HomeMy WebLinkAboutApplication and WC ` , ��..� �. � �
� TOWN OF YARMOUTH BOARD OF HEAL�'����'
APPLICATION FOR LICENS �- ' ``�� ',� . OCT 3 1 Z017.
' * P lease comp le te form an d a tt ac h a 1 1 necess �- �o y� b �i 1�.��=T. , '
Failure to do so will result in the re `` f y ' ` application . �
ESTABLISHMENT NAME: AX I •
LOCATION ADDRESS: A.B. PIZZA II, �NC. TEL.#• .��.��3��- �g
MAILING ADDRESS: dlbla ROYAL II RESTAURAN 8
E-MAIL ADDRESS: Ov J a��'�15 MAIN STREET (Route 5A)
OWNER NAME: Yarmouth Port,
CORPORATION NAME(IF APPLICABLE): � `Z Z !9/'� '
MANAGER'S NAME: G ' TEI;.#: �� � J �
MAILING ADDRESS:
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operat.o • equired by State law. Please list the designated
Pool Operator(s) and attach a copy of the certificatio is form.
1. . 2, - _ __ -
Pool operators must list a mini of two employees currently certified in standard First Aid and Community
Cardiopulmonary Resuscita ' (CPR), having one certified employee on premises at all times. Please list the
employees below and a copies of their certifications to this form.The Health Department will not use past
years' records. Yo ust 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 file at your establishment. ,
�
1.��- ,� � ��'� �st..��G-�-�7 2:
�
PERSON IN CHARGE:
Each foo tablis ent must hav at least one Person In Charge(PIC)on site during hours of operation.
-- . _ - _ ---- ;
Z _
_ 1. `- �r�t,� _ __ _ _ . �
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 estabGshment. '
1• ' �1/�5��fl �-��f��.—� 2.
HEIMLICH CERTIFICATIONS:
All food service establiShments with 25 seats or more must have at least one employee trained in the Heimlich
1Vlaneuver on the premises at all times. Please list your employees trained in anti-cholcmg procedures below and
attach copies of employee certif cations to this form. The Health Department will not use past years' records.
You m st provide new cop' s and maintain a file at your place of business.
1. � _ 2_
3. 4,
RESTAURANT SEATING: TOTAL#
___ - — --- ---- -- --- - - _— _ __ ---- �
OFFICE USE ONLY
LaDGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
I1�1N $55 C�� $55 _MOT'EL $110
CAMP $55 SWIMMING POOL$i l0ea.
�LODGE $55 _TRAILER PARK $105 _WHIRLPOOL $110ea
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
LO-100 SEATS $125 �}5 CONTINENTAL $35 NON-PROFIT $30
>100 SEATS $200 / COMMON VIC. $60 ��- � =WHOLESALE $80
RE'I'AIL SEKVICE:
—RESID.KITCHEN $8U
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_<50 sq.ft. $50 >25,000sq ft. $285 VENDING-FOOD $25
<25,000 sq.R. $150 _FROZEN DESSERT $40 _TOBACCO $110
NAME CHANGE: $i s AMOUNT DUE _ $ �8 S. Q d
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** �Q�}F��l�_-�j?j G�
� ��
�. . ,
ADMINISTRATION �
I
{ 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 i
Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR
�
CER'T'.'OF INSIJR�AI�E ATTACHED f I
� OR �
WORKER'S COMP.AFFIDAVIT SIGN�D`AND ATTACHED�
Town of Yarmouth taxes and liens must be paid prior o renewal or issuance of your permits. PLEASE CHECK !
APPROPRIATELY IF PAID:
YES NO '
�MOTELS AND OTHER LODGING ESTABLISHMENTS �
TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hot�l use,Transient occupancy sha11 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 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 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 pseudornonas,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
elosing.
FOOD SERVICE 1_..�.. - ;
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 mus�notify the Yarmouth Health Depariment by filing the j
requ�red Temporary Food Service Application form 72 hours prior to the catered event. These forms can be j
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 Boazd of Health.
OUTDOOR COOKING:
Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited.
_ _ _ _ _ _. {
NO�'ICE: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 15,2017.
�
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 S T PL '
DATE: ^�� T SIGNATURE:
PRINT NAME &TITLE: ��� L-- ��� �►`J�� ���
Rev. 10/12/17
� • � � 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 Businesse's
Applicant Information Please Print Le�iblv
. . , .
Business/Organization Name: dlbla ROYAL II RESTAURANT 8 GRILLE
oute 6A)
Address: Yarmouth Port, MA 02675
City/State/Zip: Phone #:
Are you an employer? Check the appropriate box: Business Type(required):
1.❑ I am a employer with employees (full and/ 5. ❑ Retail
or part-time).* 6. �] RestaurantlBar/Eating Establishment
- --- - — __-- _ _ _
f 2.� I am a sole propnetor or partnership and have no �, � Office and/or Sa1es(incl. real estaxe, 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 officers have exempted themselves,but the corporarion has other employees,a workers'compensation policy is required and such an
organizafion should check box#L
I am an employer that is providinC�r�k�rs'�mpens�insurance for my employees. Below is the po[icy information.
Insurance Company Name:__ � r �
Insurer's Address: A d �� -� �/'� ��� li'V///"� �•�`�/� ��-3
City/State/Zip: �/rJ� ��1m�_ ��- �� ����__�
Policy#or Self-ins.Lic. # �`���� ��3 � Expiration Date: ��`�r'``� �
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
--- --- -___ _ _
fine up�o ,�T�DQ:Difiari�r one-year imprisonment,as weI as civr penalties in the form of a STOP WORK ORDER and a fine
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 certi ,un r the pains an enalties ofperjury that the information provided above is true and correct.
� �� � v�
Si ature: �� Date: / �� �T
Phone#: ����' ��G �'��;l�� �v0 �i�r ����
Official use only. Do not write in this area,to be compteted by city or town officia�
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#:
www.mass.gov/dia
'
G��•\
NOTICE � NC�`I'ICE
x � TO
TO " �
� � wd
i EMPLOYEES � , EMPLOYEES .
,�
i , e„�
�
' f Massachusetts
The Commonwealth o
DEPARTMENT OF INDUSTRIAL ACCID
EN
TS
1 Congress Street, Suite 100, Boston, 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 COMP�NY
P.O. Box A-H, 16 S. River Street, Wiikes-Barre, PA 18703-0020
ADDRESS OF INSURANCE COl�IPt1NY o3/is/2o1� o3/ss/2o1s
a�wca13339 EFFECTIVE DATES
POLICYNUMBEK 973 Iyannough Road P.O. Box 1990 508-775-1620
DOWLING &0'NEIL INSURANCE � Hyannis, MA 02601 _. pHONE#
NAME OF INSURANCE AGENT ADDRESS -.;._
q.B, pizza II Inc 715 RTE 6A Yarmauthport, MA 02675
EMPLOYER ADDRESS
02/11/2017
EMPLOYER'S WORKERS' COMPENSATION OFFICER(IF ANY) DATE
MEDICAL TREATMEN�'
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 Warl�ers' Compensation Act. A copy of the First Repc�i�t of Injuty must be given to 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 EI�IPLOYER