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Home My WebLink AboutApplication and WC TOWN OF YARMOUTH BOARD OF HEALTH APPLICATION FOR LICENSE/PERMIT-2020 *Please complete form and attach all necessary documents by December of your application e 13 2019. NOTE: Faket. ALL BUSINESSES WITH LIQUOR to do so will LICENSES in the Q T RETURN FORMS BY NOVEMBER 15m, ESTABLISHMENT NAME: Y 1e 13 ona Id is TAX 1D. </ LOCATION ADDRESS: /0/ K1TEL .i: , MAILING ADDRESS: -3/3 C/t tit r Si S)ee -16 N-YitoN- t a Oa:in-to EMAIL ADDRESS: ,i o'At I r 4 At ' /4 -A s , OWNER NAME: )1/la r k nif_n P CORPORATION NAME(IF APPLICABLE): MANAGER'S NAME: \J 1.14 L . S 1 -Loa I"EL.#: 54AP 3 9 -01363 MAILING ADDRESS: �.• •L .r r 11016, -.e s . ,.a, 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. '4 x7. 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. Please list the w employees below and attach copies of their certifications to this form.The Health Department will not use past � a years'records. You must provide new copies and maintain a file at your place of business. -7112 1. 2. 3. 4. NOV 122019 FOOD PROTECTION MANAGERS-CERTIFICATIONS: H =i_.T H 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. _ \/ LYltL1t 124 /veil 2. R1,Y►oL l i1�QT�Gt PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC)on she during hours of operation. 1, VVII fl i4-Stir 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. II 1. U 111.0,6 nits Lt lsdc 2, 'r,odZ_AL14..„ 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. I. L1 L 17 LC.,tiv-g NA S i t ift/ 2. AV r RESTAURANT SEATING: TOTAL# 60 4F--IS-ogZ4—0$ OFFICE USE ONLY SING, LICENSE REQUIRED FEE PERMITS LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT ERR $55 CABIN $55 MOTEL. $110 1N1+I $55 CAMP $55 —SWIMMING POOL$11Oca. _LODGE $55TRAILER PARK $105 WHIRLPOOL SI Ilea. FOOD SERVI LICENSE REQUIRED FEE P IT ti LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT _1_0-100 SEATS $125 0 __CONflNENTAL $35 NON-PROFIT $30 >100 SEATS $200 I COMMON VIC. $60 4•4713. S WHOLESALE $80 RETAIL SERVICE: —RESIT}KITCHEN $80 LICENSE REQUIRED FEE PERMIT if LICENSE REQUIRED FEE PERMIT S LICENSE REQUIRED FEE PERMIT S <50 ,ft. $50 >25,000 nit $285VENDING-FOOD$25 I -<25,e sq.ft. $150 FROZEN DESSERT$40 1•7:70•„, ar 'a:•3 T'roaACco $110 NAME CHANGE: $15 AMOUNT DUE _ $ ?'a .CO *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** , z 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 ANI)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 eustomarily 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 640,as amended,shaft generally be considered Transiert. 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 NOM: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: Al!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 wwwyarmolith.tukus 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 run annually from January 1 to December 31.IT ISYOUR 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 (Le. PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT, RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: If/7Ji cl SIGNATURE: PRINT NAME&TITLE; 10/15/19 The Commonwealth of Massachusetts _*vel_ I, Department of Industrial Accidents C _;71MI 1 Congress Street,Suite 100 4_ 4= Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly • Business/Organization Name: MC- 13 ge. '/ 11 f r kSeS 1_ . Address: SD 0 LtivP,r 8�) She. 10--1 Vfil City/State/Zip: ]\) . 2,14S ,y1 J'Y1,f- p4.3'510 Phone#: 671 S- d..3 D-2J QD Are you an employer?Check the appropriate box: Business Type(required): 1.® I am a employer with i/6, employees(full and/ 5. (51 Retail or part-time).* 6. 0Restaurant/Bar/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. ❑Nop-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]** 11.0 Health Care 4.❑ We are a non-profit organization,staffed by volunteers, with no employees.[No workers' comp.insurance req.] 12.0 Other *Any applicant that checks box 41 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 41. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: il-r}-1,l/' Gala 4-CO . Insurer's Address: 3Q/Sb TL°Legrvi, d rr��-- City/State/Zip: F tri j .m PGx rings 01.1. 'y& 8- / Policy#or Self-ins.Lic.# 'm f}We___-17q 73 Expiration Date: i /t�o2D Attach a copy of the workers' compensation policy declaration page(showing the policy number an 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 perjury that the information provided above is true and correct. Si afore: .. n/ Date: / LS Phone#: 62 c) .�d —0. 0 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 aita Massachusetts McDonald's Operators' Workers' Compensation Group, Inc. WORKERS' COMPENSATION AND EMPLOYER'S LIABILITY CERTIFICATE DECLARATIONS ITEM 1. Name and Address of Member: Certificate Number.MAWC-17973(19) McBee Enterprises,LLC Type: Corporation McDonald's Restaurants FEI#: 50 Oliver Street,Suite W-1 B North Easton,MA 02356 Locations: All usual workplaces of the member at or from which operations covered by this fund are conducted and located at the above address unless otherwise stated herein. ITEM 2. contract Period: From 01/01/2019 to 01/01/2020 12:01 AM.Standard Time at address of member stated herein. ITEM 3a, Coverage A of this certificate applies to the workers'compensation law and any occupational disease law of Massacusetts. ITEM 3b. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3. The limits of liability under Part Two are: Bodily Injury By Accident 500,000 Each Accident Bodily Injury By Disease 350,000 Each Employee Bodily Injury By Disease 500,000 Policy Umit ITEM 3c. Other States Insurance: Part Three of the policy Applies to the State,if any,listed here: Massachusetts ITEM 3d. See Endorsements: End No.1,End No.I(2/82),End No.R(12/93),End.No.G(4/84) ITEM 4. RATES CONTRIBUTION CLASSIFICATION OF CODE BASIS PER$100 CONTRIBUTION OPERATIONS REMUNERATION SUPERVISORS 8742 $432,287 0.12 $519 CLERICAL 8810 $317,214 0.07 $222 RESTAURANT 9079 $7,938,060 1.03 $81,762 SUBTOTAL: $82,503 Experience Modification 1.11 $9,075 $91,578 ARAP 1.04 $3,663 $95,241 Expense Constant $338 $95,579 DIA Assessment Factor $1,345 $96,924 Net Contribution with DIA Assessment $96,924 DEPOSIT CONTRIBUTION See Enclosed Payment Schedule By: Fund Administrator