HomeMy WebLinkAboutApplication and WC J��YAk� TOWN OF YARMOUI'H BOARD OF HEAL '"� �'`��.
��,z APPLICATION FOR LICENSE/PER1tiIT#'-,�,2�"�i `� �t� � � � � � � � �7 � DD
iAN 0 3 2008
* Please complete form and attach all necessary documents iry 155ecember 3 2007.
Failure to do so will result in the return of your application packet. HEALTH DEPT.
NAMEOFESTABLISHMENT: C�PEt� Z�iLPNDS AVTIiENTZC TNAi CUISZNESTEL. # 5�08 ��1 �L�{
LOCATION ADDRESS: Sq 4 MI+IN Si. w�ST y �2 MOUT li rHA o Y 6�3
MAILING ADDRESS: 4 M ATn� . W ES Y� RMO UT H �"�A O g 6'�3
OWNER NAME: E AV M po RN S 1 T i 2 P4UM TAX ID (FEIN or SSNI:
CORPORATION NAME (IF APPLICABLE): y,jp�V(� g Rt7 oM �cv�AfJ- �SN � .
MANAGER'S NAME: PIGHET N�y0lh SI N TEL. # SOg �al
MAILINGADDRESS: �iq4 MAz/� �j}. wFSi YAR VTF► Mq oQ(,�3
POOL CERTIFICATIONS:
The pool supervisor must be certitied 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 Cazdiopuimonary Resuscitation(CPR). Please list these employees below and attach copies ofemployee
certifications to this form. The Health Department will not use past years' records. You mast provide aew�
copies and maintain a file at your place of business.
l. 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 cenification to this application. The Health Department wi}I not use past years'records.
You must provide new copies and maintain a file at your establishment.
i_ PZCNFT NI yDMSl'N Z.
PERS(9N IN C�-TARGE:
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operarion.
1. �ZCNET N� YO �"�SZN 2,
HEIMLICH CERTIFICATIONS:
All food service establislunents with 25 seats or more must have at least one employee trained in the Heunlich
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' rewrds.
You must provide new copies and maintain a Cle at your place of business.
1, prc+�Ez NrYOMSrn� 2. �RAN �C TOwNS
3. 4.
RESTAURANT SEATING: TOTAL # 3�7
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PER'�IIT# LICENSE REQL'IRED FEE PER4II7� LICENSE REQL'IRED FEE PERbfIT=
_B&B 550 _CABIN S50 _M07EL S50
INN S50 CA.'�fP S50 _SN'I�I.�4INGPOOLS75ea �
LODGE S50 TRAILERPARK 5100 ��'FIIRLPOOL S75ra.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT� LICENSE REQI;IRED FEE PER1•IIT a LICEtiSE REQti IRED FEE PERbtIT=
I 0.100 SEATS 575 �Q� _CONTINENTAL � S?0 _NON-PROFIi S25
>100SEATS 5150 1 COYIl�IONVIC. 550 �bP'OE�O R7-IOLESALE 575
RETAIL SERVICE: . —RESID.KITCHEN S75
, LICENSE REQUIItED FEE PERMTI= LICENSE REQUIRED FEE PER�D'I= LICEIv'SE REQL7RED FEE PER4SIT=
_<50 sq.ft. 545 >25.000 sq.ti. 5200 _VENDING-FOOD S20
_Q5,000 sq.ft. S75 _FROZEN DESSERT S35 _TOBACCO S50
vaHe C��vice: sio AMOUI�T DUE _ $ /�5•od
� •""*'PLEASE TL'R.\O�'ER?1_\D C031PLE'IE OTHER SIDE OF FOR�i•"**"
N4� ow�lER�oftP.
.. ;.
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 dces 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 taues and liens must be paid prior to renewal or issuance of your permits. PI.EASE CHECK
APPROPRIATELY IF PAID:
YES NO
MOTELS AND OTHER LODGING ESTABLISHMENTS
TRANSIENT OCC[JPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be
limited to the temporary and short term occupancy, ordinazily and customarily associated with motel and hotel use.
Transient occupants must have and be able to demonstrate that they maintain a principal place ofresidence elsewhene.
Transiern 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 si�c(6)month period. Use of a guest unit as a residence or
dwelling unit shall not be considered transie�t. Occupancy that is subject to the collection of Room Occupancy
Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient.
* NOTE: En�tosea Motel Census must be completed and returned w;ch tt�s�pticarion.
POOLS
POOL OPENING: All swimming,wading and whirlpools which have been closed for the season must be ins ected
by the Heakh Department prior to opening. Contact the Health Department to schedule the inspection five(�days
pnor to opening.
