HomeMy WebLinkAboutApplication and WC � 't
� TOWN OF YARMOUTH BOARD OF HEAL�'#�;,,� i
��� APPLICATION FOR LICENST�� T -2015 J'�� d�� p'�=�-� � � lO95 !
* Please complete form and attach all nece����'� c ���I)ecemher 1 S.2014. - '
Failure to do so will result in the re�i o application pack�:- ---�
ESTABLISHMENT NAME: PPU N A/A- F C £N v)- TAX ID: y G- � !'1 y o G �
LOCATIONADDRESS: /(, Z IZ•f-� 6a' �A�MsUMF�R� w�c�e TEL.#: tC�F - 7 '14-7aGL
MAILINGADDRESS: 4 � ��u�Ni�� � �� F H -P ° w� r
E-MAILADDRESS: C �. 7' � "�p,,�rs O !'��t-, eo�
OWNERNAME: Lk M �r2�+t c � 41
CORPORATION NAME (IF APPLICABLE): �' �i 1 n'�P•A�t� � t L
MANAGER'S NAME: LK �''�x�ti<< <n- TEL.#: �"'�� 7Ny�� �[�
MAILINGADDRESS: `�a � �wryi✓� ��.CI✓L `�-/� a2� ��'
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 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 oftheir certifications to this form.The Health Department wili
not use past years' records. You must provide new copies and maintain a tile 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 Establishxnents, 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 Chazge (PIC) on site during hours of operation.
1, 2.
ALLERGEN CERTIFICATIONS:
All food service establishxnents 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�le at your establishment.
l. 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 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
I7VIV $55 CAMP $55 SWIMMINGPOOL$IlOea
_LODGE $55 _'I'RAILER PARK $105 _WHIRLPOOL $1IOea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
0-100SEATS $125 _CONTINENTAL $35 NON-PROFIT $30
>100 SEATS $200 _COMMON VIC. $60 ���D.KITCHEN $80 �
IL SERVICE: -
LICEN E REQUIRED FEE RMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT k
�<50 sq.ft. $50 >25,000 sq ft. $285 VENDING-FOOD $25
_QS,OOOsq.ft. $150 _FROZENDESSERT $40 TOBACCO $ll0
NAME CHANGE: $15 AMOUNT DUE _ $ I �o "'�'
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*'***
ADMINISTRATION
lJndar Chapter 152,Seatiox125C, Subsectio�6,the Town c�f Yannauth is now required to hold issuance or renewal
af any license or permit to operate a business if a person or company does not have a Certificate of Worker's
Compensation Insurance. THE ATT'ACHED STATE WOI2KER'S COMPENSATION INSUILANCE
AFFIDAVIT MUST SE COMPLETED AND SIGNEll, pR
CERT. 4F 1NSURANCE A'1"TACHED
(7R
WORKER'S CdMP. AFFII7AVIT SIGNED ANI3 A`I'TACHED
Town of Yannouth taaces and liens rnust be paid prior to renewal ar issuance of your permits. PLEASE CHBCK
APPROPRIATELX IF PAID:
YES NO _
MOT�L5 AND OTHER IADGING ESTABLISHMENTS
TRANSIENT OCCUPANCY: For purposes of the 19mitaUons of Motel or Hotel use,Transient occupancy shall be
lrrnited to the temporary and short term occupancy,ordinarily and customarily associated with mateI and hoteT use.
Transient occupants must have and be able to demonstrate that they maintain a principal place af residence
elsewhere.Transient opcupancy shall generally refer to continuous occupancy ofnot rnore than thirry(30)days,and
an aggregate of not more than ninety(90)days wxthin 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 col4ection of Room 4ecupancy
Excise,as defined in M.G.L. c. 64G ar 834 CMR 64Ci,as amended, shall �;enerally be considered Transient.
POOLS
POQL OPENIIVG:All swimming,wading and whirlpaois which hava been ciosed for the seasan must be inspected
by the Health Deparhnent prior to opening. Contact the FIealth Departrnent to schedule the inspection three (3)
ciays priar to opening. PLBASE NOTF,: People are Nd"C allowed to sit an the paa2 area until the pool has been
inspected and opened.
POOL WATER TESTING: The water must be tested for pseudamonas,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 CL48ING: Every outdoar in ground swirnming poal must be drained or covered within seven(7)days of
closing.
FOOD SERVICE
SEASONAL FOOD SERVICE OPENING:
All food service estabiishments must be inspected by the Health Department priar to opening. Please cantact the
Health Departrnent to schedule the inspection three (3)days prior to opening.
CATERING POLICX:
Anyone who caters within Yhe Town o£Yarmouth must notify the Yarmouth Health Department by filing the
required Temporary Food Servica Application form 72 haurs prior to the catered event. These forms can be
obtained at the Health Department,oz from the Town's website at www.yarmouthma.us under Health Department,
Aownloadable Forms.
FROZEN DESSERTS:
Frozen desserts must be tested by a State certified lab pricar to apening and rnonYhly thereafter,with sample results
submitted to the Health Department. FaiIure to do so will result in the suspension or revocation of your Frozen
Dessert Permit until the abcrve terms have been met.
CtUTSIDE CAFESe
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must haue prior approval frorn tha Board o£Health.
