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Home My WebLink AboutApplication and WC .. ., � ltlr-`7�IJkS-- . a TOWN OF YARMOUTH BOARD OF HEALTH ,1�J(,� �� APPLICATION FOR LICENSE/PERMIT,-28��'�` � -, Y�,';�,. � : p;�v '� 4 ZUt4 * Please complete form and attach all necessary docume�ts�y " 1� b P'IS 2014. Failure to do so will result in the return of:your a�}i�atio�pac t. HEALTH DEPT. ESTABLISHMENT NAME: �'� ' TA D: � o w.v.yo*is^s /E'S� S n EL.#: sa 8-39 - �985 LOCATION ADDRESS: 3 � � T MAILING ADDRESS: 66 �a--y,s�.�- C.�.��- >.�� r�s�+ o z 6 3a E-MAIL ADDRESS: ��x � ��a�• ��7 OWNERNAME: ,vis-��-E �'ozrt� Go.eia CORPORATION NAME ( _IF APPLICABLE): ��-� /�-ti� �° MANAGER'S NAME: ��-� ��c.y TEL.#:so 8-360 -zBBs MAILINGADDRESS: 2� �t"/-�n �� f''Ym�^'�� /7� � Z6o/ � 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. _ - -_ __ _ _ __Z:-- __. Pool operators must list a minimum of two employees currently certified in basic water safety, 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 prov�de new copies and maintain a £►le at your place of business. 1. Z• 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments aze 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. !�i�,a,.�-�'� ��x�y 2. � /"� �.�..9-�c� PERSON IN CHARGE: Each fo��bli�m�ave at��ny erson In Charg� (PIC) on site duri�ws of�io� / 1. �vta+rw�c� . ALLERGEN CERTIFICATIONS: All food service establishments aze 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 Deparhnent will not use past years' records. You must provide new copies and maintain a f t your establishment. C�-✓ 1. �.�"�"�C��"�k� 2. ^�� r 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-cholang 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 mamt ' file at your place of business. C� 1. /•E��-^ —'\ �1cy 2. �i+� �"r G�-- 3. 4. RESTAURANT SEATING: TOTAL# �� OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 � CABIN $55 MOTEL $110 —I1VIV $55 CAMP $55 SWIMMING POOL$t l0ea LODGE $55 �CRAILERPARK $105 _WHIRLPOOL $110ea. FOOD SERVICE: �L CENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100SEATS $125 #�S-db7 CONTINENTAL $35 NON-PROFIT $30 � >100 SEATS $200 �COMMON VIC. $60 �S� _WHOLESALE $80 — —RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 Q5,000 sq.ft. $l50 1 FROZEN DESSERT $40 �� _TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE _ $ 2 Z-S •00 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM**•*" �� I E�� 2?'�69 ►i�i`��G`� ADMINIS'TRATI4N s ,. . Under Chapter 152,Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal af any license ar permit to aperate a business if a person or company does not have a Certificata af Warker's Compensation Insurance. THE ATTACHEll STATE WOI2KE:R'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNEll, OR CBRT'. OF INSURANCE ATTACHED � OR W4RKER'S C(3N1P. AFFIDAVIT SIGNED AND ATTACHED Town of Yarcnoutkt taYes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPRQPRIATELY IF PAID; f YES �/ NO MO'TELS ANI? OTFIER I,ODGING ESTABLISHMENTS TRANSIENT OCCUPANCX: Fot purposes ofthe limications oflVlotel or Hotel use,Transient accupancy shail be limited to the femparary and short term occupancy,ordinarily and customarily associated with matel and kotel use. Transient occupants must have and be able ta deinonstrate thak they maintain a principal place pf residence elsewhere.Transient occupancy shall generally refer to continuous occupancy of not more than thirty(30)days,and an aggregate ofnot more than ninety(90}days within any six(6)month period. Use af a guest unit as a residence ar dwelling unit sha11 not be