HomeMy WebLinkAboutApplication and WC � —
a � TOWN OF YARMOUTH BOARD OF HEALTH
��� APPLICATION FORLICENSE/PER�1��o5, ��; U�.� CJ � YO�4
* Please complete form and attach ail necessary do m nts by Dece �be • ,�,�PT �
UN tT E Failure to do so will result in the return of your agplication p
ESTABLISHMENT NAME: Y `� r� � 7w '.5 !z Z v TAX ID: �
LOCATIONADDRESS: �,� t �5fv-� /J /�v�- �'c���'��-cfl �1f G'�e'��yTEL.#: 5-cd-��5'-6G�'•�''
MAIL,INGADDRESS: 6s �i/���i'n6���>' Ci`vc%� ,�s� �n�-oc. ,u% oz65��
E-MAILADDRESS: / -r� �n 's ��'e �c%� fne� . con�
OWNER NAME: �'�'r< � ; m i�- z hr� /-r ✓
CORPORATION NAME (IF APPLICABLE): CC j`�'�z z�.; -����
MANAGER'S NAME: �� i��i/��•= T�� �'e v ' TEL.#:3z�.� �c"G -�176�%
MAILINGADDRESS: Sf�/Q��v�r'S ��J U����f a�-naG��/� �G//� OZ6'7�
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.
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1 2 _ _
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 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. l��c��i no_ L��-z �/�% 2. �r��? �Xi.�S17-� di.�-
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 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 Department will not use past years' records. You must
provide new copies and maintain a file at your establishment.
1. �z�.�- li�)�__ L�, �v;; 2. �n,�v �t' VS� � d�LL
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 wpies and maintain a file at your place of business.
1. 2.
3. 4.
RESTAURANT SEATING: TOTAL# �
OFFICE USE ONLY
LODGING:
L[CENSE REQUIRED FEE PERMIT# LICENSE REQU]RED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
B&B $55 CABIN $55 MOTEL $110
INN $55 CAMP $55 SWIMMINGPOOL$110ea.
LODGE $55 TRAILERPARK $105 WHIRLPOOL $110ea.
FOOD SERVICE:
LICENSE REQUIRED FEE P RMIT# LICENSE AEQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
I 0-100 SEATS $125 lS-0 CONTINENTAL $35 NON-PROFIT $30
>]00SEATS $200 �COMMONVIC. $60 �r�� 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 _TOBACCO $110
NAME CHANGE: $IS AMOUNT DUE _ $ � gS •OCJ
*****PLEASE TURN OVER AND COMPLETE OTHER S►DE OF FORM*****
1Z2� `c( ,�I�S. 6d
(�-�o�� i�c�b���\
ADMINISTRATION
Uxider Chapter 152,Section 25C,Subsection 6,the Town af Yarmouth is naw required ta hold issuance or renewal
o£azry license or permit to operate a business if a person or compar�y does not haue a Certificate of Worker's
Compensation Insurance. THE AT'TACSED STATE WOi2KER'S COMPENSA7"IQN INSURANCE
AFFIDAVIT MUST BE COMPLETF.D AND SIGNED, OR
CERT. OF INS'[JRANCE A"TTACHE:D�_
OR „ l
WORKER'S CtJMP. AFFIDAVIT SIGNED AND ATTACHLD `1
Town of Yannouth taxes and liens rnust be paid prior to renewal c�r issuance ofyour permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES t� NO
MOTELS AND OTHER LODGING ESTABLISHMENTS
7'RANSIENT OCCUPANCY: For purposes ofthe limitarioras oYMotel or HoY�l us�,Transi�nt 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 ahle To demonstrate that they maintain a principal place af residence
elsewhere.Transient occupancy sha11 generally refer to continuous occupanoy of'not more than thiriy(30)days,and
an aggregate of not more than ninety(90)days w'rthin any six(6)mqnth period. Use of a guest unit as a residenoe or
dwelling unit sha(1 nat be considered transient. Occupas�cy t]1at is subject to the coilection of Kaom Occupancy
Excise,as defined in M.G.L. c. 64G or$34 CMI2 64G, as amended, shall generally be considered Transient.
