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Home My WebLink AboutApplication and WC ' � • ' � 7-Et.�vetJ � a � TOWN OF YARMOUTH BOARD OF HEALTH �G\' �, APPLICATION FOR LICENSE/PER11�Ii�' -2Q�15p�'�y, \ i;;y a , O 2014 * Please complete form and attach a11 necessary documerits�Sy ece� er I S 2014. Failure to do so will result in the return of your application pac et. HEAL DEPT. ESTABLISHMENTNAME: 7- r1-Ct�c�.+' FooD 57��ez TAXID: LOCATIONADDRESS: t�4 �19RlrJ ST• �t- 24I LU /uKmav7tr��.TEL.#: (5��77ft-�fi��`i MAILING ADDRESS: Ss�mG �2G"�3 E-MAIL ADDRESS: ryn ua t5�-m c@ `/ahv o- 4•r� OWNERNAME: MuArSin'1 C1tA+�alf.�y CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: /Yli� i/Y] (.�1�(-quDH72 A-SirY1 G�/fA-i�Z�if�Y TEL.#:C�s� 3b�7-o �zl MAILING ADDRESS: / WCSTyA-�rYls�Tht �J GJ�T yf1�h'!D u 7N /1'I A a�73 POOL CERTIFICATIONS: The pool suQeruisor must be certi£ed as a Pool Operator,as required by State lasv. Please list the desigiated 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 basic water safety, standard First Aid and Community Cazdiopulmonary 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 £►le at your place of 6usiness. 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. 2• _ �RSQI�IN CHlYttf'iE: _ __ __ -- — . _ 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 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 file at your establishment. 1. 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-chokmg 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. 2. 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 —INN $55 CAMP $55 _SWIMMING POOL$l l0ea. LODGE $55 _'I'RAILERPARK $105 _WHIRLPOOL $ll0ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 _CONTINENTAL $35 NON-PROFIT $30 >]00 SEATS $200 COMMON VIC. $60 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 �<25,000 sq.ft. $150 —FROZEN DESSERT $40 1 TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE _ $ 2(00. O� _ *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF F RM*'*"* �I��•� � i�.td� tr �7��+�{ �# 23� / i ♦ ADMIIVISTRATION Under Chapter 152,Section 25C, Subseatioiz 6,the Town of Yarmouth is now required Ya hold issuance or renewal o£any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insuranee. THE ATTACHETI STA'TE WOI2KER'S COMPENSATION INSUI2ANCE AFFIDAVIT MUST BE COMPLETED AND SIGNEA, OB CERT. dF INSURANCB ATTACHED OR WOR.KER'S COMP. AFFIDAVIT SIGNED ANL7 ATTACHED 'Tawn of Yazmouth taxes and liens must be paid prior to renewal ar issuance of your permits. PLEASE CHECK APPROFRIATELY IF PAID: YES _ NO _ MOTELS AND �THER LODGING ESTABLISHM�NTS TRANSIENT OCCUPANCY: Far purposes of the 1Smitations of Motel or Hotel usa,Transient occupancy sha11 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 eisewhere.Transient occupancy shall generally refer to continuous occupancy of not rnore 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 shalt not be considered transient. Occupancy that is suhject #o the collection of Room Occupancy �xcise,as defined in M.G.L. c. 64G or 834 CMR 64G,as amended, shall generally be considered Transient. POOLS PQt1L OPENING:All swimming,wading and whirlpools which have been closed far the season must be insgected by the Health llepaxtment prior to opening. Contact the Health Department to schedule the