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Home My WebLink AboutApplication and WC� r � � R�CEI � � TOWN OF YARMOUTH BOARD OF HEALTH ,4� � � APPLICATION FOR LICENSE/PE T,- 0 �f��' �; j r��j� � � �"°' * Please complete form and attach all necess a�� s mb r 16 2016. Fai lure to do so wi l l resu lt in t he return o l f yo�r�p�l�t� E PT. ESTABLISHMENT NAME: .EN S TAX ID: c��- 08� ^5��' � '' LOCATION ADDRESS: 3 Z �� 6 w�%'�st�� .�r.sf TEL.#:s�'� �'35'y�-'z9�'j MAILING ADDRESS: 6v� s�sz?�.E �'�-�.�-�' .E�zv�,�.E �.q 62632 E-MAIL ADDRESS: �'n� � Co'��ra�: .-✓�7 OWNER NAME: �•g�..c.E' /�� C'o•��a.S.v z�a-v � CORPORATION NAME (IF APPLICABLE): �'�� /�'�� o.��'-��'.�o•�/ MANAGER'S NAME: T�'�� C�c'�'�'.�'o TEL.#:so S- 3 5' -Z9�S � MAILING ADDRESS: 6� �_�s��' -�� 'z-�-<-E' �'.� a2632 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. 1 -- ---- - - -- - -- -- - - -- �. 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. j 3. 4. � FOOD PROTECTION MANAGERS - CERTIFICATIONS: i 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 file at your establishment. 1. �'�.��/-1 O c�r��a 2. �.�r�r�,�,E' ��( �/i�-� PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) o site during hours of operation. �.��1 OC/9�i-l�0 0� - ��i�c.f.� � 1. 2. h��r,xt.�.c,�'+�c i __ _ — 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. ��G2.4 O ci9i'7/�D 2. �i'.�.�.t�-�,..c ^ � �\\1 V 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. ' 1. �i4�t��1 �c.�ry.�b , 2. /.E'.�� i7zc i � 3. 7om.1 �.c��n.��✓ 4. ,.f��-� �.t� -�i-�..�v�rv� f i RESTAURANT SEATING: TOTAL# �� I a ' OFFICE USE ONLY .� LVLVl .._. . - _....__-'- _-.- ' 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$1 l0ea. � _LODGE $55 TRAILERPARK $105 _WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE P T# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LO-100 SEATS $125 �� CONTINENTAL $35 NON-PROFIT $30 >100 SEATS $200 �COMMON VIC. $60 17– 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 _<25,000 sq.ft. $150 �PROZEl�'DESSERT $40 �� _TOBACCO $110 � NAME CIlANGE: $is AMOUNT DUE _ $ 225.00 ! *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** � 8o��-L5-�a�9 -(� 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 Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: / YES �/ NO MOTELS AND OTHER LODGING ESTABLISHMENTS � �.-:r,�.-_��__.��..--�_ .._�_.._ __ _ . ,. .. . . ..._.. .- ..='."wseTy'•]Y.'F4.r^,�zh.� .. , . . . . . . 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. 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 t closing. � _ _ �_� M..-- -- -_ _.�- --- � _ __ ...... - �t�-� �__._�__""=-�x�. —> rc; .-�_ i _ - - - — FOOb S�-R�IC-� ---_- —�;- -�� ,'�=-- - 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. 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 priar to the catered event. These forms can be obtained at the Health Department,or from the Town's website at www.yarmouth.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: putdoor 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 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 APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCE ENT. RENOVATIONS MAY REQUI . �� DATE: �� 20 �6 SIGNATURE: PRINT NAME & TITLE;,Eie.�r,�7 �ky �.c��y,.�� ' Rev. 10/12/16 . � The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations � I Congress Street, Suite 100 ; � Boston, MA 02114-2017 � www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses A licant Information Please Print Le ibl Business/Organization Name• .g� �� -�-�` \`� "-�"'�ys ' Address: ;.3.2 6-�,.� �v�.�.,��o�� City/State/Z��=� ��'�1 026j2 Phone #: �a 8 - �0 7- 6 3 2-Z Are y u an employer?Check the appropriate box: Business Type(required): 1.�I am a employer with�employees(full and/ 5. ❑ Retail or part-time).* 6. [►/�Restaurant�BarlEating Estal�ment , , - - ,. �. ,: .. - -- --- — � 11 � ' � �l� 11 r 7. Office and/or Sa1es(incl. real estate, auto, etc.) 