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Home My WebLink AboutApplication and WC *,..C� TOWN OF YARMOUTH BOARD OF HEALTH , ,.,iltikAPPLICATION FOR LICENSE/PERMIT-2020 V'�'' *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 WITHIJOUOR LICENSES MUST RETURN FORMS BY NOVEMBER IP. ESTABLISHMENT NAME: _ • .,+' , . IE LOCATION ADDRESS: -. .0, . !,'/i• ..•. j TEL.#: Fes' g 79,5-O4 P. MAILING ADDRESS: SG.»s O 0.5 0 hip✓P e12 G,73 E-MAIL ADDRESS: /7-2.z.04,..6 C fp a ��YQ • fe rt OWNER NAME: AZ704Y� 14i?713 LI. CORPORATION NAME(IF APPL BLE): ' �if- :i=.eL,o, /tea�� MANAGER'S NAME: A// ,t. Q `,1,! "��Lgl I"TEL.#: • MAILING ADDRESS: , GL. - Gl bf✓Q„ -- A---v). a Litaoaeo POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operators)and attach a copy of the certification to this form. I z p 1 2. m c (,it 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�at all times. Please list the = co �n employees below and attach copies of their certifications to this form.The ealth Department will not use past 1 o Iii years'records. You must provide new copies and maintain a file at your place of business. lli _ `` 1. 2. 3. 4. FOOD PROTECTION MANAGERS-CERTIFICATIONS: 9r 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 establishmm�entt.��,� i!,� / 1. 439.ild., d?dam h1LC45 2. [��`�"E'�' l�Vf �(/k1 o PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. 713 1. Nif4 1./.10...0 2. liz.e4 ,4s1 0.athja el -wiii, 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. kJ.,1. .Ph j��,/ �O/U5 2. �J7t t iod a v.L iEL HEllk CH CER T II4CATIONS: 'CCIAkki.. e- C 0, 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 Dt will not use past years'records. You must providenewcopies and maintain a file at your place o business.Cs. /�_ p i. C�4_ ttbC�C1Ci 1Cr�Qt��> 5 2. e C U t-i i Yi c��o uo5 3. 4' RESTAURANT SEATING: TOTAL# ��& 604F-15—(036q_o5 OFFICE USE ONLY CADGING: LICENSE REQUIRED FEE5PERMIT# LICENSE REQUIRED QUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT _ _ —'SWIMMINGPOOL$11oea. —LODGE $55 TRAILER PARK 5105 _WHIRLPOOL $1 I0ea. FOOD SERVICE: REQUIRED LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQ T� $30 PERMIT# 0-100 SEATS $125 CONTINENTAL $35 --WHOLESALE ROIT $30 >I00 SEATS $200 /_4IIaL 2.. COMMON VIC. $60 Z�11Z� _REBID.KITCHEN 580 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICVENDINREQUIRED FOOD$25 PERMIT <S0 .ft. $50 >25,000 sq t. $285 --TOBACCO $110 -- _<25 I I•sq It. $150 .7:FROZEN DESSERT $40 NAME CHANGE: $15 AMOUNT DUE = S 21,00.00 *****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 r 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 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 prior to opening. Contact the Health Department to schedule the iaspecdon 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 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: y All food service establishments must be inspected b the Health Department prior to opening. Please contact the Health Department to schedule the inspection three(3)days prior to opening. CATERING POLICY: fi` ,_ the required Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department Temporary Food Service Application form 72 hours prior to the catered event These forms can be o at the Health Department,or from the Town's website at www.yarmouth.ma.us under Health Department,Downloadable Forms. FROZEN DESSERTS: with sample results submitted to Frozen desserts must be tested by a State certified lab prior to opening and monthly thereafter, P 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 Ito 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 ' QUIRE A SITE PLAN. DATE:1. 1) 1\,aQl G` SIGNATURE: . AlitI a s .►.a. a� . 1_11, PRINT NAME&TITLE: P be_kra. 'CL)9O. OS Rev.10115/19 l The Commonwealth of Massachusetts Department of Industrial Accidents iti...,_ 1„!--=11....a 't. Office of Investigations "- ' 1 Congress Street,Suite 100 ��, � gr c-,... =rim:;1_ Boston,MA 02114-2017 : www mass gov/dia Workers' Compensation Insurance Affidavit: General Businesses Please Print Legibly Applicant Information IP_ Business/Organization Name: a fa _ e a D • �e� ,..,_ Ma 01.fo ,2 Address: . a'. City/State/Zip: s ( ..A- .A..