HomeMy WebLinkAboutApplication and WC �,r TOWN OF YARMOUTH BOARD OF HEALTH
APPLICATION FOR LICENSE/PERMIT-2019 4
s PI form and attach all mammy _d MUST��,� ER i3".
NM ALL aillure�w�t t m the return r application packet.
ESTABLISHMENT NAME: _ . _ -
LOCATION ADDRESS: "� r. i�•'t1
MAILING ADDRESS: . L * I in
lifetti-=ciglo#E-MAIL ADDRESS: i►!>>�. 'A���b - QS
OWNER NAME:
f:z.
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CORPORATION NAME(I!`'APpLI i E): : i_../ _ - 'A #: �: , 87D!/r9
MANAGER'S NAME: At • ,
44.
MAILING ADDRESS: 0-
POOL CERTIFICATIONS: Operator, required by State law. Please list the designated
The Operator(s)pool supervisor must be cerof the tified certification Pool to this form
Pool and attach a copy
2.
1.
must list a minimum of two employees currently certified in standard First Aid and Community
Pa r operators onpremises at all times. Please list the
Cardiopulmonary Resuscitation(CPR) having one certified employee will not use past
employeesbelow and attach copies of their certifications to this The Health of
fD business. RECEIVED
yearr ds. You must provide new copies and maintain a file at your place
1• _, 2. NUY 7 5 2018
FOOD PROTECTION MANAGERS-CERTIFICATIONS: HEALTH DEPT.
to have at least one full-time employee who is certified as a Feed
All food service are requiredCode for Food Service Establishments,105 CMR 590.000.
Protection Manager,as defined in the State
Sanitary
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 yourestablishment.
aki
1. �! �l 1 t'"r'si _ S 2. ��+
PERSON IN CHARGE: on.
Each food establishment must have at least one Person In Charge(PIC)on site during hours of opemti nc
_
ALLERGEN CERTIFICATIONS:S: who has Allergen certification,
arerequired tohave at least one full-time employee
Alt food service State establishmentsY 3
as defined in the State Sanitary Code for Food Service Establishments,105 CMR 590.009(GX3xa}. 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. `i
��� �J2
1. `�rriails' x .a 2'
N..;
HEIMLICH CERTIFICATIONS: to trained in the Heimlich
All food service establishments with 25 seats or more must have at least one emp y
tizi
Maneuver on the premisesyour r,i . --trained in anti-choking procedures below and a
at all times. Please list �
attach copies of employee certifications to this form. The : - ,, Department will not use past years'records. 11You must provide new copies and maintain a file at your place ofbusiness. I
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RESTAURANT SEATING: TOTAL# '/ VI
O
OFFICE USE ONLY
IICENSE FEE PERMIT* LICENSE REQUIRED FEE PERMIT LICENSE REQUIRED FEE PERMIT S IMOTFL $1 10 O,
SWIMMING POOL$11044.---
-LODGE
t r0ea
u5 —TRAILER PARK $105 __WHIRLPOOL 51104a.
LOON SERVICE: FEE PERMIT 0 LICENSE REQUIRED FEE PERMIT#
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED 435 NON-PROFIT
=O ilk $EATS MO .-�q-� ��MMOTT VIC $60 ��J�--_ R}.KITCHEN S80
RETAIL SERVICE: +-'--_# LICENSE REQUIRED FEE PERMIT LICENSE REQUIRED FEE PERMIT S
<50 at LICENSE REQUIRED FEE PST_____ >25.000 wit��_ S283 VENDING•FOOD S25
71.1.5, NIL S150 �."Flt4M-1 DESSERT S40 —TOBACCO 5110
AMOUNT DUE
NAME CHANGE: 515
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM**e**
ADMINISTRATION
152,Section 25C,Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal
of
any Chapter operate a business if a person or company does not have a Certificate of Worker's
Compensation sInsurance.rt THE 'S COMPENSATION INSURANCE
ATTACHED STATE WORKER
AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR
CERT.OF INSURANCE ATTACHED
OR
WORKER'S COMP.AFFIDAVIT SIGNED AND ATTACHED
prior to renewal or issuance of your permits. PLEASE CHECK
Town of Yarmouth taxes and liens must be paid
APPROPRIATELY IF PAID: YES V/
NO
MOTELS AND OTHER LODGING ESTABLISHMENTS
of the limitations of Motel or Hotel use,Transient occupancy shall be limited to
TRANSIENT OCCUPANCY: For ordinarily
and customarily associated with motel and hotel use. Transient occupants
the
must have abe aborto demonstraterm occupancy,that they maintain a principal place of residence elsewhere.Transient occupancy shall
must have and to cont toof not more than thirty(30)days,and an aggregate of not more than ninety(90)days
within
generally yef six t( )month
period.occupancy unit as a residence or dwelling unit shall not be considered transient.