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 c. 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 also fill out the section below showing their workers'compensation policy information. **If the corporate o�cers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#1. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Narrie: /�'�� /�7'�'� ✓7'�.�G�'�'''�� V'v� �''� '� ��'�-� • Insurer's Address: / • O � �o�X 8�9`22 Z - ��Z Z City/State/Zip: ��►v�� /-7/'� ��Z f�S" Policy#or Self-ins. Lic.# 4 i�}005'0 3 o S S�'ii,6 Expiration Date: �� Attach a copy of the worke eompensation 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 ___�}��,�� Q, cnn nn�lcrr e�e-ye��r.��;., as sv�lf�c��i� ...�i�s :n tl��fo�o`a��'`�3P i�'C�3�EP�an�3 a�'ine r ,...,.,.�., 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 certify, u • �utii�a�idlties of perjury that the information provided above is true and correct. Si ature: Date: /��' Phone#• �Dg ' �Z�7-' 6 3 �-'� Official use only. Do not write in this area,to be completed by city or town official iCity 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#• www.mass.gov/dia INFORMATION PAGE RENEWAL AGREEMENT Insurer• PRODUCER: Agent�� 59b0 MA Retail Merchants WC Group Inc. Association Benefits Insurance Age PO Box 859222-9222 299 Ballardvale St, Suite 1 Braintree, MA 02185 Wilmington, MA 01887 (Carrier Code: 343�5) Carrier Policy �k: 014005030559116 Carrier Prior Policy �k: 014005030559115 1. The Insured: Fashion Food LLC Wendy's ' Mailing Address: 6b Pondside Circle Centerville, MA 02b32 Eein: 861176398 Other workplaces not �hown above: Type of Business: Corporation SEE SCHEDULE OF OPERATIONS Risk ID: 2. The policy period is from 12:01 a.m. on �01 2016 to X2:01 a.m. on _ 1�1L2017_ at the insured's mailing address. 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers Liability Insurance: Part �ao of the policy applies to work� in each state listed in Item 3.A. The limits of our liability under Part �ao are: Bodily Injury by Accident $__� 100 000 ___ each accident Bodily In�ury by Disease $____ 500 000 ____ policy limit Bodily Injury by Disease $__ 100.000 ___ each employee C. Other State� Insurance: D. This policy includes these endorsements and schedules: WCOOOOOOC{O1/15) WC000310(04/84) WC000406(08/84) WC000414(07/90) WC000422B(Ol/15) WC200301(04/84) WC200302(Q5/86) WC2003�3B(07/99) WC200306B(06/13) WC2004�5(06/Ol) WC200bO1A(07/08) 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 verification and change by audit. Classifications � Code Eremium Basis Rate Per Estimated No. Total Estimated $100 of Annual Annual Remuneration Remuneration Premium SEE SCHEDULE OF OPERATIONS Total Estimated Annual Premium $ 22,2b1.00 Minimum Premium $ 219.00 Expense Constant .00 Deposit Premium • SCHEDULE OF OPERATIONS FOR: PAGE: 1 Wendy' s Carrier Policy #: 014005030559116 Fashion Food LLC Fein: 86117b398 55 Pondside Circle Centerville, MA 02632 DIV #: 00000 E/L Number: 0000000001 OTHER WORKPLACES: Fashion Food LLC Wendy' s 554 Route 28 State Risk ID#: 000072530 Hyannis, MA 02601 Eff date: 01/01/15 NAICS: 722511 DIV #: 00000 E/L Number: 0000400001 Fashion Food LLC Wendy' s 15 Canal Road State Risk ID#: 000072530 Orleans, MA 02653 Eff date: 01/01/15 SIC: 5812 DIV #: 00000 E/L Number: 0000000006 Fashion Food LLC Wendy' s 45 Commerce Way State Risk ID#: 72534 Plymouth, MA 02360 Eff date: 01/01/16 SIC: 5812 DIV #: 00000 E/L Number: 0000000004 Fashion Food LLC Wendy' s 69 Long Pond Drive State Risk ID#: 000072530 Plymouth, MA 02350 Eff date: 01/01/16 SIC: 5812 DIV #: 00000 E/L Number: 0000000005 Sparkle Food Corp. Fein: 010809540 Wendy' s 32 Old Townhouse Road Eff date: 01/01/16 South Yarmouth, MA 02632 NAICS: 722513 DIV #: 00001 Mailing: E/L Number: OOOOOOOOQI 65 Pondside Circle Centerville, MA 02632 WC 00 00 01 B