— +pt- Phone#: IA `-- _ ^ 04g • (required):(required):Are you an employer?Check the appropriate box: 5. 0 Business Retail Type1.❑ I am a employer with employees(full and/ or part-time).* 6. [i Restaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7. ❑Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. 8. ❑Non-profit [No workers'comp.insurance required] 3.0 We are a corporation and its officers have exercised 9. [J Entertainment their right of exemption per c. 152, §1(4),and we have 10.0 Manufacturing no employees. [No workers' comp.insurance required]** 11 ❑Health Care 4.0 We are a non-profit organization,staffed by volunteers, 12❑ with no employees. [No workers' comp. insurance req.] Other their workers'compensation policy information. *Any applicant that checks e#1 must also fill out the rporatione section below owing has other employees,a workers'compensation policy is required and such an s'If the corporate officers have exempted ______ organization should check box#1. — —,-- -- -- —v— compensation insurance for my employees. Below is the policy information. I am an employer that is providing workers' Insurance Company Name: f\ �L �" C M�:S 4-) Insurer's Address: 9, 0 , )c?( CI5 \off& — c a City/State/Zip: CV11M1 - . 1Th 0•._. OI' . Expiration Date: Policy# copy Self-ins.Lie.# declarationpage(showingthe policynumber and expiration date). Attach a of the workers'compensation policy sition of criminal penalties of a Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the impo fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER of this statement may be forwarded to th Office land a fine of up to$250.00 a day against the violator. Be advised that a copy Investigations of the DIA for insurance coverage verification. penalties of perjury that the information provided above is true and correct I do hereby eertify,under the pains and p Date: ►�,� ,_ �� Si '1attire' .i_1. .. 0 �. k+ _ a�. 1 4, i _�. Phone#: (1 4) cDaA - A 01 (S$) c - 1a fete. 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 Phone#: Contact Person: —_-- ----------- — — — www.mass govldia Workers Compensation and Employers Liability insurance Policy carrier P-' #: p.., .. Insurer ID No(a):343613 01/01/2019 to 01/01/2020 MA Retail Merchants WC Group inc. 014005030290419 k PO Box 888222 D22a Braintree,MA 02186-0000 Renewal Agreement Ca�� Prior- « Renee si 030290118 Agreement Information Page FEIN: Item 1: Named Insured and Address yowling&O'Neil Insurance Agency Azzaro Yarmouth,LLC o B Bx iS90 The Lobster Boat Restaurant PO PO x 190,MA 02604 681 Main Street Route 28 02$73` West Yannauth MA Other Workplaces Not Shown Above: See Schedule of Operations Additional Named Insured: See Additional Named Insureds if Appilcalbe Federal IDS: 3 Type of Business: Corporation20066639 !Bureau;s:34355 Risk ID: Fid ft:014005030290119 Unemployment ID�: Item 2.Policy Period The is from 12:01 AM on 01/01/2019 to 12:01AM on 01/01/2020 based on the insured's mailing period me zone. Item 3.Coverage: to the Workers Compensation Law of the states listed: A. Workers Compensation Insurance: Part One of the policy of our 1'�abitity under Part B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed In Item 3 A. The limits Two are: Bodily Injury by Accident $500,000.00 each accident Bodily injury by Disease $500,000.00 policy limit Bodily Injury by Disease $500,00000 each emPloYee C. Other States insurance: D. This policy includes these endoreements and schedules: 01/15),=000414(07/90),WGppp422B(01/15),NOE(01/01),WC200402(01/14),WC200301(04/84),WC200302A(09/08), WC200303D(08110),WC200306B(06f13),WC200405(06/01),WC200601A(07/08) item 4: PremiumRating Pins. M information required below will be determined by our Manual of Rules,Classifications,Rates and The Premium for the policy is subject to verification and change by audit. Rate Per$100 of Estimated Annual Premium Classifications Code# Premium Basis Total Estimated Remuneration Annual Remuneration See Schedule of Operations on Following Page(*) mated Annual Premium e�er�e C�stant Molt prorated piurn $0.00 $0.00 Minimum Premium _..... $1,269.00 $265.ea �1,269.00 Countersigned by: 12b.)`-.0'4(7 Form it WC 00 00 01 C (Ed.) p,�„ ,nt n insurance.inc.Ail Ricnts Reservstl, !�,rnn,,rnhf?nt't tdflSnnl,�r;rntre3f on C,AtriDlnSltiC . _