cany is month eUse of a guot
Occupancy that is subject to the collection of Room Occupancy Excise,as defined in M.G.L.c.64G or 830 CMR 640,as
amended,shall generally be considered Transient.
POOLS
the
POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must �)�P ,to
Health Department prior to opening. Contact the Health Department to schedule the inspection
are NOT allowed to sit in a pool area until the pool has been and opened.
opening.PLEASE NOTE:Peoplecount by a State.
POOL WATER TESTING:d The water must t entt�fe(3)days
totald and quarterly standard .
certified lab,and submitted to the Health Department �)da of closing.CLOSING:Every outdoor in ground swimming pool must be drained or covered within seven(7)days
FOOD SERVICE
SEASONAL FOOD SERVICE OPENING: bythe Health Department prior to opening. Please cow the Health
DepartmentAil
efinspected
to scheduleinspection three(3)days days prior to opening.
CATERING POLICY: the Yarmouth Health Department by ebbtailin the requthe ired Anyone ry who Food Services thel Town ofr Yarmouth2 mustr notify o
Temporary Application form 72 hours prior to the catered event. These fortris� �Forms.
Department,or from the Town's website at www vermouth nia.us under Health Department,
FROZEN DESSERTS: and monthly thereafter,with samFle tesu �rtlts si'
Frozen desserts must be tested by a State certified lab prior to opening Dessert
bmitted to
the Health Department, Failure to do so will result in the suspension or revocation of your Frozen
until the
above terms have been met.
OUTSIDE CAFES:
Outside cafes(i.e.,outdoor seating with waiterlwaitress service),must have prior approval from the Board of Health.
OUTDOOR COOKING: product b a retail or foodservice establishment is prohibited.
Outdoor cooking,preparation,or display of any food y
TOBACCO PRODUCT PERMIT CAP
A tobacco permit holder who has failed to renew his or her permit within thirty(30)days of the previous year's
permit expiration date is considered an expired license,and the tobacco license cap is reduced.
NOTICE:Permits run annually from January 1 to December 31. TT IS YOURRESPONSISILTTY TO RETURN
THE COMPLETED RENEWAL APPLICATIONS)AND REQUIRED FEE(S)BY DECEMBER 15,2018.
R
L (i.e.,
, NEW
ALL PMENT,RENOVATIONS TMUST
NY FOOD BE REPORTED TO AND�OVED BY, MOTEL OTHEBOARD OF HEALTH PRIOR
EQUIPMENT,ETC.), � t. A S �PLAN.AF
TO COMMENCEMENT. RENOVATIONS MAY RE' //
j SIGNATURE: I,0,44/4. e �.�.•1..�!�•
DATE: 701,11111115 1/"." / ►
PRINT NAME&TITLE: iii 1/•—
Rev 10.23t141
The Commonwealth of Massachusetts
Dint ofindustrial Accidents
t=— Ayr Office of Investigations
7147-f=—:-.: 1 Congress Street,Suite 100
\1/4.._
F',:-Al Boston,MA 02114-2017/
.. wryw sass�/dIa
, . �/Ni7.1. > Businesses
Workers' Compensation Insurance Affidavit: General BusiI
• it L , a, koicee.441--'
Business/Organization Name: Z2..,,,r .., All CA
,,
n' ! _
Address: p 2to' 3 (5 $� `J �� I
C` IState/Zip:
.AS61 U.• . Phone#: O
employer?Check the appropriate box: SBusineS6Ty(required):
Are you an 1:3
Retail I am a employer with employees(full and! 6. �estaurantlBartEatir►$Establishment
time * and have no 7. []Office and/or Sales(incl real estate,auto,etc.)
or )•
2.❑ I am a sole proprietor or partnership
employees working for me in any capacity.