POOL WATER 1'ES1'ING: The water must be tested for pseudomonas,total coliform and standard plate count
by a State certified lab, prior to opening and quarterly thereafter.
POOL CLOSING: Every outdoor in ground swirruning pool must be drained or covered within seven(7)days of
closing.
FOOD SERVICE
CATERING POLICY:
Anyone who caters within the Town of Yazmouth must notify the Yarmouth Heatth Depart�nent by filing the required
Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the
Healt6 Department.
FROZEN DESSERTS:
Frozen desserts must be tested on a monthly basis by a State certiSed lab. Test results must be sent to the Health
Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit wrtil the
above terms have been met.
OUTSIDE CAFES:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must haue prior approval&om the Board of Health.
OUTDOOR COOKING:
Outdoor cooking,prepazation,or display of any food product by a retail or food service establishmert is prohibited.
N01TCE:Permits run annuaily from January 1 to December 31. TT IS YOUR RESPONSIBILI'TY TO RETURN
THE COMPLETED APPLICATION(S) AND REQUIItED FEE(S)BY DECEMBER 31, 2007.
ALL RENOVATIONS TO ANY FOOD ESTABLISf�vIENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT, ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR
TO COMME:VCEME�IT. REVOVATIONS MAY REQUIRE A SITE PLAN.
DATE: SIGNATURE: wANIDA 4Rl7oMKu�Ar1
PRI:VTNANiE&TITLE: •1NhNf� P �Rf�aMKwAN-
io?on�
� The Coinmonwealth of Massackusetts
Dcpartment of Industrial Accidentc
NK/N�
600 R'ashington Street, 7`k F[oor
Boston,Mass. 02111
Workers'Compe�satioe Iav�a�ee A�davil:Baildiog/Plambug/Eledrleal Contnctors
s....H...r�.u.�.�t.,.. Pkatle PRiPiT Ie�blv
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,�g: 5q �- M �{arv St.
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��s��i�n�rrwi�5r
❑ I am a 6omoowner petfoiming all wotk myself. Project Type: ❑New Camstiuc.Kion❑Remodel
❑ I am a sole proprietm and have no oce wo�lcing in any capacity. ❑Bwlding Addition
❑ I am an employer providin,g wortkecs'compengation faz my employees wodcing on this job.
�mo,..��- CAPt & �SCANI�S �TN�NTZI. T+�AZ C�ISINES
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❑ I am a sole propiietor,geeeral eo�trxMr,or iomeow�a�(cirde owej�d have Lired tbe con4xtois listed below who Lave
the following workas'compensation polices:
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ox ynn'imprbaaoeat a�ew,u eM peWtles�e me fara Ma 37O!WORIC ORDER atl a Bee NtIM.N a da�aphst.e. I mdnsh�d Hu a
ropy a[tlb ehrseel m�y 6e f�}waM[d!s tht Omce�Inatl�en stHe DIA hr cevenge verMnllx.
/do 6ereby cer6fy axder tAe patns anJ pewltfes o.�P`7�+RY dYH Me Infanwdion�savtJeAabore Le bwe °�ry
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Print name � `�f'1`� �I t T I' � G'^'� Phone# �D�S� "7�7 � ol T 6'�J
a�cial me aely do 9et wrke b t�s area te 6e nsPlMd bY dl9 or Ywa a�cLi . .. . .
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NOTICE NOTICE
TO V; ; TO
EMPLOYEES ; EMPLOYEES
The Commonwealth of Massachusetts
DEPARTMENT OF INDUSTRIAL ACCIDENTS
600 Washington Street, Boston, Massachusetts 02111
617-727-4900
As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this will give you
notice that I(we)have provided for payment to our injured employees under the above mentioned
chapter by insuring with:
ASSOCIATED INDUSTRIES OF MASSACHUSETTS MUTUAL INSURANCE COMPANY
NAME OF INSURANCE COMPANY
54 THIRD AVENUE P.O. BOX 4070 BURLINGTON MA 01803-0970
ADDRESS OF INSURANCE COMPANY
VWC 6005913012007 08/27/2007 - 08/27/2008
POLICY NUMBER - EFFECTIVE DATES
Elizabeth S Puleo Insurance 6 Munroe Street
Agency Lynn MA 01901 (781) 581-5656
NAME OF INSURANCE AGENT . � ADDRESS PHONE �
Cape& Island Thai Food Corp 594 Main St. W. Yarmouth, MA 02673
EMPLOYER � � .- � ADDRESS
OS/27/2007
EMPLOYER'S WORKERS COMPENSATION OFFICER(IF ANY) DATE
MEDICAL TREATMENT
The above named insurer is required in cases of personal injuries arising out of and in the course of employmen[to furnish
adequate and reasonable hospital and medical services�in accordance wifh the provisions of[he Workers Compensation Act.
