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Home My WebLink AboutApplication and WC � � TOWN OF YARMOUTH BOARD OF HEALTH � APPLICATION FOR LICENSE/PERMIT-2017 � *Please complete form and attach all necessary documents by D n ber l6 2016. �L� Failure to do so will result in the retum of your applicauon pac et. ± ESTABLISHMENI'NAME:_ �i 2�r�� h� E'v,�t1 Tt�x ID: R 1—4 Fi Fi 1 2 9 7 � � LOCATIONADDRESS: 559 ROLte 6A, Yarmo � hnort TEL.#: SOR—�6 —79'7'7 `�� ' MAILINGADDRESS: S.amP a� ahn��a E-MAILADDRESS: .-r;vanaf_@_c..s�m.cast_._n.et � � � /� , OWNER NAME: CORPORATION NAME(IF APPLICABLE): JOCA,� LLC MANAGER'S NAME: i m].t T'1 I vanc�.f TEL.#: 7 g� _5�A_ti �� MAILING ADDRESS: d�,(1 �t a t i nn �c�a y S .�ar�nauth� A�J.�--(12�6 4 POOL CER'TIFICATIONS: The pool supervisor must be certified as a Pool Operator,as reqaired by State law. Please list the designated Pool Operator(s)and attach a copy of the certification to this form. � 'r .� .� � 1. 2. -...� � �,. � ,:_ � '. Pool operators must list a minimum of two employees currently certified in standard First Aid and Commumty "3 Cardiopuimonary Resuscitation(CPR),having one certified employee on premises at all times. Please hst the�-r. -�� em plo yees below and attach co pies of their certifications to this form.The Health De partment will not use past ,�� years'records. You must provide new copies and maintain a t51e at your place of business. ;=;j � t.7 0 � 1. � 2. �-; c� ._ �� 3. 4. � ' a ' � ' S..-...�_...._.__...__......_..,..y: 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. T6e Health Department will not use past years'records. �` ,;:� You must provide new copies and maintain a file at your establishment. , `_'� 1. Dimitri Ivanof 2. W�sgner Goncalves , � ` ¢c,. PERSONIN CHARGE: �r,� Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. �, Dimitri Ivanof 2. Wactner Goncalves �"a"" ^ � `+'.:��;;. . +KY 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(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 Tile at your establishment i Dimitri Ivanof 2. Wagner Goncalves HEIMLICH CERTTFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at a11 times. Please list your employees trained in anti-cholcuig 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 fde at your place of business. 1, Wagner Goncalves 2, Audrey Boucher 3. Ally Mullaney 4. RESTAURANT SEATING: TOTAL# 31 OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# H&B S55 CABIN $SS MOTEL 5110 —1NN SSS —CAMP S55 =SWIMMING POOL S110ea. �,ODGE a55 lTRAILER PARK 5105 _WHIItLPOOL S110ea FOOD SERVQICE: L�01100 SEA7'SIRED �FE2S �T ///_ =COMMONrV C D S60 pE��I S I-1VI OLESALE� S80 PERMIT# _>l00 SEATS 5200 ��'L�{'P —RESID.KITCHEN SS0 RETAIL SERVICE: LICENSE REQUIRED FEE PERMiT# LICENSE REQUIRED FEE PERM[T# LICENSE REQU[RED FEE PERMIT# <50sq ft. S50 >25,000sq R 5285 VENDING-FOOD S25 =<25,000 sq.ft. 5150 ' �ROZEN DESSERT S40 TOBACCO S110 NAMECHANGE: SIS AMOUNTDUE _ $_(SS•CX� � �� *"**«PLEASE TURN OVER ANf * I �,��R?61DE OF F'ORM*#"•" r ADNIINISTRATION 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 Compensadon Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR � CERT.OF INSURANCE ATTACHED Appl ied f or oR S�� attached WORKER'S COMP.AFFIDAVIT SIGNED AND ATTACHED