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Home My WebLink AboutApplication and WC TOWN OF YARMOUTH BOARD OF HEALTH ��• � '� � APPLICATION ONF FOR E N S E/PERMIT- 2020 DEC 2 0 2019 * Please complete form and attach all necessary documents b ! Failure to do so will result in the return of your applicat `''7' A t4 NOTE:ALL BUSINESSES WITH LIOUOR LICENSES MUST RETURN FO• S BT fs,OVEM.fJ t 1 , I ESTABLISHMENT NAME: S64Lk aLkSnc.I 's Dv-1-6 ck TAX ID: LOCATION ADDRESS: / i !iv t to r , , /o TEL.#: a , Co? . -p MAILING ADDRESS: ! , l Dila E-MAIL ADDRESS: donor ( U oc a,[ a... awl OWNER NAME: D0✓101/4 13wr-ot, a� CORPORATION NAME (IF APPLICABLE): Mttele6 00.49Tn� MANAGER'S NAME: " on& ".8urettl-rt TEL.#: 5D$ 375-- MAILING ADDRESS: kg ( Loo-It.tip yofinoc o�- t►�(a� O Lel< 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. I. 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. 6(t-0 I c,0 2. az, I''1e_ NastAtxrLi PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. 'Donk 'a Aret, 2. m )( Po n c(,tAg_ 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. - o n -3 a.r(-N-zt 2. Alt x 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. R,oI4F-15-1e3Z-{6. 1. leenivAivutik,(A)t vt 2. v{7 �v 3. ffylGS5K Nlc. K rvt. 4. FS 0436 26-0% 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 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. `_. The Commonwealth of Massachusetts I F - Department of Industrial Accidents ' Office of Investigations .„ 1 Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Tat-V.6 r()4-bacsj Jl id,l ks 01)+444- i(-- Address: Address: I CI goof it' �IA 0a�s City/State/Zip: / t 0`t v,t D ,. Phone#: 5-6,7- 36)a - Lo lo ?0 Are you an employer I/Check the appropriate box: Business Type(required): 1.121 I am a employer with I employees(full and/ 5. 0 Retail or part-time).* 6. 0 Restaurant/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] .. 0 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]* 4.❑ We are a non-profit organization,staffed by volunteers, 11.0 Health Care with no employees. [No workers' comp.insurance req.] 12.0 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 insurance for my employees. Below is the policy information. Insurance Company Name: 4(b I Insurer's Address: HO 0 (A 0 W Y1 G' D iO K �(\✓G City/State/Zip: au(rl G rvt0 ?_1(9i Policy#or Self-ins.Lic.# 'as 0 0 S'a d-3 Expiration Date: (2.' 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 certi ,under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: /2. 10 • 17 Phone#: Col 3&? (p& 4 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 NOTICE NOTICE TO EMPLOYEES ~Nip'` LL TO ( EMPLOYEES 1 l�iLt The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street,Boston,Massachusetts 02111 617-727-4900-http://www,mass.gov/dia As required by Massachusetts General Law,Chapter 152, Sections 21,22 & 30, this will give you notice that I (we)have provided for payment to our injured employees under the above mentioned chapter by insuring with: Arbella Protection Insurance Company NAME OF INSURANCE COMPANY 1100 Crown Colony Drive, Quincy,MA 02169 ADDRESS OF INSURANCE COMPANY 4220059223 POLICY NUMBER 12/4/19—12/4/20 EFFECTIVE DATES RogersGray Inc 434 Route 134 S Dennis, MA 02660 NAME OF INSURANCE AGENT ADDRESS Slack's Outback Inc dba Jack's Outback II 161 Main St Yarmouth Port, MA 02675 EMPLOYER ADDRESS EMPLOYER'S WORKERS COMPENSATION OFFICER(IF ANY) DATE MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Worker's Compensation Act.A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the ser- vices provided by the treating physician will be paid by the insurer,if the treatment is necessary and reasonably connected to the work related injury.In cases requiring hospital attention,employees are hereby notified that the insurer has arranged for such attention at the Name of Hospital Address TO BE POSTED BY EMPLOYER Florio, Mary Alice From: dona@jacksoutback2.com JAN 2020 Sent: Monday, December 23, 2019 1:26 PM To: Florio, Mary Alice Subject: RE:Jack's OUtback II - Food Service and Common Victualler License•Fees 1440 LA Hi MaryAlice, I'm SO SORRY I Duh! I will put the check in the mail to you! Dona ...tis the season... Original Message Subject: Jack's OUtback II - Food Service and Common Victualler License Fees From: "Florio, Mary Alice" <MFlorio@yarmouth.ma.us> Date: Mon, December 23, 2019 12:57 pm To: "'dona@jacksoutback2.com"' <dona@jacksoutback2.com> Good afternoon. Thank you for submitting your 2020 application for licenses issued through the Health Department. However, there was no check enclosed for payment of the fees. The food service fee is $125 and common victualler fee is $60, for a total of $185.00 owed. Please send the payment to our department at your earliest convenience so that we can process your licenses. Thank you for your attention to this matter. Have a happy holiday season. MaryAlice Florio Principle Office Assistant Yarmouth Health Division 1146 Route 28 South Yarmouth, MA 02664 508-398-2231, ext. 1241 1