HomeMy WebLinkAboutApplication 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.
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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
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.
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PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge(PIC)on site/during hours of operation.
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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. /�
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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#
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