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Home My WebLink AboutApplication and WCr TOWN OF YARMOUTH BOARD OF HEALTH k APPLICATION FOR LICENSE/PERMIT-2019 *Please complete form and attach all necessary documents by December 15,2018. NOTE;ALL BUSINESSES WITH LIQUOR LICENSES MUST RETURN FORMS BY NOVEMBER I56. Failure to do so will result m the return of your application packet. ESTABLISHMENT NAME: 6101, a/A ?' ',0,-1 -- LOCATION ADDRESS: J // dGerf° '1Ot r.1 7$ ‹:6 5/eke'',aciit TEL.#: 59 — 39k— 72,00 MAILING ADDRESS: 5'ia m e O 246 y E-MAIL ADDRESS: 1Jarmor...—L4- 4.42A&J,'iyj a, 60/yj OWNER NAME: 01/6n 1/ac'Pv 11-5 Z,j,"VIO ' CORPORATION NAME(IF P ICABLE): SP / '>O MANAGER'S NAME: 6i' TEL.#: �O$ - 39'fi 72.0L, MAILING ADDRESS: 13// /y° 2 gr S Q c9 26-G'. 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 D CC.) Cardiopulmonary Resuscitation(CPR),having one certified employee on premises at all times. Please list the r 2employees below and attach copies of their certifications to this form.The Health Department will not use past = - 1 yearsrecords. You must provide new copies and maintain a file at your place of business. 1.3. 2. '° 00 0 4. '-i 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. P You must provide new copies and maintain a file at your establishment. 1. van 44/ c4ev 2. %mac G/cz./b'ca o4,4, PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC)on site/during hours of operation. 1. /l/a/ /�1�octil°v �Oca (/(2. /, .s70a4 ALLERGEN CERTIFICATIONS: ...q 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 establishment. /� 1. &ex/y-a i/ce./f Q novo 2. Ar S/G v ?- , //X10.2v' 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. dal- /a�' 7 V/60 2. `mac !/e,6aoZDv4 3. 4. RESTAURANT SEATING: TOTAL# LODGING: OFFICE USE ONLY oovtRo-(gSU-0Zi LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT 4 B&B $55 CABIN $55 MOTEL $110 —LOD $55GE $55 CAMP $55 _SWIMMING POOL$110ea TRAILER, PARK $105 WHIRLPOOL $110ea FOOD SERVICE: LICENSE REQUIRED FEE RESIMITALICENSE REQUIRED FEE PERMIT 4 LICENSE REQUIRED FEE PERMIT 4 j_0-100 SEATS $125 Of -(( Z CONTINENTAL $35a NON-PRO IT $30 >100 SEATS $200 J_COMMON VIC. $60 �V WHOLESALE $80 RETAIL SERVICE: —RESID.KITCHEN$80 LICENSE REQUIRED FEE PERMIT 4 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# ,_<50 sq.ft. $50 >25,000ft. $285 VENDING-FOOD $25 ,_<25,000 sq.ft. $150 FROZEN sq. $40 ^TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE = $ 185.4p *****PLEASE TIM"'nvIR AND COMPLETE OTHER SIDE OF FORM***** ADMINISTRATION j 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 to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: NO YES 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 bei 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 opening.Health PLEASE NOTE:Perior to ople afire NOContact allowed to ith s t in he pool area until the poolent to schedule the inspection threehass been inspected and opens prior opened. to POOLed lab,rER TESTING: The water and submitted to the Health Departmentt be ted for three(3)days priopseudomonas, to opening,antotal d and th tphereafter. ount by a State certifiPOOL 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.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 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 REQ A SITE PLAN. DATE: /2- /7 /1' SIGNATURE: PRINT NAME&TITLE: ./v /67// Giv Rev.10/23/18 SZk The Commonwealth of Massachusetts I!, Department of Industrial Accidents _. iii!-=,AY/ Office of Investigations • — 1 Congress Street,Suite 100 ' - `' Boston,MA 02114-2017. :'',="1 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: 11),) Ll CO(' a N ou-N1n kAo O4- Address: 61U1 City/State/Zip: COEt�1 y d'(`'fl'rola, In OX6IfPhone#: o g -44.624:1- 6.kLiu Are you an employer?Check the appropriate box: Business Type(required): 1. I am a employer with 4 employees(full and/ 5. 