inspection three(3) days prior to opening, PLEASE NOTE: People are NOT allowed ta sit in the poal azea until the paol has tseen inspected and opened. POOL V4TATER TESTING: The water must be tested for pseudomonas,tota(coliform and standard plate count by a State certified lab, and submitted to the Health Departrnent three (3) days pcior to opening, and quarterly thereafter. i'4ClL CLOSING: Every autdaor in graund swimming pool must be drained or covered w3thin seven{7)days af closing. F40D SERVICE SEASONAL FOOD SERVICE UPENING: Ali food service establishments must be inspected by the Health Department prior ta opening. P2ease contact the Health Deparfsnent to schedule the inspection three (3)days prior to opening. CATERING POLICY: Anyotte who caters within the Town of Yarmouth must notify the Xarmouth Health Department by filing the required Tempauy Food Service App]icatian form 72 hours priar to the catered event. These forms can be obtained at the Health Department,ar from the Tawn's website at www.yatmouth.nxa.us under Health Department, Dowztloadablc Forms. FROZEN DESSERTS: Frozen desserts must be tested by a State certified lab prior to opening and rnonthly thereafter,with sampla results submitted to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit untii the above terms have been met. OUTSIDE CAF'ES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approvai from the Board of Health. OtiTrit3UR CaOKTIVG: _ __ _____ Outdoor cooking,preparation,c�r display ofaany faod product by a retail or food service establ'tshment is prahibited. NOTICE:Pezrnits run annualIy from January 1 to December 31. I'C IS YOIIR RESPONSIBILITY TO R.ETURN THE COMPLETED REiV�WAL.4PPLICATIQN(S}AND REQUIRED FEE(S}BY I3ECEMBER 1 S, 2014. ALL RENOVATIONS TO ANY FOQD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMBNT, ETC.}, MUST BE REPQRTED TC} AND APPROVED BY THE BC3ARD OF HEALTH PRI4R TO COMMENCEIvIENT. RENOVATIONS MAY REQUIRE A SITE PLAN. �ATr: I f� 20 —�1 � szG�aTu�: ��.-�;.:_. C�,s-, .; �-'t��.,r- PRINT NAME& TI1'LE: fJ'�O(�7'S!t}'] Rev. Itf03114 � t� The Commonwealth ofMassachusetts Department oflndustrial Accidents Office oflnvestigations I Congress Street, Suite I00 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legiblv Business/OrganizationName: % - ELC-VEN STO12L Address: 4��I I'}��}/N �7"�'CC-T d2fi• Z£� City/State/Zip: Ct)f�ST� y�(L(Yl pc117+�/YI F}o zb�j Phone#: S��—�7�-H��l Are you an employer? Check the appropriate box: Busine s Type(required): 1.[� I am a employer with � employees (full and/ 5. �Retail or part-time).* 6. ❑ RestauranUBarBating Establishment 2.❑ I am a sole proprietor or partnership 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] g• ❑ Non-profit 3.❑ We aze a corporation and its officers have exercised 9. ❑ Entertainment their right of exemprion per c. 152, §1(4),and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]* 1 I.❑ Health Care 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 Sll out the section below showing the'v workers'compensation policy infoimation. :•If the colpornte officets have exempted themselves,but the corporatlon has other employees,a workers'compensation policy is required and suc6 an organization should check box#1. I am an employer that is providing workers'compensation insurance for my employees. Be[ow is the po[icy information. InsuranceCompanyName: /Y717SU/ SU91�170M0 ��RR7✓�l3 C�mP�M'y Insurer'sAddress:�PLfFCrs �N7E/z E�ST, a.