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HomeMy WebLinkAboutApp, WC License & Certifications Ta 1�4 lS Pty OF.,.. TOWN OF YARMOUTH BOARD OF HEALTH 444:, APPLICATION FOR LICENSE/PERMIT - 2021 * Please complete form and attach all necessary documents by December 18, 2020. Failure to do so will result in the return of your application packet. ESTABLISHMENT NAME: TI-V- FIZZ,- TAX ID: ' LOCATION ADDRESS: 5417 MA.It.( 3/442..t.4 OUTt-{ TEL.#: SCI'- 77 l -333 MAILING ADDRESS: f1 1v1,6,1 tom( 51- W, y ,p.rI OV MAO (fly E-MAIL ADDRESS: IY(1Xe±l • s f_ _ •nr) ODWNER NAME: L4.-MNJ i A & OC` .et.ISKI CORPORATION NAME (IF APPLICABLE): l3L�Cf< LI<f•(1 CCS--Kit /MANAGER'S NAME: L.,1-11P42--11.-11 DROCzL-1.4 TEL.#: ,5)t oZ,.& - 47 MAILING ADDRESS: 104-a VE2 ED. iM.,602-11-0.1- WILLS, W. 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 years' records. 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. L,64.44 LS I V --'re"-QS PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PiC) on site during hours of operation. I. 2D C`7 C 4V-( - 2. L tr -t lel yprt--tom 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. I. I�- ,�-r�-� �P OC- e-K—Sc'( 2. i-o&MC , l VA-PeT-1. k4.c�s 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. K i-n-t S2e)C7 K) c t - t LIA<MP,e4tir Venc C 3. 4. RESTAURANT SEATING: TOTAL iI 2D OFFICE USE ONLY LODGING: LICENSE REQUIRED FEL PERMIT II Ll('IiNSIF, REQ1 FEE P1 RMI I iI LICENSE RI QtJIRED PBI: PERMIT Ii ADMINISTRATION AnIli 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 ✓ O/t / 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: I YES NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or l lotel 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.E. c. 640 or 830 CMR 640, as amended, shall generally be considered 'transient. POOLS POOL OPENING: All swimming, wading and whirlpools which have been closed for the season must he inspected by the I lealth Department prior to opening. Contact the I lealth 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 I lealth 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 l-lealth Department, Downloadable Forms. FROZEN DESSERTS: Frozen desserts must be tested by a Slate certified lab prior to opening and monthly thereafter,with sample results submitted to the I lealth 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 CAH S: 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. 1 NOTICE: Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN '1'1117 nCP A1r r•rrrr n171,117\1!A 1 A nnr rr A Mir-NAT/0 A Mrn rrr irn a rric' r-1,r.rrr.A1-117r1 10 -ln"In The Commonwealth of Massachusetts Fee (1°' Town of Yarmouth $185.00 Food Establishment License Number: BOHF-14-0368-08 Issue Date: 1/1/2021 Mailing Address: Location Address: BLACK UNICORN INC 547 ROUTE 28 TAKIS PIZZA WEST YARMOUTH. MA 02673 1042 RIVER ROAD MARSTONS MILLS, MA 02648 IS HEREBY GRANTED A 2021 LICENSE TO OPERATE: Food Service; Common Victualler This license is granted in conformity with the statutes and ordinances relating thereto, and expires December 31, 2021 unless sooner suspended or revoked and is not transferable. Conditions SEATING: 30 Board Hillard Boskey, M.D.,Chairman Mary Craig, Vice Chairman of Charles T. Holway, Clerk Debra Bruinooge Health Eric Weston 4 A Bruce G. Murphy, MPH,R .., CHO/Mallory R. Langler, R.S. Health Director/Assistant Health Director The Commonwealth of Massachusetts _ L' .."•••••=.1. Department of Industrial Accidents a.�t- 4 Office of Investigations 1 Congress Street, Suite 100 I Boston, MA 02114-2017 A fes._ 0'01 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: TA K-L S Pl ZZ Address: 117 City/State/Zip:WA02073Phone #: qg ,r3 `�� Are you an employer? Check the appropriate box: Business Type (required): 1.7 I am a employer with employees (full and/ 5. 17:1 R tail or part-time).* 6. 2/Restaurant/Bar/Eating Establishment 2.IJ 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. ,[�'o workers' comp. insurance required] 8. 7 Non-profit 3.N4 We are a corporation and its officers have exercised 9. Entertainment their right of exemption per c. 152, §1(4), and we have 10.[1 Manufacturing no employees. [No workers' comp. insurance required]` 11.7 Health Care 4.[ I We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.17 Other `Any applicant that checks box k1 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 l I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: Insurer's Address: City/State/Zip: Policy # or Self-ins. Lic. # 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 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, und•r the pain. and penalties of perjury that the information provided above is true and correct. ' Sienature: / I ' ' Date: o ( oZ 2 Phone #: ( 5 �y ` 3 g l 1 . 33 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 #: ..�TION�' -"°4''':• International CPR Institute,Inc. p t.� 101 MarketsideAve., Ste.404-339 International CPR Institute Inc. %,,. yoc i Ponte Vedra,FL 32081 www.icpri.com i KEITH SROCZENSKI Security Control # 1042 RIVER ROAD 883797 MARSTONS MILLS, MA 02648 Completion Date:Aug-14-2020 Instructor Name: Sal Coppolino Expiration Date: Aug-14-2022 Instructor#: D1317S KEITH SROCZENSKI ' Has successfully completed the International CPR Institute's CPR/AED Course Adult/Child/Infant ii The International CPR Institute's cognitive assessment of the CPR/AED Course based on the current standards for CPR and ECC. THIS DOCUMENT IS VOID IF REPRODUCED .. w__.,... .--- Cut out card below ..„0.0N,�.,..., _4'' . More life-saving courses from .N International CPR Institute Inc. snru7E.4KEITH SROCZENSKI www.icpri.com 4 � i Y p' This certifies that the person named above has successfully • New CPR /AED completed the International CPR Institute's c • CPR /AED Renewal CPR/AED Course Adult/Child/Infant Completion Date: Aug-142020 • Healthcare Provider, B.L.S. security control# Expiration Date: Aug-142022 883797 • First Aid ).1 • Bloodborne Pathogens Instructor D1317S Cardholder's Signature Keep this card for your records. Void if reproduced. • Pediatric First Aid, CPR /AED www.icpri.com Cut out card below fs. ;x More life-saving courses from \. International CPR Institute Inc. `�ST � LAMBRINI VARETIMOS u:u:m.icpri.com �+•i1ON New CPR /AED This certifies that the person named above has successfully • .. completed the International CPR Institute's teua` °"`°"' CPR/AED Course • CPR /AED Renewal Adult/Child/Infant Healthcare Provider, B.L.S. 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TO EMPLOYEES EMPLOYEES y ,0 141 o1M r Sv The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS LAFAYETTE CITY CENTER, 2 AVENUE DE LAFAYETTE, BOSTON, MA02111 (617) 727-4900 — 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: ZURICH-AMERICAN INSURANCE GROUP NAME OF INSURANCE COMPANY P.O. BOX 4614 BUFFALO. NY 14240-4614 ADDRESS OF INSURANCE COMPANY (6ZZUB-0762N00-8-20) 05-22-20 TO 05-22-21 POLICY NUMBER EFFECTIVE DATES CHAGNON INS AGENCY INC 411 RT 28 W WEST YARMOUTH MA 012673 NAME OF INSURANCE AGENT ADDRESS PHONE# VARETIMOS, STEVE DBA 547 MAIN STREET ROUTE 28 0 _ TAKIS PIZZA WEST YARMOUTH MA 02673 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 o employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers' 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 services 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 009038 W20P1G15 TO BE POSTED BY EMPLOYER