HomeMy WebLinkAboutApplication and WC 1` TOWN OF YARMOUTH BOARD OF HEALTH
�.7,i APPLICATION FOR LICENSE/PERMIT-2020
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*Please complete form and attach all necessary documents by December 13.2019.
Failure to do so will result in the return of your application packet.
NOTE:ALL BUSINESSES WITH LIOUOR LICENSES MUST RETURN FORMS BY NOVEMBER 15"'.
ESTABLISHMENT NAME: jr'rg QLD/ise /I l / /! / jTAX ID:
LOCATION ADDRESS: d"IA /f/fr iv cSl" At TEL.#: ,322e-7,r—lijK2
MAILING ADDRESS: 7t91-0/01114/1 I/ t9,1471E-MAIL ADDRESS: .L 3/ys� @ BL. 4'#qOWNER NAME: �j /44114W/,1 . ,g.vf4' AR,A9lr4440
CORPORATION NAME(IF APPLICA LE): ' {
MANAGER'S NAME: iP11 CJ9'Y'i, Ljjsja TEL.#:SWF-M=02,1)
MAILING ADDRESS: GI yok ' 1i,S7" AAA 6uGfrtysu(1,Amt 44 6ri
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 on premises at all times. PIease list the
employees below and attach copies of their certifications to this form.The Health Department will not use past
yearsrecords. You must provide new copies and maintain a file at your place of business.
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3. 4.
FOOD PROTECTION MANAGERS-CERTIFICATIONS: ire:
All food service establishments are required to have at least one full-time employee who is certified as a Food -ri r.'
Protection Manager,as defined in the State Sanitary Code for Food Service Establishments,105 CMR 590.000. -i c43 f=.
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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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:
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 59O.009(G)(3)(a). Please attach d
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.
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
`A(m'ustprrovide new copies and maintain a file at your place of business.f
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3. 4.
RESTAURANT SEATING: TOTAL# 1 CAF't`(r '0305—o
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$1 IOea.
LODGE $55 TRAILER PARK $105 WHIRLPOOL SI Ioea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
0-100 SEATS $125 _CONTINENTAL $35 NON-PROFIT $30
]>I00 SEATS $200 J_COMMON VIC. $601 —WHOLESALE WHOLESALE $80
—RESID.KITCHEN $80
RETAIL SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
<50 sq.& $50 >25,000 sq.ft. $285 VENDING-FOOD $25
<<25,000 sq.ft. $150 _FROZEN DESSERT $40 TOBACCO $110
NAME CHANGE: $15 AMOUNT DUE = $2..(4O.00)
*****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 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.MG or 830 CMR MG,as
amended,shall generally be considered Transient.
POOLS
POOL OPENING:A11 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 the pool area 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.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 13,2019.
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 SITE PL
DATE:/1 5- / SIGNATURE: (2
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PRINT NAME& 1'f CLE: Ea"'4it, -7
Rev.10/15/19
PALE/0,0
The Commonwealth of Massachusetts print Form
Department of Industrial Accidents
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7-_-_-7311t ' Office of Investigations
G gid `y 1 Congress Street,Suite 100
11 Boston,MA 02114-2017
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www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name: /#j 4 ,Ii,Jn (,J /moi , 1/, r,A4v/—
Address: .:;2 '.-az /7/9-/ni
Dat;
City/State/Zip: Wert j//ty#4?/// /t/4 Phone#: SSD(- 791 0jjj
Are yo an employer?Check t e appropriate box: Business Type(required):
1. I am a employer with /S- employees(full and/ 5. 0 Retail
or part-time).* 6. estaurantBar/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
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 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.] I2.0 Other
*My 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 i urance for my employees. Below is the policy information.
Insurance Company Name: L)6 P i1/I�Pte/ -,, -�V./411 'ce / c ti
Insurer's Address: A. to A.° QC /8 r�
City/State/Zip: 49 ti N TO Al i/ 4 Op& /e-e
Policy#or Self-ins.Lic.# f 6 / P3 Expiration Date: 9,//obc O
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 ce i ,under the pa' s and pen ties ofperjury t the information provided above is true and correct.
