HomeMy WebLinkAboutApplication and WC *-1`.mi.; OF YARMOUTH BOARD OF HEALTH
,. ` APPLICATION FOR LICENSE/PERMIT-2019
__ *Please complete form and attach all necessary documents by i r 15 2 1 .
ALL BUSESWITHLJ�QQUQI ERIS'r
Failure to do so will result in the n
ESTABLISHMENT NAME: 15 ArARIS V. 1T'Y‘AtTAX ID:
LOCATION ADDRESS: f.i L1 2e. .2.1, W/a/f 8t& MA Q24,TEL.#: oB 790 SSO'o
MAILING ADDRESS: l\ 13
E-MAIL ADDRESS: pokay CC ®Tool,ft vV\
OWNER NAME: c
CORPORATION NAME(IF APPLIC x B( Q,IS f '-C LLC
MANAGER'S NAME: TEL.#: cOt 361t14i, _ = ED
MAILING ADDRESS: 'Wt SaWiptirCae‘ Fel W vc t, f 83" m RI
POOL CERTIFICATIONS: I——4o R
The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designatec = (-7/ o
Pool Operator(s)and attar a copy of the certification to this form. m o c
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Pool operators m list a minimum of two employees currently certified in standard First Aid and Community
Cardiopulmonary Resuscitation(CPR),having one certifiedloyee 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 vide new copies and maintain a file at your place of business.
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FOOD PROTECTION MANAGERS-CERTIFICATIONS:
All food service establishments are required to have at least one full-time employee who is certified as a Food E (
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. '':s
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new copies and maintain a file at your establishment.
i. MS�dm"! ID. /S 2.
PERSON IN CHARGE:
Each food establiis�hmestablishment Qin vea�t least one Person In Charge(PIC)on site during hours of operation.
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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(GX3Xa). Please attach
copies of certification to this application. The Health Department will not use past years'records. Yon must
provide new and m taa file at your establishment.
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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.
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RESTAURANT SEATING: TOTAL# 1 lc Qy 64k-F-‘8-O OZ(-0(
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMITS LICENSE REQUIRED FEE PERMIT it LICENSE REQUIRED FEE PERMIT it
B&B $55 CABIN $55 MOTEL. SI10
INN $55 CAMP $55 =SWIMMING POOL S110ea
_LODGE $55 =TRAILER PARK $105 _WHIRLPOOL $Moen
FOOD SERVICE
LICENSE REQUIRED FEE PERMIT# LICENSEREQUIREDFEE PERMITS
IRED $125 T
>100 SEATS $200 45
—RESID.KITCHEN S80
RETAIL SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_� $50 >25,000 .R. $285 VENDING-FOOD$25
aq A 5150 =FROZEN DESSERT 540 --TOBACCO S110
NAME CHANGE: $15 AMOUNT DUE = S 1111 _
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
Town of Yarmouth taxes and liens must be paid prior renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES NO
MOTELS AND OTHER LODGING ESTABLISHMENTS
TRANSIENT OCCUPANCY: For purposes ofthe 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 prior to opening. Contact the Health Department to schedule the inspection three(3)days prior to
opening. LEASE 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 pseuds,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 . q• the required
Temporary Food Service Application form 72 hours prior to the catered event These forms can be . - at the Health
Department,or from the Town's website at www.varmouth.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 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 Ito 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 CO C T'. RENOVATIONS MAY A SITE PLAN.
DATE: i SIGNATURE: 11.
PRINT NAME&TITLE: M (.) Uu< y Qi) l
Rev.10v23n1
The Commonwealth of Massachusetts
Department oflndustrialAccidenls
,• _'_k= ., Office oflnvestigations
__ 'I=_" 1 Congress Street,Smite 100
• - �'_ _ Boston,MA 02114-2017
_.�,. www.mass.gov/dia
Workers' Compensation Insurance Affidavit General Businesses
ADDlicant Information Please Print Legibly
I
Business/Organization Name: DLL:,_ ji:.,,ilk/, CCL - • ` : • B • , 5 3 6"
s ori
Address: j 1. l 4Q
City/State/Zip: c�Q/fAA 61.1 11W O -(2'73Pbone#: CS O i •, g5co
Are you an employer?Check the appropriate box Business Type(required):
14 ' I am a employer with employees(full and/ 5. 0 Retail
or part-time).* 6Restaurant1Bar/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.
workers'compinsurance 8. ❑Non-profit i
[� � required] i
3.0 We are a corporation and its officers have exercised 9. 0 Entertainment
their right of exemption per c. 152,§1(4),and we have ia.0 manufacturing
no employees.[No workers'comp.insurance required]**
4.0 We are a non-profit organization,staffed by volunteers, 1,.❑Health Care
with no employees.[No workers'comp.insurance req.] 12.0 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 corporation has other employees,a workers'compensation policy is required and such an
organization should check box#1.