-J11 N N f}SKELL. /-�-VEy STE�dp L•8-8' CiTy/State/Zip: �PrLLRS TX 752D`1 -7�9g Paiicy#-ar3�lf=ins:tic.#-- ��}�{� �-s��s�4L --- --- ----�xpiratianBate�- �=L---��-SJ- - Attach a copy of the workers' compensation policy declararion page(showing the policy number and espiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalries 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 forwazded to the Office of Invesrigations of the DIA for insurance coverage verification. I do hereby certify,under the pains andpena[ties ofperjury that the information provided above is true and correct. Sienature• �l!l�J.�-� Date• � � � Z� �' 1 Phane#: Official use only. Do not write in this area,to be comp[eted 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 - rcxicVrii�vteeR WCP8525402 STANDARD WOFKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY Mitsui Sumitomo Insurance Group wc 00000ia POLICY NO -WCP8525402 INFOFiMATION PAGE -STANDAI� POLICY -RENEFTAL NCCI COMPANY NO. 19089 • -• � � . r�resasaoa oi-oi-zoia oi-oi-zois nar�v�. a•: MITSUI SI7MITOMO INSIIRANCE oo3osoo wceasasaoa COMPANY OF AMERICA � • � • ��- � 1.MUATSIM CHAUDHRY �AON RISK SRVC SW/FRNCHS 7-11 DBA: '7-ELEVEN NO. : 2464-25933D CITYPLACE CENTER EAST 444 MAIN STREET . 2711 N. HASKELL AVE. , STE 800 L.B.8 WEST YARMOUTH MA 02673 DALLAS TX 75204-2999 FEIN # laatlons-NI usual work placetl W�he inwretl at or irom whid�operauons oovered by Mis Doliq are conduded or loceted at Ihe ebove atltlress unless otl�envise staietl herein: SEE IXtENSION OF MFORMATION PPGE ENTITY OF INSUFiED - INDIVIDIIAL 2. THE POLICY PEF�OD IS FROM 01-01-2014 TO 01-01-2015 12:01 AM STANDARD TIME AT THE INSUF�D': MAILING ADDRESS. 3A. WORKERS COMPENSAT�ON INSURANCE: PART ONE OF THE POLICY APPLIES TO THE VNOFKERS COMPENSATIO� LAW OF THE STATES LISTED HERE: PlP, 36. EMPLOYERS LIABILITY INSUR4NCE: PARTTWO OF THE POLICYAPPLIES TO 1M�F�( IN EACH STATE LISTED IN ITEIv 3A. THE LIMITS OF OUR LIABILITY UNDER PARi TWO ARE: BODILY INJUFiY BY ACCIDENT $ 500,000 EACH ACCIDENT BODILY INJURY BY DISEASE $ 5U0,000 EACH EMPLOYEE BODILY INJUFfY BY DISEASE $ 500,000 POLICY LIMIT 3C. OTHER STATES INSURANCE: PARf 3 OF THE POLICY APPLIES TO THE STATES, IF ANY LISTED HERE: ALL STATE: EXCEPT STATES LISTED IN 3A AND ND OH WA WY 3D. THIS POLICY INCLUDES THESE ENDORSEMENTS AND SCHEDULES: SEE EXTENSION OF INFOf�fNATION PAGE. 4. THE PREMIUM FOR THIS POLICY WILL BE DETEFMINED BY OUR MANUALS OF flULES, CLASSIFICATIONS, RATES ANI RATING PLANS. ALL INFORMATION REQUIfiED BELOW IS SUB.IECT TO VEPoFICATION AND CHANGE BY AUDIT. PREM BASIS RATE EST ST LOC CODE CLAS$IFICATION DESCPoPTION TOTAL EST PER$100 ANNUAL ANNUAL REMUN REMUN PREMIUM SEE EXTENSION OF INFORDMTION PAGE $ 2,011 i PREMIUM DISCOUNT: $ ! MINIMUM PREMIUM $ 232 EXPENSE CONSTANT: $ 338 � DIVIDEND PLAN(S): TOTAL ESTIMATED CHARGE: $ 2,455 ASSESSMENTS& TAXES: $, 67 DEPOSIT PREMIUM: $ 2,455 BILLING INFOFiMATION WILL FOLLOW � � � � � PREMIUM ADJUSTMENT SHALL BE MADE ANNUALLY. `� �� _�'c"""c-- COUNTERSIGNED THIS DAY OP ,79 - ISSUE DATE 01-06-14 ISSUINGOFFICE: LOS ANGELES AUTHOPoZED REPflESENTATIVE COPYRIGHT1987,NATIOWILCOUNCLONCOMPENSATION INSUR4NCE WC 990A(1-97, MSUR�COPY