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HomeMy WebLinkAboutApplication and WC TOWN OF YARMOUTH BOARD OF HEALTH APPLICATION FOR LICENSE/PERMIT-2019 *Please complete form and attach all necessary documents by December 1 S 201 . NOTE:ALL BUSINESSES HITHLIQUOR LICENSESMUST RETURN FORMS BYNOVEMBER15(* Failure to do so will result in the return of your application packet. /� LOCATION ADDRESS: 5 v ��di c� / 3 TEL.#: r]�J q 3 MAILING ADDRESS: j 47 _ ( aa,G _ E-MAIL ADDRESS: / C ]/Y) OWNER NAME: r, ,-- Ce.11�y.r 0 4 Y>-Ay) ?..%%.. r CORPORATION NAME PLICABLE): t i 11* 1 C• 6 i t_ ,- MANAGER'S NAME: ' ;�I:- ,if / °tall TEL.#: 4.---# ; '- F i m-1'J J 5 F MAILING ADDRESS: /5-0/a “'tut-Ch lift r /p e e� 1'j I (}a(0 t7Z (11 -1:4POOL 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. g 1. 2. 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 m © G>� employees below and attach copies of their certifications to this form.The Health Department will not use past D years'records. You must provide new copies and maintain a file at your place of business. .- R I 1. 2. 0 iv ' 3. 4. Fiu - . U 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. I Please attach copies of certification to this application. The Health Department will not use past years'records. You m provide new copies and maintain a file at our establishment.R 1. `r i 4 / .1()r 1`e S(S/) / . r' ` F"`.17`"`r PERSON IN CHARGE: Each establishment must have at 1 one Person In Charge(PICC site during hours of operation. /� /y 1. IAV r!50 1 7; (lei poi nark 2. / �-4i c/a lent r/C / /u`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, 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 provid ew copies and maintain a file at your establishment. i 1. G Yic16 /CPh f-1 l ed`JaA. 4011 c ix 7 • /tIeP; m'11 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. 2. 3. 4. C} RESTAURANT SEATING: TOTAL# 3 t OFFICE USE ONLY T LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $110 -I; - GE S55 CAMP $55 _SWIMMING POOL S110ea. \ _TRAILER PARK $105 WHIRLPOOL $110a. .3 FOOD SERVICE: LICENSE REQUIRED FEE P # LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 1 0-100 SEATS $125 aCONTINENTAL $35 NON-PROFIT $30 >100 SEATS $200 !,COMMON VIC. $60 */47-6'fOIDKITCHEN$80� RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50:..ft. 550 >25,000 ft. $285 VENDING-FOOD $25 --<25,111 sq.ft. $150 - TFROZ EN DESSERT$40 TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE = $ 2.2.5.00 PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM lZk The Commonwealth ofMassachusetts =.� Department ofIndustrial Accidents '�—_=1;i,_' � Office of Investigations • . ,..-7__,..„---:!1'-_; 1 Congress Street;Suite 100 "= Boston,MA 02114.2017 �~ www massgov/did Workers' Compensation Insurance Affidavit: General Businesses { Applicant Information Print Legibly ' Business/Organization Name: fi 1 L, 1 2 .® t ! i! ' Address: / 9 , '�-- ,ce Ya v �) 7 - 7 7f- 93�Clty/State/Zlp: ��- � �- ane#: Are yo n employer?Check the appropriate box: Business Type(required): 1.L1L'I am a employer with / 2- employees(full and/ 5. 0 Retail or parttime).* 6. ❑Restaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7. 0 Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers' comp.insurance required] 8. El Non-profit 3.❑ We are a corporation and its officers have exercised 9. 0 Entertainment their right of exemption per c. 152,§1(4),and we have 10.❑Manufacturing no employees. [No workers' comp.insurance required]*' ❑Health Care 4.❑ We are a non-profit organization,staffed by volunteers, 11. He - C with no employees. [No workers'comp.insurance req.] 12. Other __-)-) Ce 14e--0-41"- /4-26/0 *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 corporation has other employees,a workers'compensation policy is required and such an organization should chedc box#1. I am an employer that is pro ' ' g workers' mp n insurance for my employees. Is the policy information. Insurance Company Name: �V vVl �VYI 1 lnn l 5 CO /,� 1 Insurer's Address:Atte.„--. 1' / l Ct V �( S j I l� / t , e-i Imo,, y� 1 City/State/Zip: Li'0 V► �(J` I Yl]S f- C S 41ti� l r ( I l A 4'0A 6p 3- Policy#or Self-ins.Lic.# ao o I V V 16 l7 1p Expiration Date: I - -o I —V`"'I I Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration 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 to$1,500.00 and/or one-year imprisonment,as well as civil 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 c ►,under Date:. the pains and penalties of perjury that the information provided above is true and correct. a, l ? Signature:,r h,t,C.r� 4.4141-'97}/XiCh��L�/I'l� �.t�J, / , Phone#: 5f 91/Y-419 Official use only. Do not write in this area,to be completed by city or town official 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.govldia r ` r� r �+ '',ct'�h .,," as c r3 ' � 2r ,��.. '`�� � �n � �' `� POLICY NUMBER:2001 W7976 SERVICED BY YOUR AGENT: 3020 MARK SYLVIA INSURANCE AGENCY LLC 404 MAIN ST CENTERVILLE MA, 02632-2916 ISSUED TO: PENQUINS GOT THE SCOOP LLC 15 BLACK WATCH WAY MASHPEE, MA 02649-2215 IN WITNESS WHEREOF, the Company has caused this policy to be signed by its President and Secretary, but if required by state law, this policy shall not ibe valid unless countersigned by a duly authorized representative of the Company. 7,-z-- 4 . (-4-22.14Y4 Secretary President To Notify Us Promptly of a doss, Please Call 1-800-948-3276. Thank You. X-4971 (04/16) 2001 W7976 10-29-2018 22:05:41 AC NOTICE NOTICE r =Fi TO - marls =e,. TO _I_ EMPLOYEES ," ' t -z- EMPLOYEES 1ii`� q> MO - The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 1 Congress Street, Suite 100, Boston, Massachusetts 02114-2017 617-727-4906- 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: Farm Family Casualty Ins. Co. NAME OF INSURANCE COMPANY P.O. Bo)656, Albany, New York 12201-0656 ADDRESS OF INSURANCE COMPANY 2001 W7976 12-01-2018 POLICY NUMBER I EFFECTIVE DATES MARK SYLVIA.INSURANCE AGENCY LL(404 MAIN ST,CENTERVILLE MA, 02632-2916 508-428-0440 NAME OF INSURANCE AGENT j ADDRESS PHONE# PENQUINS GOT THE SCOOP LLC 15 BLACK WATCH WAY, MASHPEE, MA 02649-2215 EMPLOYER , ADDRESS EMPLOYER'S WORKERS' COMPENSATION OFFICER (IF ANY) DATE MEDIAL 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 reasqnable hospital and medical services in accordance with the provisions of the Workers' Compensation Act. A copy of the First Report of Injury 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 jury. In cases requiring hospital attention, employees are hereby notified that the insurer has arrang d for such attention at the NAME OF HOSPITAL ADDRESS TO BE PO$TED BY EMPLOYER '., 2001 W7976 10-29-2018 22:05:41.00