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Home My WebLink AboutApplication and WC '►'vzA TOWN OF YARMOUTH BOARD AEALT RECEry APPLICATION FOR LICENSE/P {, -2 i 2 I * Please complete form and attach all necessa � $I• I's •y Dece berg EB 2079 Failure to do so will result in the return of your application pac!et. NOTE:ALL BUSINESSES WITH LIQUOR LICENSES MUST RETURN FORMS BY 0 •' �= T ESTABLISHMENT NAME: '-ftK[ S' 121.2.2.4 TAX ID: - LOCATION ADDRESS: 5.4 7 Mp 1 e ST- IAA )/iR ill 0u fti/ /j' O S VELA.Sp(- 7 7 I->701 MAILING ADDRESS: E-MAIL ADDRESS: WA.very.,y - " 6-14, / �-, �'c� CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: TEL.#: MAILING ADDRESS: 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. Please 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. 1. 2. 3. 4. 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. 5r Elie f YAt .E'Ti /`'10 Y 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. 2. 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(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. 1. 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. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY &rile- / t—6368 —10(Q LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B_ $55 _CABIN $55 MOTEL $110 CAMP $55 SWIMMING POOL$110ea. LODGE $55 _$55 TRAILER= PARK $105 _WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# j_0-100 SEATS $125 020 063 CONTINENTAL $35 NON-PROFIT $30 _>100 SEATS $200 f COMMON VIC. $60 . •-Q . —WHOLESALE $80 RETAIL SERVICE: —RESID.KITCHEN $80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 _<25,000 sq.ft. $150 =FROZEN DESSERT $40 _TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE = $ /8 5.00 *****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. 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 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 CAFÉS: 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 REQUIRE A SITE PLAN. DATE: IA. . 13 . cfft SIGNATURE: /P PRINT NAME&TITLE: V,ve-- I /o\ Rev.10/15/19 • The Commonwealth of Massachusetts Department of Industrial Accidents It Office of Investigations 1 Congress Street, Suite 100 1rp, Boston, MA 021I4-2017. www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: 1.—A 4T S 1 221 Address: 7 i)Z N cl City/State/Zip:to,),q/ Q(7)4 DI o Z.677 Phone#: Are you an employer? Check the appropriate box: Business Type(required): 1.�am a employer with employees(full and/ 5. D Retail or part-time).* 6. Rilestaurant/Bar/Eating Establishment 2. I am a sole proprietor or partnershi - p 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.❑ 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.❑ 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: 7--uril 614 Insurer's Address: C.n try r e Gia • l 1V e r Po • lJ O b City/State/Zip: J4 Ct 4 Po,2 el G T. (e)102 Policy#or Self-ins. Lic. # lei Z z Li 13 - 67624,(61(3 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 fme 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 perjuiy that the information provided above is true and correct Signature: Date: Phone#: 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 Rl_ M �O N Q ›- 0. O CO 1.l N W l- O J < 0 = as m } it I.