I am an employer thatis workers' . , „ insurance for my employer& Below is Eke policy information.
Insurance Company Name: -( h- VL + 1' s
Insurer's Address: . 10iWit
City/State/Zip: 'j 4ivj, MA C0Z10
Policy#or Self-ins.Lic.# W E Il 1-514 A Expiration Date: -7162 11 I
Attach a copy of the workers'compensation policy declaradon 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.
Ido hereby . „ under acre pains , , .'r „ ,of - tate information provided above is true and correct.
Sim: ( I \ Date: (a►., l 1./1 g
.% no
I
Phone#: a -790
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#:
t
www.mess.gov/dia
THE INSURANCE AGENCY
OF CAPECODC
July 18,2018
Bagels Beyond CC LIC
311 Route 28
West Yarmouth MA 02673
RE: Workers Compensation
7/6/2018 through 7/6/2019
Dear Mike:
Enclosed you will find your new Workers Compensation policy effective 7/6/2018 written with Norfolk&
Dedham Group.
Please take a moment to review the policy paying special attention to the coverage's and exclusions to be
certain the policy provides you with the appropriate coverage's needed for your business. Also,please
notify our agency if there is any change in the operations of your business through out the policy term.
After review of the policy should you find any changes are required or you would like to review the policy in
greater detail together please do not hesitate to call our office.
We appreciate the opportunity to provide you with this important coverage and look forward to providing
you with exceptional customer service.Please keep in mind we are a full lines agency capable of assisting
you with all your insurance needs and would be happy to review your entire account.
Thank You.
Sincerely,
-co:44j
Etiysia Moreis
Phone(508)888-2766 www.insuranceoncapecod.com Fax(508)833-0909
WORKERS COMPENSATION AND EMPLOYERS'LIABILTY
INSURANCE POLICY—INFORMATION PAGE
INSURER: POUCY NO: WE187314A
NORFOLK & DEDHAM MUTUAL FIRE INSURANCE COMPANY
222 AMES STREET NEW BUSINESS
DEDHAM, MA 02026 NCCI Company No: 21059
Account No:
hitt
FEIN:
ITEM 1. NAMED INSURED AND MAILING ADDRESS: AGENT NAME AND ADDRESS:
BAGELS BEYOND CC, LLC THE INS. AGCY OF CAPE COD
311 ROUTE 28 PO BOX 1053
W YARMOUTH, MA 02673 SANDWICH, MA 02563
AGENT NO.: 20110
LEGAL ENTITY: LIMITED LIABILITY COMPANY (LLC)
OTHER WORKPLACES NOT SHOWN ABOVE: (See Workers Compensation Classification Schedule)
ITEM 2. POLICY PERIOD:From: 07/06/2018 To: 07/06/2019
Effective 12:01 A.M.Standard Time at the Insured's mailing address.
ITEM 3. COVERAGE:
A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the
states listed here:
MA
B. Employers'Liabilfty Insurance: Part Two of the policy applies to work in each state listed in Item 3A The limits
of liability under Part Two are:
Bodily Injury by Accident: $ 100,000 each accident
Bodily Injury by Disease: $ 500,000 policy limit
Bodily Injury by Disease: $ 100,000 each employee
C. Other States Insurance: Part Three of the policy applies to the states, if any,listed here:
SEE ENDORSEMENT WC 20 03 06 B
D. This Policy includes these Endorsements and Schedules:
See Schedule of Forms and Endorsements.
ITEM 4. PREMIUM:The premium for this Policy will be determined by our Manuals of Rules,Classifications,Rates and
Rating Plans. Allinformation required on the Workers Compensation Classification Schedule is subject to
verification and change by audit.
Total Estimated
Minimum Premium: $ 215 Annual Premium: $ 1,657
Audit Period:ANNUAL Additional/Return Premium:
Comments :
Issued At:
Date:07/03/2018 Countersigned by
WC 00 IM 01 A Copt 1987 National Council on Compensation Insurance