OUTDOOR COOHING:
Outdoor cooking,prepazation,or display of any food product by a retail or food service establishment is prohibited.
NOTICE:Percnits run annually from January 1 to December 31. IT"IS YOUR 12ESPONSIBILI'('Y TO RETUIZN
THE COIv1PLETEI}RENEWAL APPLICA'I'ION{S}AND REQUIRED FEE(S}BY DECEMBER 15,2414.
ALL RENOVATIONS Td ANY FOOD ESTABLISHMENT, MO'1'EL dR POOL (i.e, PAINTING, NEW
EQIJIPMfiN"I',ET'C.},MI13T BE REPORTED'1'O AND APPROVED BY THE BOARD OF HEAI.TH PRIOR
TO COMMENCEMENT. RENOVATTONS MAY REQUIRE A SITE PLAN.
I7ATE: SIGNATURE:
PRINT NAME& TITLE:
Kev.]iJ43t14
� The Commonwealth ofMassachusetts ____
, _ . -
Department oflnde�strialAccidents ' _ - . --
Office oflnvestigations �
�1 Congress Street, Suite 1 DO � �"�%�'•� � � L 015
Boston, MA 02114-2017 �.,-.�a-�-,
www.mass.gov/dia ._ _ __.
Workers' Compensation Insurance Affidavit: General Businesses
Auplicant Information Please Print Leeiblv
Business/OrganizationName: /U ° NN� £L� ��
Address: 4 a ��v N H � K/£ 1 R �� �
City/State/Zip: '� r��ou� �Nc-��' /�Z� 61G���phone#: ��� �`�y"�D�' Z
Are you an employer?Check the appropriate bos: Business Type(required):
1.[�I am a employer with �c employees(full and/ 5. ❑ Retail
or part-rime).* - 6. ❑ RestawantlBaz/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.❑ We are a corporarion and its officers have exercised 9. ❑ Entertainment
their right of exemption per c. 152, §I(4),and we have I 0.❑ Manufacturing
no employees. [No workers' comp. insurance required]*
4.❑ We aze a non-profit organizarion, staffed by volunteers, I l.❑ Heakh Care
with no employees. [No workers' comp. insurance req.] 12.� Other
'Any applicant that checks box#1 must also fill out the section be(ow showing their workecs'compensation policy infoimation.
**If the cotporate officers have exempted theavselves,but ihe corporation has other employees,a workers'compensation policy is required and such an
orgadvalion should check box#1.
I am an employer that is providing workers'compensation insuranee for my employees. Be[ow 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 ezpirafion date).
Failwe 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-yeaz imprisonment,as well as civil penalues 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
Investiga6ons of the DIA for insurance coverage verification.
I do hereby certify, nder the pains and penalties ofperjury that the information provided above is true and correct.
Sianature: ^ Date• �1'Z �/� ��
Phone#: � � L�`� 7�� �
O�cia[use only. 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 HealtL 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office
6.Other
Contact Person: Phone#•
www.mass.gov/dia
Mass. Corporations, external master page Page 1 of 2
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Corporations Division
Business Entity Summary
ID Number: 462174066 ;Request certificatei New search:
Summary for: CU IMPORTS, LLC
The exact name of the Domestic Limited Liability Company (LLC): CU IMPORTS, LLC
Entity type: Domestic Limited Liability Company (LLC)
Identification Number: 462174066
Date of Organization in Massachusetts:
03-04-2013
Last date certain:
The location or address where the records are maintained (A PO box is not a valid
location or address):
Address: 40 DAUPHINE DR 40 DAUPHINE DR
City or town, State, Zip code, YARMOUTH PORT, MA 02675-1316 USA
Country:
The name and address of the Resident Agent:
Name: LUCILLE MATRASCIA
Address: 40 DAUPHINE DR
City or town, State, Zip code, YARMOUTH PORT, MA 02675-1316 USA
Country:
The name and business address of each Manager:
Title 4rad'ovidual name Address
MANAGER LUCILLE MATRASCIA 40 DAUPHINE DR YARMOUTH PORT, MA
02675-1316 USA
MANAGER LUCILLE MATRASCIA
In addition to the manager(s), the name and business address of the person(s)
authorized to execute documents to be filed with the Corporations Division:
Title Individual name Address
SOC SIGNATORY JOANNE BENYO 40 DAUPHINE DR YARMOUTH PORT, MA
02675-1316 USA
The name and business address of the person(s) authorized to execute,
acknowledge, deliver, and record any recordable instrument purporting to affect an
interest in real property:
http://corpsec.statema.us/CorpWeb/CorpSeazch/CorpSummary.aspx?FEIN=462174066&... 3/20/2015
Mass. Corporations, external master page Page 2 of 2
Title �Individual nam� f 1Address
REAL PROPERTY JOANNE BENYO 02675U1316 USA YARMOUTH PORT, MA
� : -v 'Confidential�- ;Merger
Consent Data Allowed Manufacturing
View filings for this business entity:
' ALL FILINGS
Annual Report � j
Annual Report - Professional =
i Articles of Entity Conversion
Certificate of Amendment w i
_� ,. _��_�:__
View filings;
Comments or notes associated with this business entity:
i
� '
I
�i
1
New search',
http://corp.sec.state.ma.us/Corp Web/CorpSearch/CorpSuminary.aspx?FEIN=462174066&... 3/20/2015
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