considered transient. Occupancy that is subject to Yhe collection of Room Occupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient. POQLS POH�6�'�NHW�: Ai3 swimnling;wading andwhi:t�oo}swhiclrhavebeenc}ose��'arthe se�san-rn�tbei��ed hy the Health Department prior to opening. Contact the Health Department To schedule the inspection t6ree{3} days prior to opening. PLEASE NOTE: People are NOT allowed to sit in the pool area until the paol has been inspected and opened. POOL WATER`�`ESTING: The water must ba tested for pseudomonas,total coliforxn and standard plate count by a State certified lab, and submiCted to the Heaith Department three {3) days priar to opening, and quarCerly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FO011 SEI2VICE SEASONAL FOOD SERVICE dPENING: All faod service establishments must be inspected by the IiealCh DeparCment prior ta opening. Please contact the Health Departrnenl to schedule the inspection three (3} days prior to opening. CATERTNG POLICY: Flnyane who caters within the Town af Yannouth must notify the Yazmouth Heaith Departmeni by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health Deparqnent,ar frarn the To�vn's website at www.varmouYh.ma.us under Health I}epartnient, Downloadable Forms. FROZEN DESSk.RTS: Frozen desserts must be tested by a State certified lab prior to apening and monthly thereafter,with sample results submitted to the Health Department. Failure to do sa will result in the suspension or revocation of your Frozen Dessert Permit untiT the abave terms have been rnet. OUTSIDE CAFES: Outside cafes(i.e.,autdaor seating with waiterlwaiiress serti�ice},must have prior appcoval from the Baard of Health. OUTDOtJR Cdf1KING: dutdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. NOTICE: Perncits run annually frorn January 1 to December 31. IT IS YQUR RESPONSIBILITY TO R�TtTRN THE COMPLBTED RENEWAI.APPLICATION(S) AND REQUIRED FEE(S)BY D�CEMBER 15, 2014. ALL RENOVATIQNS TO ANY FOOD �STABLISHMENT, IvIOTEL OR POOL {i.e., PAIN'1"ING, NEW EQUIPMENT', ETC.), MUST BE REPQRTED TO AND APPROVED BY THE BOARD OF HEALTH PItIOR TO COMMENCEMENT. RENdVATIONS MAY RE DATE: �r �Q/zor� SIGNATI7RE: • •�-e�-�.t aw PRINT NAME&TITLE: ��z7' i'� .•,z:y ,.,,,K,�� — x��. wosna � � t� The Commonwealth ofMassachusetts Department of Industrial Accidents � Office oflnvestigations 1 Congress Sireet, Suite l00 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensarion Insurance Affidavit: General Businesses A licant Information Please Print Le 'bl Business/Organization Name: '�� '�"'� Address: �� g�-�-= G' '�� ` City/State/Zi . �cv�� 0 2-L3 2 Phone#: �a$ ' Z o 7- �3�Z Are y u an employer?Check the appropriate box: Business Type(required): 1.�I am a employer with � employees(full and/ 5. � etail or part-rime)* 6. /�RestawanUBar/Eating Establistunent - -----LL_- - ' .- ----_ — 2� I am a sole proprietor or parmership and have no 7, � p�ce 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 corporarion and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4),and we have 10.0 Manufacturing no employees. (No workers' comp. insurance requiredj* 11.� Health Caze 4.❑ We aze 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 5ll out the section below showiag the'v workeis'compensation policy information. "If the cotpornte office:s 6ave exempted themselves,but the corporation has otha employees,a workers'compensaYion policy is requ'ved and such ar, orgam�Gbn'shoutd eheck box#1:- �. . :. .... . . ... . . , . . . . . . . . I am an employer that is providing workers' pensation insurance for my em oyees. e[ow is o[icy dnformalion. Insurance Company Name: �/4 �� "`��'"'"�y��G �'�� Insurer's Address: / • D . �� S 922 2 ' / Z 2 2 City/State/Zip: ��✓�'p `` �� o��g S Policy#or Self-ins.Lic. # �� 0503�5 9�� Expiration Date: / � z�+�s' Attach a copy of the workers' compensafion policy declaradon page(showing the policy nnmber and ezpiration date). Failure to secure coverage as required under Section 25A of MGL�. 