Signature: Date: /� —/y
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Phone#: 3t`-7.d Oi3?
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
.° 'Y0 THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
BUSINESS CERTIFICATE
Date Filed: August 27,2019 Certificate Type: Renewal
Expiration Date: August 26,2023 Certificate Fee: $30.00
Certificate Number: 2019-149 Original Filing Date: 3/7/1989
In conformity with the provisions of Chapter One Hundred Ten(110),Section Five(5)of the Massachusetts General
Laws,as amended,the undersigned hereby declare(s)that a business is conducted under the title of:
Business Title: Giardino's Family Restaurant
Business Address: 242 Route 28
West Yarmouth,MA 02673
Business Type: Restaurant
Business Owner(s): Owner(s)Address:
Edward A.Giardino,Jr 81 Trowbridge Path,West Yarmouth,MA 02673
SS/Tax ID#: 04-2490039
Signature(s):
In Accordance with the provision of Chapter 337 of the Acts of 1985 and Chapter 110,Section 5,of Mass General
Laws,business certificates shall be in effect for four(4)years from the date of issue and shall be renewed each four(4)
years thereafter. A statement under oath must be filed with the town clerk upon discontinuing,retiring,or
withdrawing from such business or partnership.
Copies of such certificates shall be available at the address at which such business is conducted and shall be furnished
on request during regular business hours to any person who has purchased goods or services from such business.
Violations are subject to a fine of not more than three hundred($300.00)and no/100 dollars for each month during
which such violation continues.
On August 27,2019 the above named person(s)personally appeared before me and made an
oath that the foregoing statement is true. 41110P 4111
111111.
Stephanie J. o
Notary Public
Clerk: Stephanie Cappello Commission
Expiration Date: November 12,2021
Worker's Compensation and Employer's Liability Policy
11
v 0Berkshire Hathawayce NorGUARD Insurance Company-A Stock Co.
Policy Number GIWC044696
GUARD Compare es Benewal of CCI No. [58441
Policy Information Page
[1]Named Insured and Mailing Address Agency
Giardino's Tastee Tower Inc. COMMONWEALTH INSURANCE PARTNERS LLC
242 Main Street 2 Heritage Drive
Yarmouth,MA 02673 Suite 301
North Quincy, MA 02171
Agency Code: MACOIN10
Federal Employer's ID Insured is Corporation
[2] Policy Period
From September 1, 2019 to September 1,2020, 12:01 AM,standard time at the insured's mailing address.
[3] Coverage
A. Workers'Compensation Insurance-Part One of this policy applies to the Workers'Compensation
Law of the following states: Massachusetts
B. Employer's Liability Insurance-Part Two of this policy applies to work in each of the states listed
in item[3)A. The limits of our liability under Part Two are:
Bodily Injury by Acddent-each accident $500,000
Bodily Injury by Disease-each employee $500,000
Bodily Injury by Disease-policy limit $500,000
C. Other States Insurance- Part Three of this policy applies to all states, except any state listed in
item [3]A. and the states of North Dakota, Ohio,Washington,and Wyoming.
D. This policy indudes these endorsements and schedules:
See Extension of Information Page-Schedule of Forms
[4] Premium
The Premium Basis and,therefore,the premium will be determined by our Manual of Rules,
Classifications, Rates,and Rating Plans. All required information is subject to verification and change by
audit. (Continued on another page)
•
Total Estimated Policy Premium $ 2,670
Total Surcharges/Assessments $ $78.00
Total Estimated Cost $ $2,748.00
INTERNAL USE 12797 Page- 1- Information Page
MGA :GIWC044696 WC 000001A
Date :08/23/2019
MANOTE
Issuing Office:P.O.Box A-H,39 Public Square,Wilkes-Barre,PA 18703-0020•www.guard.com