HomeMy WebLinkAboutApplication and WC TOWN OF YARMOUTH BOARD OF HEALTH
APPLIC4TION FOR LICENSE/PERMIT-2019
_ *Please complete tbrm and attach all documents by Dib 15 Z
NOTE:ALL BUSINESSES WITH 0,8LIi�STRIsTURNFORM 13''
Failure to do so will t m the return o your application packet.
ESTABLISHMENT NAME: -1-IN ti t 5 P 0....7.t4 TAX ID:
LOCATION ADDRESS: S`1"J M1giLJ T TEL.#:3 )g' 77Ji 333
MAILING ADDRESS: S.44-1 11 41 N VT' lilt.V LZ/1114ety 3 h> MLI..617 6.13
E-MAIL ADDRESS:
OWNER NAME: '/ E1,g" 1/4 r2. 7 7 +4 CLC
CORPORATION NAME(IF APPLICABLE):
MANAGER'S NAME: TEL.#: P'231"- -
MAILING ADDRESS: 3-2 f1LV Set ill• JI 12r1 yeq 11.11/4#2W17/22,-0 7- /Ll Ai.192Z ` S
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 m F
Cardiopulmonary Resuscitation(CPR),having one certified employee on p at all times. Please list the
employees below and attach copies of their certifications to this form.The H�Department will not use past rD-
years'records. Yon must provide new copies and maintain a file at your place of business. _ c G,
1. 2. 0 IVrn o Iii Il
3. 4. ccoo
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. 2.
PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. n_ -` '`7%'
1. 2. '',1
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. You must
provide new copies and maintain a file at your establishment.
1. crEve p. 141Ar"7-/rV s- 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. /
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RESTAURANT SEATING: TOTAL#
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMITS LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
B&B $55 CABIN $55 MOTEL $110
—INN $55 CAMP $55 SWIMMING POOL$I10ea
BODGE $55 =TRAILER PARK $105 =WHIRLPOOL S110ea
FOOD SERVICE:
LICENSEFEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIREDFEE PERMIT S
_p,_0-100 SEAEATSS $125 CONTINENTAL $35 NON-PROFIT $30
>100 SEATS $200 COMMON VIC. $60 --WHOLESALE $80
=RESID.KITCHEN$80
RETAIL SERVICE:
LICENSE REQUIRED FEE PERMIT S LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
<50 aq.R. $50 >25,000 IL $285 VENDING-FOOD $25
=F. DE
=<25,000 sq.tt $150RdZENDESSERT$40 'OBACCO $110
NAME CHANGE: $15 AMOUNT DUE = S 185.66
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 to wal 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 prior to opening. Contact the Health Department to schedule the inspection three(3)days prior to
opening.PLEASE NOTE:People are NOT allowed to sit in die pool area until the pool has been inspected and opened.
POOL WATER TESTING: The water must be tested for p mons,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 . 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.yarnouth.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 nm 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 A S TE PLAN.
DATE: /• ZS - if SIGNATURE: I
PRINT NAME&TITLE:& ()E P, ilefre51 J>A-9 O'•(
Rev.10/23/111
The Commonwealth of Massachusetts
Department of Industrial Accidents
1. —77------7-7.4f7--
=_ �_ .� Office ofinvestigations
n= 1 Congress Street,Suite 100
- '— Boston,MA 02114 .2017.
www mas&gov/dia
Workers' Compensation Insurance Affidavit General Businesses
Auolicant Information Please Print LeEibly
Business/Organization Name: 174 6(c P12z.6'
Address: 5x-ii 11m4 1 4/ Si--, Lei Yrnn-m rxi+Lt, /vl pg .
X2676
City/State/Zip: Phone#: 5-O • 7 7 1 • ? 3 3 I
Are yyoo an employer?Check the appropriate box: Business Type(required):
1. la I am a employer with 6 employees(full and/ 5• 0 Retail
or part-time).* 6. 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. ❑ o
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]** 11.0 Health Care
4.0 We are a non-profit organization,staffed by volunteers,
with no employees.[No workers'comp.insurance req.] 12.0 Other
'Any applicant that thetics 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
orgion should check box#1.
I am an employer that is providing workers'compensation insurance for my employees. Below le the policy information.
Insurance Company Name: /3/YieR/CCIV .g j/21 edi l ;S V f le
Insurer's Address:
City/State/Zip:
Policy#or Self-ins.Lic.# Expiration Date:
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 the pains and penalties of that the information provided above is true and correct.
Signature: f, - Date: /• . - 1
Phone#: S^O e, 8`S9.49'g'eYd
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#: Q
v
www.mase.gov/dia
POLICY NUMBER: (6ZZUB-0762N00-8-18)
RENEWAL OF (6ZZUB-0762N00-8-17)
INSURER: AMERICAN ZURICH INSURANCE COMPANY
NCCI CO CODE: 17965
1.
INSURED: PRODUCER:
VARETIMOS, STEVE DBA CHAGNON INS AGENCY INC
TAKIS PIZZA P 0 BOX 355
547 MAIN STREET ROUTE 28 WEST YARMOUTH MA 02673
WEST YARMOUTH MA 02673
Insured is AN INDIVIDUAL
Other work places and identification numbers are shown in the schedule(s) attached.
2. The policy period is from 05-22-18 t0 05-22-19 12:01 A.M. at the insured's mailing address.
3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers
Compensation Law of the state(s) listed here:
MA
B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed in
item 3.A. The limits of our liability under Part Two are:
Bodily Injury by Accident: $ 100000 Each.Accident
Bodily Injury by Disease: $ 500000 Policy Limit
Bodily Injury by Disease: $ 100000 Each Employee
C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here:
COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06B
D. This policy includes these endorsements and schedules:
SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE
4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating
Plans. All required information is subject to verification and change by audit to be made ANNUALLY.
DATE OF ISSUE: 05-24-18 WC ST ASSIGN: MA
OFFICE: ZURICH-ORLAN 809
PRODUCER: CHAGNON 'INS AGENCY INC 73CGR '
010823