8. 0 Non-profit
[No workers'comp.insurance required] 0 Entertainment
3.0 We are a corporation and its officers have exercised 9. Manufacturing
their right of exemption per c.152,§1(4),and we have ng
no employees.[No workers'comp.insurance Wil* 11,ri Health Care
organization,staffed by volunteers, 12,Q Other 4,❑ withWare a ploye o insurance req.]no employees.[No workers'comp.
•may the c that checks box ex meted so � corporationut the w ,yam,a workers'comp�'�D policy is uired raid such an
.a� officers have exempted
organization should cheek box st. Below Is the pOIlC.V inform.
that its Prov ing workers'co ,, .,,,,,to , ce for my emplo3' i•: kr
I axe an employer ► Ct. l � � 1 s• I r
Insurance Company Name: 1 .
Insurer's Address: ' $ 11 • a a -
- • a'
City/State/Zip: •Y't • A a TA • s a �O! �l7
» 0404 .A,/ A Expiration Date:
Policy#or Self-ins.Lic.# 9number and expiration date).
Attach a copy of the workers'compensation policy declaration page(showing the policy
tion of criminal penalties of a
Failure to secure coverage as under Section 25A of MGL c.152 can lead to the imposi
.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
fine up to$ ,1500the violator. Be advised that a copy of this statement may be forwarded to the Office of
ofInvesup tigato$250.00tions of atike y againstDIA for insurance coverage verification.erag
above is true and correct,
I do hereby certify,under the pains and penalties of,�' th,. the information provided
t/ , -, z A
-_-
Official use only. Do not write in this area,to be completed by city or town o
i
Permit/License#
City or Town: i
Issuing Authority(circle one): Board S.Selectmen's {
I.Board of Health 2.Building Department 3.City/Town Clerk 4.Licensing
6.Other
! Phone#•
Contact Person:
wwWaMSs. idia
INFORMATION PAGE RENEWAL AGREEMENT
Insurer: PRODUCER: Agent# 932
MA Retail Merchants WC Group Inc. Dowling & O'Neil Insurance Agency
PO Box 859222-9222 PO Box 1990
Braintree, MA 02185 Hyannis, MA 02601
(Carrier Code: 34355) Carrier Policy #: 014005030290118
Carrier Prior Policy #: 014005030290117
1 . The Insured: Azzaro Yarmouth, LLC
The Lobster Boat Restaurant
Mailing Address: 681 Main Street
Route 28
West Yarmouth, MA 02673
Fein:
Other workplaces not shown above: Type of Business: Corporation
SEE SCHEDULE OF OPERATIONS Risk ID:
2. The policy period is from 12:01 a.m. on 1/0112018 to 12:01 a.m. on 1/01/2019
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 Two of the policy applies to work in each
state listed in Item 3.A. The limits of our liability under Part Two are:
Bodily Injury by Accident $ 500.000 each accident
Bodily Injury by Disease $ 500.000 policy limit
Bodily Injury by Disease $ 500.000 each employee
C. Other States Insurance:
D. This policy includes these endorsements and schedules:
WC000000C(01/15) W0000414(07/90) WC000422B(01/15) WC200102(01/14) WC200301(04/84)
WC200302A(09/08) WC200303D(08/10) WC200306B(06/13) WC200405(06/01) WC200601A(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 Premium Basis Rate Per Estimated
No. Total Estimated $100 of Annual
Annual Remuneration Remuneration Premium
SEE SCHEDULE OF OPERATIONS
Total Estimated Annual Premium $ 2,843.00
Minimum Premium $ 267.00 Expense Constant $ .00 Deposit Premium $ .00