letter Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRL4TELY IF PAID: XES X 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 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 witivn any six(6)month period. Use of a guest unit as a residence or dwelling unit shali not be considered transient. Occupancy that is subject to ttie 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 OPEIVING:Ail swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Depariment prior to opening. Contact the Health Department to schedute 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 ptate 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. FOOD SERVICE SEASONAL FOOD SERVICE OPEI�IING: All food service establishments must be inspected by the Health Deparhnent prior to opeaing. 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 reqwred 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. DUTSIDE CAF�S: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. 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 RESPONSIBILII'Y TO RET'[TRN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 16,2016. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINfING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR � TO COMMENCEMENT. RENOVATIONS MAY QUIRE A SITE PLA ' DATE: 1 2/1 6/1 6 SIGNATURE: �--> PRINTNAME&TITLE: Dim.itri Ivanof, Manager �.imiui6 � ! � � �'�' ' f ' 7ELEPHONE 508.775.1 b20 � � �}C�W�ICI� � �'`��'I� AGENCY FAX 508.778.1137 � 1 N�S !�? R A N C E� A G E�N� Y CC�tviMERGI�L�AX S08J78.1218 � � 973 lyannough Road,PA.Box 1990 Hyannis,MA 02601 doins.tom � Deeember 9,2016 ! � Town of Yarmouth ' � RE:Pizza's b Evan-559 Rte 6A Yarmouth ort MA � Y , p , � � To Whom it May Concern; I I! , Our office is in the process of securing quotes for both Workers'Compensation and Liquor i Liability for 10CA, LLC dba Pizza's by Evan.We will have coverage in force prior to the business opening. i � ; if you have questions please don't hesitate to contact me at 508-957-4248. , � ; Regards, � ' I C ��"".,,,�, ��_~r$�� Mark McCartin � The Cvmnionwaalth of Massachuseus Departmtnt of I,�dr�strfal Accidexts D,�"ice of Im�esrigations 1 Congress Street,Su}te IOsO Boston,MA 02114-2017. www.rnass.gav/dla Workers' Compensation Insurance AfBdavit: General Bns�nesscs Anolicant Infarmation Ple�se Print Legiblv Business/OrgenizationName: J��, Lr,c a/b/a pizzas bv Evan AddreSs: 559 Route 6A City/State/Zip:Yarmauthport, MA 02675 P$ene#: 508-362-7977 Are yoa sn employ�4 C6edc the apprope�iste boz: Bn�iaeas'l�pe(reqnired}: 1.� I am a employer with 10 employees(full and/ S. ❑Retail or part-dme).* 6. �Restaure,ntJ'Bar/Eating Establishmant 2.❑ I am a sole prnpri�tor or parpicxship and have no �, �p}��a/or Sales(incl.real estate,auto,etc.) amployees working for me in any capacity. [No workers'comp.insurance requiredj 8. ❑Non-profit 3.❑ We are a corporation and its officers have cxercised 9. ❑Ent�tainment their right of ex�m�on per c. 152,§1{4),and we have 10.❑Manufacturing no em�loyees.tNo workers'comp.insutance required]* 11.[]Healdi Care 4.❑ We are a non-profit organi�t.ion,staffed 6y volunteers, with no ernployas. [No workers'comp.insurance req.] 12.