A copy of the First Report of Injury mus[be given [o[he injured employee. The employee may selec[his or her own physician.
The reasonable cost oT-the services provided by the treating physician will be paid by the insureq if the treaiment is necessary
and reasonably connected to the work related injury. In cases requiring hospital atten[ion,employees are hereby notified tha[
the insurer has arranged�for such attention a[[he �
NEAREST AND BEST MEDICAL FACIUTY
. NAME OF HOSPITAL ADDRESS � �
TO BE POSTED BY EMPLOYER
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
AMENDMENT OF INFORMATION PAGE
AMENDMENT TO MAILING ADDRESS AS FOLLOWS:
594 MAIN STREET
W. YARMOUTH, MA 02673
Th¢entlorsemeM is altachetl ro ihe Ooliry indicaled bebw aM is eHective on ihe tlate statetl heraq�at 12:01 AM.,slantlarE time
a�ihe atldress W Ue insured as Eescribed in Ne iMormation page.
Policy No: � Safety Group 6cpira6on Date of Policy E%ective Dale of Endorsemenl Endorsement No.
VWC 6005913012007 - 08/27/2008 � OS/27/2007
Issued to � Atlditional Premium ReWm Premium
Ca e&Island�Thai Food Co
ISSUED BY: ASSOCIATED INDUSTRIES OF MASSACHUSETTS MUTUAI INSURANCE COMPANY
BOUND BY: sbindman 09/11/2007
PLACING OFFICE 604 � . . �
Countersiqnee ��
. AuMonzetl Representative
N0T10E OF ASSIGNMENT _ ____.__
--------_— -------- -- ---�pMso i.D. -- gTATUS OF EMP�vYen
EMPLOYER: � 000093202
EAVMPORI3 SITTIPLUM D8A CAPE & ISLAND � � (G 5 I_; \'A s U
AUTHENTIC THAI FOOD GpyERAGE GROUP
594 RTE 28 �t� 7 6 �QQ�
:+I YARMOUTH, MA 02673 0093202
HEAL i H DEPT.
Co�•erage under this assigzunent
Tne Wa:ver of Our Right to applies to Massach�setts
Recover from Others Endorsement operations only. For coverage
is available on Pool policies. ouCside of Massachusetts, contact
Contact your agent for details. the appropriat.e Pool or Plan for
that state.
�NSURANCE COMPANY:
AGENT ALMEIDA & CRRLSON INS AGCY I, AjI" MUTUAI, INS CO
OR 92 TUPPER RD . �
PRODUCER: SANDWICH, MA Q2563 iMS. JUDITH BARRY
i54 THIRD AVENUE
� BURLINGTON, MA Q1803-0970
; (800; 8'76-2')65, Ext: 8704
AGENCY FEIN:
�--------- ---- ------
CLASSIFICATION OF OPERATION CLASS ESTIMATED RATE ESTIMATED
CODE TOTAL ANNiTAL PREMIUM
RSM[RvERATION
RESTAURANT NOC 9679 $16, 000 1.19 $182
EMPLOYERS LIASILITY 100/100/500 9845
STAIdDARD PREMIt7Pl 5182
LOSS CONSTANT 0032 $20
EXPINSE CONSTANT 0900 $I59
TERRORISM CHARGE 974Q $5
TOTAi, POLICY MINIMUM PREMIUM $219
TOTAL ESTIMATED PREMIUM $366
DIA ASSESS. 6.38 $11
TOTAT, EST. PREMIUM PLUS ASSESSMENT $377
INSTILLLMENTBASI3; Annual DEPOSRPREMlUM: $377
-- -- —`---_--- THiS IS NOT A BILL__.
COMMENTS �
Cove:age effective 12: 01 AM on i2/02l08
Subject to 48/27 Anniversary Ra[e Date.
DATE OFNOTCE: 12J09/OB PREPARED BY: Theresa Schofield
£X': 542
• : VOL41iT11RY DIRiCT 1188Z8E�NT • •
LE7TERID: 2716858 COPY: �'MPLOYEk
The Workors'Compensation Rating and Inapectlon Bureau of Massachus�tts
101 Arch Strest• Bostan, MA 02110
{61Tj439•9030 � FAX(617ti439-6055 • www.wcribma.ory