POOLS
POOL OPEI�tING:All swimming,wading and whirlpools which have been clased far the season must be inspected
by the Health Dep�xtment prior to opening. Contact the Health Departmeilt to schedule the inspection three(3)
days prior to openin�. PLEASE NOTE: People are NOT allowed to sit in the pool area until the pool has been
inspected and apened.
POOL WATER'CESTING: 'The water must be tested fbs pseudomonas,total coliform and standard plate caunt
by a State certified lah, and submitted to the I�ealth Department three (3} days pcior to opening, and quarterly
tihereafter.
F40L CLOSING. Eeery outdoor in ground s�vsmmiflg paaC must be drained or cavered within seven(7)days of
olosing.
FOOI� SF,RVICE
SEASONAL FOOD SERVICE OPENING:
All food servsce establishments must ba inspected by the Health DeparCment prior to opening. Please cantact the
Health Department to schedule the insp��ti�n three {3)days prior to opening.
CATGItING POLICY:
Anyone who caters within the Town of Yarmouth must notify the Xarmouth Health Department by Fiting the
required Ternparary Food Service Application form 72 hours priar to the catered event. These forms catz be
obtained at the Health Department,or fram the Town's website at www.yarmouth.ma.us under Health Department,
L7ownloadable Forms.
FROZEN DESSERTS:
Frozen desserts must be tested by a State certified lab prior to opening and tnoizthly thereafter,with sample results
submitted to the Iiealth Departtnent. Failure to do so will result in the suspension or revocation of your Frozen
L}essert Permit untii ihe abave terms have been met,
t}UTSIDE CA�ES.
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health.
OUTDOOR C04HING:
Outdoor cooking,preparation,Ur display of any food product by a retail or food service establishment is prahibited.
NOTICE:Pezmits run annually from January 1 to December 31. IT IS YOUR 12ESPONSIBILITY TO RETURN
THE COMPLETED RENEWAL APPLICATIC}N{S)AND REQUIRED FEE(S}BY DECEMBER 15,2414.
ALL RENOVATIONS TO ANY FOOD ES7'ABI,ISHVIENT, MO'I'EL OR POOL (i.e., PAIN`T"iNG, NEW
TQUiPMEN'I', ETC.}, MUST BE REFORTED'TO AND APPROVED BY TT-IE Bt}Al2D OF IIEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY REQU1I�A SI PLAN.
f�
DATE: (�f z UI y SIGNATIJRE:
PRINT NAME & TI'fLE: �t-iz si/7�i l' Z�U! -� t� '�eS r �l L' /� �
Rev. 11/Q3f34
� The Commonwealth ofMassachusetts
Department oflndustrialAccidents
- Office oflnvestigations
1 Congress Street, Suite I00
Boston, MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Aunlicant Information Please Print Legiblv
Business/OrganizationName: �C �j ZZ�� lnc ��i� �e=/'�� �'�'�%-S ✓ ,�2 z�-
Address: G � Th 0/h h�r�y Gi'r���e
City/State/Zip: /�G= S ����-� �� �L G y� Phone #: :S',�-�6�"��/��
Are ou an employer? Check the appropriate boa: Business Type(required):
1.� I am a employer with /-5 � employees(full and/ 5. ❑ Retail
or part-ume).* 6. ❑ RestauranUBar/Eating Establishment
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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 warkers' comp. insurance required] 8• ❑ Non-profit
3.❑ We are a corporation 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 required]*
4.❑ We aze a non-profit organization, staffed by volunteers, 11.❑ Health Caze
with no employees. [No workers' comp. insurance req.] 12.0 Other
*Any applicant that checks box#1 mus[also fill out the secrion below showing their workers'compensation policy information.
