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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 13.2019. Failure to do so will result in the return of your application packet. NOTE:ALL BUSINESSES WITH LIQUOR LICENSES MUST RETURN FORMS BY NOVEMBER 15". ESTABLISHMENT NAME: 5O%-4 Y4.ei a,WI D4►r y kU CP.I TAX ID: LOCATION ADDRESS: 9/7 2.k ,2g 54 Vairnaul-'j, rrIA- Oat,(o V TEL.#: 571?-3 f if-453 c MAILING ADDRESS: Same- E-MAIL e- E-MAIL ADDRESS: /j/lNc Del e Hz7Tiq. /t,Co:✓1 OWNER NAME: -red DIv»acaicu/us CORPORATION NAME(IF APPLICABLE): D CA P io..f( ?a/C. MANAGER'S NAME: 1)4.i Chri3/apau/a5 TEL.#: 8k6-ea S-1/035- MAILINGADDRESS: df P 0 13 Lbc //?-o- SO, YA✓rnewAi r114 0a4,6Y POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated T -Tl 571, Pool Operator(s)and attach a copy of the certification to this form. rn rn --- Da [fill 1. 2. = �;) o til Pool operators must list a minimum of two employees currently certified in standard First Aid and Community 0 1v C Cardiopulmonary Resuscitation(CPR),having one certified employee on premises at all times. Please list the v o li d employees below and attach copies of their certifications to this form.The Health Department will not use past 7-1o � N (_) ' years'records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS-CERTIFICATIONS: V.771 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. r`iik,,, 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. Du„ Chr/s' i�ov4s 2. A `; s `' PERSON IN CHARGE: �'f .( Each food gestablishment must have at least one Person In Charge(PIC)on site during hours of operation. ''4 1. ban 1,hfakpeU/t S 2. �d3e /7d1YYjPSice' '. 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 ` �l 1. )6 avl Oh//J htek./A J 2. /4 4/j // 4 a Gk./J.ov/ 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 providernew copies and maintain a file at your place of business. 1. N/ 2. 3. 4. RESTAURANT SEATING: TOTAL# ( ObLF—(`[-6u45---0(0 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$110ea. _LODGE $55 =TRAILER PARK $105 WHIRLPOOL $110ea FOOD SERVICE: LICENSE REQUIRED FEE P RMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 'L0-100 SEATS $125 Qw ( CONTINENTAL $35 NON-PROFIT $30 >100 SEATS $200 COMMON VIC. $60 ZJ) 04( WHOLESALE $80 —RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# G50 sq.1t. $50 >25,000 sq R $285 VENDING-FOOD $25 _<25,000 sq.11. $150 /FROZEN DESSERT$40 2D.� =TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE = $ I ao *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** 5- C ( Z,�00 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 !f 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 m 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 i 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: a9/42()/02--F) SIGNATURE: haf PRINT NAME&TITLE: ✓tj vJ ( /1 Oc.0%S 1114H a y r� /Q✓ 11 er Rev.10/15/19 Workers Compensation and Employers Liability Insurance Policy Insurer ID No(s):34355 MA Retail Merchants WC Group Inc. Carrier Policy#:. Policy Period PO Box 859222-9222 014005030237120 01/01/2020 to 01/01/2021 Braintree,MA 02185-0000 Information Page Renewal Policy FEIN:043540794 Carrier Prior Policy#:014005030237119 Item 1: Named Insured and Address Agency Dara Foods,Inc. Cove Risk Services,LLC South Yarmouth Dairy Queen PO Box 859222-9222. 917 Main Street Braintree,MA 02185 Rte 28 South Yarmouth, MA 02664 Other Workplaces Not Shown Above: No Other Workplaces for this Policy Additional Named Insured: See Additional Named Insureds if Applicable Type of Business: Corporation Federal ID#: Risk ID: 000000000 NCCI I Bureau#:34355 Unemployment ID#: File#:014005030237120 Item 2.Policy Period The policy period is from 12:01 AM on 01/01/2020 to 12:01AM on 01/01/2021 based on the insured's mailing address time zone. Item 3.Coverage: A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed: 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 $1,000,000.00 each accident Bodily Injury by Disease $1,000,000.00 policy limit Bodily Injury by Disease $1,000,000.00 each employee C. Other States Insurance: D. This policy includes these endorsements and schedules: WC000000C(01/15),WC000414A(01/19),WC00042213(01/15), NOE(01/01),WC200102(01/14),WC200301(04/84), WC200302A(09/08),WC200303D(08/10),WC2003068(06/13),WC200405(06/01),WC200601A(07/08) Item 4: Premium The Premium for the policy will be determined by our Manual of Rules,Classifications,Rates and Rating Plans. All information required below is subject to verification and change by audit. Classifications Code# Premium Basis Rate Per$100 of Estimated Annual Premium Total Estimated Remuneration Annual Remuneration See Schedule of Operations on Following Page(s) Minimum Premium Prorated Premium Estimated Annual Premium Expense Constant Deposit:. $290.00 $1,851.00 $1,851.00 $0.00 $0.00 Issuing Office: 35 Braintree Hill Office Park Ste 206 Date Printed: Countersigned by: Braintree MA 02185-0000 01-15-2020 Form#WC 00 00 01 C (Ed.)