am a so�propnetar or partnership ana nave no - — - --- - - - --- --- 7. ❑ Office andlor Sa1es(incl. real estate,auto, ete.) employees working for me in any capacity. [No workers' comp.insurance required] g• ❑ Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per a 152, §1(4), and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]* 11.❑ 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 aiso 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#L I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: �'V�`� �•^$d V'�.•ce. �p,,,•�oN./, Insurer's Address: P �Q� �. Q–i�1 �6,5� 1�.�••e� c,�F�•�-'�' iADr � City/State/Zip: �� '_' �if'�!'�..,-- � �}- /��'G.�' �.n�,O Policy#or Self-ins.Lic.# A � I�J C 6 g$S� Expiration Date:�/8/�� Attach a copy of the workers' compensation policy declaration page(showing the policy number 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 _ i ,� . vr�ne- � e�t;a�-w�t�as�ivi}�enatties-in th�fcn-�n ofa STfl�'�J3RK f3R� a��,., i of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. � I do hereby cert' , nder the pains andpenalti perjury that the information provided above is true and correct. � Si atur • Date: � � Phon ..So -3G Z- Z2 8� �o$•- �— `��5— � Of�eial use only. Do not write in this area,to be completed by city or town offieiaL 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#: i www.mass.govJdia 1 , �� NOfiICE NOTICE � ,. O � , tl TC� EMPLOYEES � EMPLOYEES ,� � � The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL A�CIDENTS 1 Congress Street, Suite 100,-$oston, Massachusetts 02114-2017 617-727-4900 - http://www.state.ma.us/dia As required by Massachusetts General Law, Chapter 152, Sections 21, 22& 30,this will give you notice that I(we)have provided for payment to our injured employees under the above-mentioned chapter by insuring with: NorGUARD Insurance Company NAME OF INSURANCE COMPANY ^ P.O. Box A-H, 16 S. River Street,Wilkes-Barre, PA 18703-0020 ADDRESS OF INSURANCE COMPANY ABW C700108 03/18/2016 03/18/2017 POLICYNUMBER 973 Iyannough Road P.O. Box 1990 EFFECTIVEDATES DOW LING&O'NEIL INSURANCE� Hyannis, MA 02601 508-775-1620 NAME OF INSURANCE AGENT ADDRESS PHONE# A.B. Pizza II Inc 715 RTE 6A Yarmouthport, MA 02675 EMPLOYER ADDRESS 02/24/2016 EMPLOYER'S WORKERS' COMPENSATION OFFICER(IF AN� 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 reasonable hospital and medical services in accordance with the provisions of the Workers' Compensation Act. A copy of the First Report af Injury must be given tp the injured employee. The employee may select his or her own physician. The reasonable cost of the ser- vices 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 notified that the insurer has arranged for such attention at the NAME OF HOSPITAL ADDRESS TO BE POSTED BY EMPLOYER { — ��'^�l'kt'4F�h}Y1��,�'"�'�'4 '° ? r�r � >�tic� � �s fi i�a: vf,., k�42� tF � �� }` �:<:!'� i �� } F i � - ' . ;, ,., �, �.,, _ —_ - _ �,.r , :. .. _; , . „ .. , � �u . � .:�.., ..: .. - „. . {j __._. ...� __—_—. ._.._��. ____.,Y... �,�.,:�>,.,: 3 8 (Policy Provisions: Wc o 0 0 0 0 o B) 95 C� INFORMATION PAGE wEc WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY INSURER: TWIN CITY FIRE INSURANCE COMPANY ONE HARTFORD PLAZA, HAR.TFORD, CONNECTICUT 06155 NCCI Company Number: 14974 THE Company Code: � HaxTFoRn , su�iX LARS RENEWAL POLICY NUMBER: OS wEC CS9538 ��Oi� Prevlous Policy Number: oe w�c CS9538 HOUSING CODE: SB 1. Named Insured and Mailing Address: � pIZZA zrtc. DBA f (No.,Street,Town, State,Zip Code) (sEE ENDT) ' PO BOX 1424 f FEIN Number: 202113314 AENN2S PORT, MA 02639 State identificatlon Number(s): UIN: The Named Insured ts: CORPORATION � Business of Named Insured: RESTAURANT FAMILY STYLE: PIZZA Other workplaces not shown above: 374 LOWER COUNTY 1toAn - DENNIS PORT MA 02639 2. Policy Period: From o�/io/i6 To o4/io/i� 12:01 a.m., Standard time at the insured's mailing address. Producer's Name: DOWLING & 0'NEIL INSURANCE AGENCY PO BOX 1990 HYANNIS, MA 02601 ; Producer's Code: 088232 Issuing OffiCe: THE HARTFORD 301 WOUDS PARK DRIVE CLINTON NY 13323 (800) 962-6170 Total Estimated Annual Premium: $522 Deposit Premium: Policy Mintmum Premium: 5266 MA (INCLUDES INCREASED LIMIT MIN. PREM.) Audit Period: �U� Instaliment Tenn: � The policy is not binding unless c�untersigned by our authorized representative. Countersigned by �`�'"f C�r"`'�'`�'' o2/2i/16 Authorized Rep�esentative Date � � Porm WC 00 00 01 A (1) Printed in U.S.A. Page 1 (Continued on next page) i Proaess Date: o2/2i/i6 Policy Expiration Date: 04/10/17