**If the co:porate officers have exempted[Uemselves,but the corporauon has other employees,a workezs'compensation policy is�equired and such an
organizalion should check box#I.
I am an employer that isproviding workers'compensa/tion insurance for/my employees. Be/ow is thepolicy information.
Insurance Company Name: /`i��l�U�.0 � ��l� � �'�I �-c-�-�� �T�-�-<%� �d'��� -� �') �u i'cz l�C� ��
Insurer's Address: Z 2 Z /? �1 e S � Jr-l�' 'i
City/State/Zip: �����=� �� �������
Policy# or Self-ins. Lic. # wC (/J�yJ��� Sxpiration Date: �� l z �� =5
Attach a copy of the workers' compensation policy declaraHon page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL a 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 forwazded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify,under t pains an penalties ofperjury that the information provided above is true and correct.
Si ature: Date: Z `/ �U�y
Phone#: J� d�- 5 '�-/`��
Official use on[y. Do not write in this area,to be comp[eted by city or town officiaL
CiTy or Town: PermitlLicense#
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
WORKERS COMPENSATIQN AND ERAPF.4YERS'�lABILTY
INSURANCE POLICY--�•INFORMATION PAGE
INSURER: POLICY NO: �115996A
NORFOLR & DSDHAM MUTUAL FSR23 ZNSIII2ANCE COt+IPANX RBNEWAL
222 AMES STREET
DBDHAM, �SA 02026 NCCI Company No: 21059
Acc;ountNo: g63fl46110
FEIN:
I7EM 1. NAMEO INSURED AND MAILING ADDRESS: AGENT NAME AND ApDRE33:
KC PIZZA INCORP4RATED DSA DOMItT4'S PTZZA A. DAVID 12ISMAN INSVRANCE
65 THOI2NS�RRY CSI2CLE p+��Y
MASHl'SE MA 02649 6$9 88LLSPFAY
MEAPOE�D, MA 82155
AGENT NQ.: 2d722
tEGA�EN71TY. �pRP4RATION
O7H�R WORKRLACES NOT SHOWN ABOYE: (See Workers Campensation Classification Schedule)
ITEM2. P4E.IGYPERIOQ: From: 04J12J2414 To: 09J22J2015
Effective 12:01 A.M.Standard Time ai tMe Insured's maili�g address.
ITEM 3. COVERAGE:
A. Workers Compensation Insurence: Part One of the policy applias to the Workers Compensation Law of the
states Iisted here:
MA
B. Empioyars'Liabiiity insurance: Part Two of the pdicy appiies to woric in each s3ate Iisted in item 3.A. The iimits
of lia4ility under Part Twa are:
Bodily injury by Accident: $ 500,040 each a�ident
Badily Injury by Disease: $ SG4, OOp policy limft
Bodiiy injury by Disease: $ �p��ppp each empioyee
C. Qther States Insurance: Part Three oi the pniicq apaliEs:o t!:=stakes, if a�y,listed here:
SSS SNDOIt3TsMSNT WC 20 03 OS B
D. This Policy irrciudes these Endarsemsnts a�rd Schecfuies: -
_. - .
See 5chedule of Forms and Endorsemerrts. -- "�
_ _ __,_ __, ._....
iTEM 4. PREMIUM:The premium for this Policy will be determir�etl by our Manuals of Rules, Clessifications, Rates and
Rating Plans. A3i information reguired on the Workers Compensatian C3assi#"�cation Schedule is subjed to
verification and change by audit.
7ofai Estimated
Minimum Premium: $ 4gg flnnual Premium: $ 3g, 971
Audit Period: g�pi, Rdditianal/Retum Premium:
Comments :
Issued At:
Date: 08/O5/2414 Countersigned by
WC W1 00 Q1-A Copydpht 1887 Nationai Councli on Compensetion insuranca
�ruuaEo coar