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�ine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwazded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify,under s and es ojperjury that the information provided above is ue and correct. Si ature: Date: �� '� Z�� Phone#• v��g - 2� 7 - 6 3 2 � O�cial 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 Healt6 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Oftice 6.Other Contact Person: Phone#: www.mass.gov/dia �RKERS COMPENSATION AND fiMPLOYERS LIABILITY INSURANCS CERTIFICATE . a � INFORMATION PA6E RENEWAL AGREBMENT � � Producer: Agentq 5960 MA Retail Merchanta WC Oroup Inc. � � Aasociation Benefite Insurance Age PO Box 859222-9222 � . 299 Ballardvale St, Suite 1 � Braintree, MA 01285 � � Wilmington, MA 01887 � � (Carrier Code: 34355) � � � Certificate #: 014005030559114 � � Prior Certi£icata #: 014005030559113 � 1. The Employer: � Wendy'e � . - � � � Fashion Food LLC � Mailing. Addresa: 66 Pondeide Circle . - Centerville, MA 02632 . � � � � � Fein: � other workplacee� not ehown above: Type of Businsae: Corporation SEB 3CfiEDULE OF OPfiRATIONS � Risk ID: " � 2. The certificate period is from 12:01 a�.m. on � 1/O1/2014 to 12:01 a.m. on , 1/O1/2o15 at the ineured's mailing addreae. � � 3. A. Workere Compensation Coverage: Part One� of the certificate applies to the Workere Compensation Law of�the atates listed here: MA B. Employera Liability Coverage: �Part Two of the certificate appliee to work i❑ - each atate listed in Item 3.A. The 1lmite of our liability under Part Two are;, . Hodily Injury by Accident $ 100,000� each accldent. . � � . Sodily Injury by Diaeaee -$ 500,000 � certificate limit Bod11y Injury by Dieeaee $ 100,000 each employee � � C. Other �5tatae Coverage: � �. Thia certificate includea these endorsementa and echedules: . . WCOOOODOA(04/92). WC000310(04/84) WC000406A(08/95) WC000414(07/90) WC000422A(09/08) � WC200301(04/84) WC200302(OS/86) WC2003038(07/99) WC200405(06/01) WC200601(06/92) 4. The contribution for this certificate will be determined by our Manuala of Rules, � - Claesificatione, Ratea and Rating Plane. Al1 information required below is subject to verification .and change by audit.. �� . Claeaificationa Code , Contribution Baeie Rate Per Estimated . � No. Total Eatimated � $100�of Annual . � Annual Remuneration Remuneration - Contribution 3EE 9CHEDUL& OF OPERATIONS � � Total Eatimated Annual Contributios 19,813.00 . � Minimum Contribution $ 216.00 Expenae Conatant $ .00 WC 00 00 O1 A Ieaue Date: 1/27/2014 CounCereigned by � � SCH$4UUE OF O$&RATZ4NS FOR: PAGE: 1 . Wendy's Certific�te #: 014005030559114 . Fashion Faod LLC Fein: . 66 Pondaide Cirele , Centerville, MA 02632 OTHER WORKPLACES: , Wendy's , Fashion Food LLC 554 Route 28 , Hyannis, MA d260S , Wendy's Wendy�s . Sparkle Food Corg. , 32 Old Townhouse Road 66 Pondside Circle . South Yarmouth, MA 02532 CentervilZe, MA 02632 . Fein: 0108095A0 , Wendy�s , Fashion Food LLC , AS Commerce Way , Plymouth, MA 02360 , Wendy's , Fashion Food LLC , 69 Long Pond Drive , Plymouth, MA 02360 , Wendy's , Fashion Faod LLC , 15 Canal Road , Orleans, MA 02653 . . , WC 00 00 Q1 A