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HomeMy WebLinkAboutApp, WC License & Certifications ?j rr►„�y 5 Roast- (3e-e-c• ,oF....►,q` TOWN OF YARMOUTH BOARD OF HEALTH )2‘ 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: —6•r..A0 aat-e. TAX ID: LOCATION ADDRESS: \al iA TEL.#: SO3 77 S--9673 MAILING ADDRESS: aVyx, E-MAIL ADDRESS: (_0\i q v\G, cx, - OWNER NAME: CORPORATION NAME (iF APPLICABLE): \R:5 Erkc4)A‘.et • MANAGER'S NAME: — W3 \ ��\\Ai TEL.#: 3 6 cf f Sdr MAILING ADDRESS: L\ �j w j'o�1 I"•• A \\5 t�`'�G oa 6`1? / 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. L 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. JAN 14 2021 FOOD PROTECTION MANAGERS - CERTIFICATIONS: HEALTH DEPT, 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. 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. I. 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 toren. 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 It OFFICE USE ONLY LODGING: LICENSE REQUIRED PLL PLRMrr ll LICENSE REQUIRED FLI: PERMIT N LICENSE REQUIRED HE PERMIT t! nza .Ccc f•A DIM a'cc • nnrir �•i in r 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 pri r to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRn NSI NT LCCUPANCY: For purposes of the limitations of Motel or I 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.L. c. 64G 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 lcalth Department prior to opening. Contact the I lealth Department to schedule the inspection three (3) clays 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 colilorm and standard plate count by a State certified lab, and submitted to the I lcalth Department'three(3) clays 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 llcalth Department prior to opening. Please contact the l-Iealth Department to schedule the inspection three(3) days prior to Opening. CATERING POLICY: -_- Anyone who caters with-tin the " ,wu uI' y rin-out -.unLs1 • ' ) . lr•tltl� Drpariment by [iliac the re rid---- Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the I-Iealth Department, or From the Town's website at www.yarnouth.ImLus 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 Ilcalth 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. NOTICE: Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN ....5-.- 1.-•... . , . ...-t. .r. . . V,- .I.r.. . , ,r- r.r'e-NI Ivr rr-, rr ri n\ nv U)Y A C 1) 1 0 �n�n The Commonwealth of Massachusetts Fee Town of Yarmouth $125.00 Food Establishment License Number: BOHF-15-1351-06 Issue Date: 1/1/2021 Mailing Address: Location Address: TRS ENTERPRISES INC. 198 ROUTE 28 TIMMY'S ROAST BEEF WEST YARMOUTH. MA 02673 198 ROUTE 28 WEST YARMOUTH, MA 02673 IS HEREBY GRANTED A 2021 LICENSE TO OPERATE: Food Service; 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: None *RESTRICTION: Disposable service only. Board Hillard Boskey, M.D.,Chairman Mary Craig, Vice Chairman of Charles T. Holway, Clerk Debra Bruinooge Health Eric Weston v Br ce G. Murphy,MPH,R.S., CHO M. ory R. Langler, R.S. Health Director/Assistant Health Director 1 m S _ li lin_Lair rpt s c3afi n ServSare .‘ ., .. ....... _ . CERTIFICATION TIMOTHY SILVA for successfully completing the standards set forth for the ServSafeg'Food Protection Manager Certification Examination, which is accredited by the American National Standards Institute(ANSI(--Conference for Food P otection(CFP). 3 as 5285 , 794096 r,UMBER EXAM FORM NUMBER r s,... 11/1 11/13/2022 DATE OF E DATE OF EXPIRATION Local laws apply.C •ency for recertiiicafion requirements. ,mss, r acrsro1rrs csnsxse Sh- airtilvpr�rahs�nar,Iexeora +!0655 13 Ie.. v,o a , • mor C1 . LGI`,+xa k - logos..so looks of elle MUFF. ra 1 , `v vess '' $�„, s+' Conan us wdh 4,..b.ns a 175 W 1ed;son Blvd_S.1500,Chiu,1.6060e.x Sm'So(@r�rxxw.c p. el,*. - /At AA Farm Family Casualty AMERICAN Insurance Company An American National Company NATIONAL 344 ROUTE 9W I GLENMONT,NY 12077-2910 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE NCCI COMPANY NO. 16721 MARK SYLVIA INSURANCE AGENCY LLC POLICY NO. 2001W6070 404 MAIN ST EFFECTIVE 07/24/2020 CENTERVILLE MA,02632-2916 TRANSACTION TYPE Endorse FEIN tI 04-3056561 508-428-0440 ITEM 1.INSURED INSURED AND MAILING ADDRESS: TRS ENTERPRISES INC SEE EXTENSION SCHEDULE 198 ROUTE 28 WEST YARMOUTH,MA 02673-4660 THE INSURED IS CORPORATION Workplaces covered by this policy: ST WP NO. ADDRESS OF WORKPLACE RTG.BUR NO. INTRASTATE NO. MA 1 198 ROUTE 28 345867 WEST YARMOUTH MA 02673-4660 (ITEM 2. POLICY PERIOD --- 0 0 The policy period is from 07-24-2020 to 07-24-2021 12:01 A.M.Standard Time at the insured's mailing address. ITEM 3.COVERAGE A. Workers Compensation Insurance:Part One of the policy applies to the Workers Compensation Law of the state listed here: 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 Bodily Injury By Disease Bodily Injury By Disease $ 100,000 each accident $500,000 policy limit $100,000 each employee C. Other States Insurance:Part Three of the policy applies to the states,if any,listed here: All states except the states designated in item 3.A.of the information page and ND,OH,WA,and WY D. This policy includes these endorsements and schedules: WC000001A0319 Copyright 1987 National Council on Compensation Insurance PROCESSED 2020-08-25 WC000001A Edition 0349 2001W6070 s The Commonwealth of Massachusetts / _ Department of Industrial Accidents Pt ..m 4 _ � Office of Investigations y —mai- p 1 Congress Street, Suite 100 . _ • == =, Boston, MA 02114-2017 '= .,�..vot" www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly- Business/Organization Name: Address: City/State/Zip: Phone #: Are you an employer? Check the appropriate box: Business Type (required). 1.7 I am a employer with employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2.❑ 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. [No workers' comp. insurance required] 8. ❑ Non-profit 3.E We are a corporation and its officers have exercised 9. ❑ 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 4.7 We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.111 Other 'Any applicant that checks box g 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. I Insurance Company Name: Insurer's u;�ess' City/State/Zip: Policy k or Self-ins. Lic. g Expiration Date: -nensation policy declaration page (showing the policy number and expiration date). Attach a copy of the workers' co��, -*ion 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,Seth as well as civil penalties in the form of a STOP WORK ORDER and a fine P t, d that a copy of this statement may be forwarded to the Office of of up to $250.00 a day against •- - , ; Investiga ons of the -----'-o' Be advisecation. r Tnprance cov rage verifi I do hereby c erjury that the information provided above is true and correct. under thL . d penalties ojp �2\ Sivnature: -Mi " W Date: (d' "c)k):4-0 Phone 4: 5.'1 C Q /54 Official use only. Do not write in this area, to bel completed by city or town officiaL Cit} or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Buildin . City/Town Clerk 4. Licensing Board 5. Selectmen's Office g Department 3 6. Other Contact Person: Phone #: