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Home My WebLink AboutApplication and WC RECEIW TOWN OF YARMOUTH BOARD OF HEALTH £ '; APPLICATION FOR LICEN *Please complete form and attach all nece , _ i�S'��d a p/ !.., 1;'t ; i o p :ALL BUSJ FS.SES WITH QU RLI :0 *ETU _1;',.':I . � Q !'Le1�Z4. Failure to do so will result m the return of your application packet. ESTABLISHMENT NAME: EMI:L. TH PFI GUIS1 NE TAX ID- LOCATION ADDRESS: t5 Lilt MitE 2% ESI vt'( ) TN Mtt bibi3 TEL.#: b f--+-0,0-145-4. MAILING ADDRESS: 5140 UT L g 1NT y tZM 0aN MPt 0 9 6+3- E-MAIL ADDRESS: P CH Pc— 60 H.of M pts. . C0 p OWNER NAME: ? MHP SO to CAA Pt 12.0E N CORPORATION NAME(IF APPLICABLE): MANAGER'S NAME: 1\11)1'1\110-A ilt S EVTINMNSVI\11-0 FA TEL.#: O'-2g0 - OgI3 MAILING ADDRESS: 2q0 MST R let N StPEET RPT- 319 1-14 c NNIS k Pc 0260 l 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. 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 onses at all times. Please list the employees below and attach copies of their certifications to this form.The 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. 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. %krNICH N SEMI\NNS 1 NA-bghl 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. 1. N UTNICH R SEOTNKSrJ t 1N 2. ?!-KCIN S OMICTI CH PPKO&N 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(GX3)(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. NU "NCHN SEDTR IRSvNom 2. 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. N O-1\1R -4 R SEtTNN U WIV N 2. PKRH A SOW,K t C,1-1 M7NON 3. 4. RESTAURANT SEATING: TOTAL# 31' boaF-t 5-12-87-0-( OFFICE USE ONLY LODGING: 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$110ea. =LODGE $55 TRAILER PARK $105 WHIRLPOOL SI l0ea—"— FOOD SERVICE: LICENSE REQUIRED Fr& P # LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 1_0-100 SEATS $125 CONTINENTAL $35 NON-PRO $30 >100 SEATS $200 J _CONTINENTAL VIC. $60 436(5WHOLESALE $80 RETAIL SERVICE: --RESID•KITCHEN $80 _,---.,__, LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 ..ft. $50 >25 000 ft $285 VENDING-FOOD $25 __<25,i s s sq.& $150 FR(ZENDESSERT $40 'TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE = S i 8 5.bb *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** 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 V 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 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 to opening. Contact the HealthDepartment to schedule the inspection three(3)days prior to opening.PLEASE NOTE:People are NOT allowed to sit in theoarea 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 closing. FOOD SERVICE 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 prior to the catered event These forms can be obtained at the Health Department,or from the Town's website at www.yarmouth.m&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 m 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: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. 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. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15,2018. 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 A SITE PLAN. DATE: 4 21 "11201 y- SIGNATURE: 1 cJ PRINT NAME&TITLE: jizie4 l 1 C4-I -D N Rev. 10/23{18 The Commonwealth ofMassachusetts — Department ofIndus�►1 Accidents = 7`':.' Office oflnv�estigations ; 7nom 1 Congress Street,Suite 100 - ,= Boston,MA 02112017. 1 •: www.mass.g v/alfa Workers' Compensation Insurance Affidavit: General Businesses ,A nulicant Information Please Print Legibly Business/Organization Name: PtST1 Th.NI CUI ST N E Address: 514 R4 UTE 2 City/State Zip: KEST N NWO UTh I\4 I t 02113Phone#: 5-0 3 — -ct 0 1 C1 51- Are you an employer?Check the appropriate box: Business Type(required): 1.12I I am a employer with 2. employees(full and/ 5. 0 Retail or part-time).* 6. [ Restaurant/Bar/Eating Establishment 2.0 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. ❑Non-profit 1❑ We are a corporation and its officers have exercised 9. 0 Entertainment their right of exemption per c. 152,§1(4),and we have 10.0 Manufacturing no employees.[No workers'comp.insurance required]" 11.❑Heal h Care 4.0 We are a -profit organization,staffed by volunteers, with no employees.[No workers'comp..insurance req.] 12.0 Other *Any applicant that checks box dl must also fill out the section below showing their wodrers'compensation policy information. **Ifthe corporate officers have exempted themselves,but the=Pension has other eacloyees,a workers'compensation policy is rem and such WI organization should check box CL I am an employer that is providing workers'conspensation insurance for my employees. Below is the policy information. Insurance Company Name: NC INS°KAHN CE COMI - Insure is Address: ?•U. 460X 59,14 3 city/statemp: MINNEPPOLIS MN 55 Lt. q Policy#or Self-ins.Lic.# M Pr K P 301 a 4'1 Expiration Date: 041 3 1 120'10 . 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for ins uame coverage verification. Ido hereby certify,under the pains andpamides of perjury that the information provided above is true and correct. Sim 'Te.--( DDate: 1111 1241 Phone#: VO$- T°tt) -1°15-4 Official use only. Ito not write In this area,to be completed by city or town officha City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Banding Department 3.City/Town Clerk 4.Licenshl Board 5.Selectmen's Office 6.Other Contact Person: Phone#: www.mass.gav/dia NOTICEg :=- NOTICE .1104.5 TO TO EMPLOYEES EMPLOYEES The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 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: Acadia Insurance Company NAME OF INSURANCE COMPANY P.O.Box 59143,Minneapolis,MN 55459-0143 ADDRESS OF INSURANCE COMPANY MAARP301949 07/31/2018 POLICY NUMBER EFFECTIVE DATES Kerry Insurance Agency Inc PO Box 1945 North Eastham,MA 02651 5082558000 NAME OF INSURANCE AGENT ADDRESS PHONE# PRACHA SOMKITCHAROEN dba:BASIL THAI CUISINE,594 MAIN STREET,WEST YARMOUTH,MA 02673 EMPLOYER ADDRESS 06/18/2018 EMPLOYER'S WORKERS' COMPENSATION OFFICER(IF ANY) DATE MEDICAL 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 reasonable 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 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 EMPLOYER MA 2585(8/07)