- V co W W d0 O ~ N O Z N Z a, NN ji o1 } z- cu ca 1-4 n 'I N W ,„4- CIL O Y M >1- - 1 N O NT �- O: O W CC 0 W CO 0 ▪ > Z Z O o )- N 10 W (13 V C) O O: • •• W H W 7 N H I J E V► M y O W OZ O. Z CO N M W Q H LO • CO N Ca O o o W Q I—E a� LU LU ai N c H Q1—M .NVIO N N E 01-1 Z W Eo_f•1Q I- X W H H �Yr- 0— N ¢a.rw w W N W '•I Z �o m NO O J •O 1- -HA u =HX O o V VO O: O OO O O••••=m CO • I- gO EZ N c,l o. Z u 018940 VDAC ZURICH WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY CHANGE DOCUMENT WC 89 06 00 (00) POLICY NUMBER: (6ZZUB-0762N00-8-19) CHANGE EFFECTIVE DATE: 05-22-19 NCCI CO CODE: 17965 INSURER: AMERICAN ZURICH INSURANCE COMPANY INSURED'S NAME: VARETIMOS, STEVE DBA TAKIS PIZZA This change is issued by the Company or Companies that issued the policy and forms a part of the policy. It is agreed that the policy is amended as follows: An absence of an entry in the premium spaces below means that the premium adjustment, if any, will be made at time of audit. ADDITIONAL PREMIUM $ 635 RETURN PREMIUM $ NIL ADDITIONAL NON-PREMIUM $ 24 RETURN NON-PREMIUM $ NIL THE CURRENT POLICY EXPOSURES AND/OR CLASSIFICATIONS HAVE BEEN UPDATED TO REFLECT THE LATEST AVAILABLE AUDIT INFORMATION. THE FOLLOWING ENDORSEMENTS ARE ADDED: WC89041500 POLICY INFO PAGE ENDT WC89060000 POLICY INFORMATION PAGE ENDORSEMENT WC89061400 POLICY INFORMATION PAGE ENDORSEMENT a� flmm immmws C 0= 0 0= 0 nmEmm mamma DATE OF ISSUE:08-30-19 We CHANGE NO: 001 PAGE 001 OF LAST POL. EFF. DATE:05-22-19 POL. EXP. DATE: 05-22-20 OFFICE:ZURICH-ORLAN 809 PRODUCER:CHAGNON INS AGENCY INC 73CGR 016941 ZURICH WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY EXTENSION OF INFO PAGE-SCHEDULE WC 00 00 01 ( A) POLICY NUMBER: (6ZZUB-0762N00-8-19) INSURER: AMERICAN ZURICH INSURANCE COMPANY 17965-MA INSURED'S NAME : VARETIMOS, STEVE DBA TAKIS PIZZA RATE BUREAU ID: 000251753 PREMIUM BASIS ESTIMATED RATES ESTIMATED TOTAL ANNUAL PER $100 OF ANNUAL CLASSIFICATION CODE REMUNERATION REMUNERATION PREMIUM LOCATION 001 01 FEIN 042784846 ENTITY CD 001 VARETIMOS, STEVE DBA TAKIS PIZZA 547 MAIN STREET ROUTE 28 WEST YARMOUTH, MA 02673 SIC CODE : 5812 NAICS: 722511 DRIVERS, CHAUFFEURS AND THEIR HELPERS NOC - COMMERCIAL 7380 9473 5 .96 565 RESTAURANT NOC 9079 152334 1 .03 1569 .950 MERIT RATING MODIFICATION (9885) $ 107 TOTAL ESTIMATED ANNUAL STANDARD PREMIUM 2027 EXPENSE CONSTANT(0900) 338 0.0300 TERRORISM (9740) 49 3 .83% MA WC SPECIAL FUND AND TRUST FUND 78 TOTAL ESTIMATED PREMIUM 2492 DEPOSIT AMOUNT DUE 2492 { DATE OF ISSUE: 08-30-19 WC ST ASSIGN: MA SCHEDULE NO: 1 OF LAST 0 ZURICH WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY ENDORSEMENT WC 89 04 15 (00)— 001 POLICY NUMBER: (6ZZUB-0762N00-8-19) POLICY INFORMATION PAGE ENDORSEMENT Item #4 is changed to the following: PREMIUM BASIS Total Estimated Rate Per Code Annual $100 of Estimated Classifications No. Remuneration Remuneration Annual Premium SEE CHANGE DOCUMENT OR INFORMATION PAGE SCHEDULE co— 0= 0= 0= wimmChnom Total Estimated Annual Premium $ Minimum Premium $ Deposit Premium $ ALL OTHER TERMS AND CONDITIONS OF THIS POLICY REMAIN UNCHANGED. DATE OF ISSUE: 08-30-19 ST ASSIGN: MA 016942 r ZURICH WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY ENDORSEMENT WC 89 06 14 (00)— 001 POLICY NUMBER: (6ZZUB-0762N00-8-19) POLICY INFORMATION PAGE ENDORSEMENT Item 3.D. Endorsement numbers is changed to read: SEE CHANGE DOCUMENT OR INFORMATION PAGE SCHEDULE ALL OTHER TERMS AND CONDITIONS OF THIS POLICY REMAIN UNCHANGED. I DATE OF ISSUE: 08-30-19 ST ASSIGN: MA