0 Retail or part-time).* 6. ®RestaurantBar/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. ❑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 10.0 Manufacturing no employees. [No workers'comp. insurance required]" 4.❑ We are a non-profit organization,staffed by volunteers, 11'0 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 that is providing workers'compensation insurance for my�employees. Below is the policy information. Insurance Company Name: , 6i4/ ! dec:/%0,1-2 ,it 01tA c/ Insurer's Address: ZU �/' t c SZL City/State/Zip: ed4a,/,-)n7 i9 Q 2.0 Policy#or Self-ins.Lic.# Gs/E/7/5 OI Expiration Date: /ic/ 2—o r,9 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 certify,under pains and penalties of perjury that the information provided above is true and correct. Signature: Date: /2 . /7 , / Phone#: (5-0g)5 7 — 72.690 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.gov/dia Policy Number WE171540A NORFOLK & DEDHAM MUTUAL FIRE INSURANCE COMPANY WORKERS COMPENSATION CLASSIFICATION SCHEDULE State of: MASSACHUSETTS Named Insured B&I CORP DBA YARMOUTH HOUSE OF Effective Date: 09/15/2018 PIZZA 1 , Agent Name BENSON, YOUNG & DOWNS INS AGCY Agent No. 20412:013A.M. Eastern Standard Time L. Rates Deviation Estimated Classification of Operation Code Annual Per$100 of Factor Annual No. Remuneration Remuneration Premium LOC #1 B&I CORP DBA YARMOUTH HOUSE OF PIZZA FEIN # 40 BARNBOARD LANE WEST YARMOUTH MA 02673 PIZZA SHOP (9079) 9079 $ 25,305 1.03 1.00 $ 261.00 PIZZA SHOP (9079) 9079 $ 25,305 1.03 1.00 $ 261.00 PIZZA SHOP (9079) 9079 $ 34,625 1.03 1.00 $ 357.00 WC 89 04 15 INSURED COPY I Policy Number WE171540A NORFOLK & DEDHAM MUTUAL FIRE INSURANCE COMPANY WORKERS COMPENSATION CLASSIFICATION SCHEDULE State of: MASSACHUSETTS " Named Insured B&I CORP DBA YARMOUTH HOUSE OF Effective Date: 09/15/2018 ki PIZZA 12:01 A.M., Eastern Standard Time .tr Agent Name BENSON, YOUNG & DOWNS INS AGCY Agent No. 20413 Rates Deviation Estimated Code Annual Per$100 of Annual Classification of Operation No. Remuneration Remuneration Factor Premium MA - STATE SUMMARY TOTAL CLASS PREMIUM $ 879.00 TOTAL SUBJECT PREMIUM $ 879.00 TOTAL MODIFIED PREMIUM $ 879.00 STANDARD TOTAL $ 879.00 EXPENSE CONSTANT 0900 $ 250.00 TERRORISM RISK INSURANCE .0300 9740 $ 26.00 EXTENSION ACT PREMIUM SUBTOTAL $ 1,155.00 MA DIA ASSESSMENT .0383 9751 $ 34.00 FINAL TOTAL $ 1,189.00 POLICY TOTAL ESTIMATED COST $ 1,189.00 WC 89 04 15 INSURED COPY Policy Number WE171540A NORFOLK & DEDHAM MUTUAL FIRE INSURANCE COMPANY SCHEDULE OF FORMS AND ENDORSEMENTS Named Insured B&I CORP DBA YARMOUTH HOUSE OF Effective Date: 09/15/2018 PIZZA 12:01 A.M., Eastern Standard Time g. Agent Name BENSON, YOUNG & DOWNS INS AGCY Agent No. 20413 WORKERS COMPENSATION FORMS AND ENDORSEMENTS LOC SCHED SCHEDULE OF LOCATIONS WC 00 00 00 C INSURANCE POLICY WC 00 03 10 SOLE PROP, PARTNERS, OFFICERS, OTHER COV WC 00 04 04 PENDING RATE CHANGE ENDT WC 00 04 14 NOTIFICATION OF CHANGE IN OWNERSHIP ENDT WC 00 04 22 B TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT DISCLOSURE ENDORSEMENT WC 20 03 01 MA LIMITS OF LIABILITY ENDT WC 20 03 02 A MA ASSESSMENT CHARGE WC 20 03 03 D MA NOTICE TO POLICYHOLDER ENDT WC 20 03 06 B MA LIMITED OTHER STATES INSURANCE WC 20 04 01 MA PENDING PREMIUM CHANGE ENDT WC 20 04 05 MA PREMIUM DUE DATE ENDT WC 20 06 01 A MA CANCELLATION ENDT WC 20 06 04 MA POLICY DEFINITION ENDT WC 88 20 01 C MA DEPARTMENT OF INDUSTRIAL ACCIDENTS WC 89 04 15 WC CLASSIFICATION SCHEDULE WC 89 06 14 SCHEDULE OF FORMS AND ENDTS WC 89 0614 INSURED COPY