[�Other �.4qy eppliceut that ched�baoc�1 must al�o fill ouc d�e section 6elow s}►owiag theu warlaas'coaipmsatioa policy infotmation. •sIf d�e colpo�ste offioC�s fuve exempDed f]10mEelves,but t�e naporsdon has otha�mplvyas,a worloeas'aompeasaSiom policy ic nqui�d and euch an aa�xnimtiau ahould cbedc bmc#1. I am en employa�tJ�at lg providing worl�ers'+compursatior�Sn�tance jor m�'employees .Below Ls tke polfcy iRja�on. Insurar�ce Company Narne: Traveler's Ind�mni ty �f Amer;ca _ Insw+er's Address: P•�• Box 3 5 6 6 Ck�,��Z�p: Orlando, FL 32802 Poticy#or Self-iits.Lia# 6S62UB-4B23571-4-1 6 Eacpitation Datc: 1�-30-17 Attach a oopy of the workera'oompena�#ioa policy declaration psge(showing the palicy nnmber aad e�pirxtion date). Failure to securo cov�age as requ'ved under Sedion 25A of MGL a 152 can lead tn the irnposition of eriminal penalties of a fine up to 51,500.00 and/ar one-year imp�isonment,as well as civil penalties in ti�e foraf of a STOP WORK ORDER and a fine of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarckd to the Office of Investigatians of the DIA for insurance coverage verificatian I do kereby cert�j'y, r the pains aTties of jury tkat the 6eform�an provtded abave ls true a�d cor� ; � 1-3-1 7 p�� 508-362-7977 Of,�et�l rise only. Do aot wri�c in dfeis area,to be co�ple�ed by city or town o,,Q�cBa� City or Town: PermitlLicense# Isaning Aathor�ly(circle oae): l.Boa�rd of HeAlth 2.Bu�ldin�Department 3.Cityfl`owo Clerg 4.I.icenei��Board S.Seketmen's Ot�ice 6.Ot�er Conhct Plerson: Phoae#• www.m�as.�ov/dia NOTICE QF ASSIGNMENT EIAPLOYER: COMBO I.D. STATUS OF EIIPLOYER JOCA LLC DBA PIZZAS BY EVAN 001013?31 Limited Liability Comp 450 STATION AVENUE SOUTH YARMOUTH, MA 02669 COVERAGE GROUP 1137012 Coverage under this asaignment The Waiver of Our Right to applies to Massachusetts Recover from Othere Endorsement operations only. For coverage is avafiable on Pooi poiicies. outieide of Massachusetts, contact Contact your agent for details. the appropriate Pool or Plan for that state. INSURANCE COM�ANY: AOENT DOWLING & ONEIL INSURANCE AGENCY TRAVELERS INDEMNITY CO OF AMERICA OR �ILY MONTGOMERY Jonathan 3charnberg PRODUCER: 9�3 IYANNdUGH RD P 0 BOX 3556 HYANNIS, MA 02601 ORLANDO, FL 32802-3556 (800) 443-4904 AGENCY FEIN: 2 7 014 3 62 5 CLASSIFICATI4N OF OPERATION CLASS ESTIMATED RATE ESTIMATED CODE TOTAL ANNUAL PREMTUM REMUNERATION -------------------------------------------- ----- -------------- ---------- ---------- RESTAURANT NOC 9079 $240,000 1.09 $2,616 DRIVERS, CHAUFFEUR$ AND H�LPER$-NOC-COMMERCIAL ?380 $].0,000 6.�8 $608 EMPLaYERS LIABILITY 506/500/500 9807 $50 STANDARD PREMIUM $3,279 EXPENSE CONSTANT Q900 $338 TERRORISM CHARGE 9790 $75 TOTAi. POLICX MINZMUM PREMIUM $533 TOTAL ESTTMATED PREMIUM $3,687 DIA A3SES5. 5.6� $181 TOTAL EST. PREMIUM PLUS ASSE55MENT 53,868 II�lSTALLMENT 6AS�: Annual DEPOSIT PREMIUM: $3,868 THIS IS NOT A BILL OOMMENTS Coverage effective 12:01 A�f on 12/30/16. Subject to 10/15 Anniversary Rate Date. Add endorsement WC 00 03 10 to this policy. A sole proprietor, partner(s} , or member(s) of an LLC has elected to be covered as an employee. DATE OF NOTICE: 12/28/16 PREPARED BY: Sherry Jones EXT 516 tr : $ERVICING GARRIER A$SI(�1T t � The Workers'Compensation Rating and Inspectlon Buresu of Massachusetts 101 Arch Skreet•Boston,IIAA d2118 {fi17�39-�G30•FAX{617}439-6055•www.wcribma.org