HomeMy WebLinkAboutApplication and WC � TOWN OF YARMOUTH BO = � � � ���''�� r�
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" . ��� APPLICATION FOR LICEN$E � � `r2�11 V �
* Please complete form and attach all n�cP� ocuments by ecember I310t013.
Failure to do so will result in the return of your applic ion �Ibi DEP7.
ESTABLISHMENT NAME: ANNt G��ar7 S K,`+tf,en TAX ID:
LOCATION ADDRESS: o TEL.#: OP- 7 - 7 7/
MAILINGADDRESS:�� nev 1-l; /I 1 S.�fcLr,»��� o ����
E-MAILADDRESS: c�L2.eCt @COMCGtS-� ./Ic�
OWNER NAME: �n �ci. ��a r�
CORPORATION NAME (IF APPLICABLE):
MANAGER'SNAME: TU I�r �UC�.t-�- r 1�hr�Dyhr TEL.#: 5o8- 3�j�-7y6�
MAILING ADDRESS:_,8 fa ne.�, l�-: l l 7Jr� S 4a rM ou-�L, TM nr o��y _
POOL CERTIFICATIONS:
The pool supervisor must be certi�ed 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 employees currently certified in basic w safety, standard First Aid and
Community Cardiopulmonary Res itaUon(CPR),having one certified em on premises at all times. Please list
the employees below and attac opies of their certifications to this foru�: e Health Department will not use past
years' records. You mus rovide new copies and maintain a-flie 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.
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PERSON IN CHARGE:
Each food establishment must have at least one Person In Chazge (PIC) on site during hours of operation.
1.��U�i`N 2.���.�[i �V� ry�
ALLERGEN CERTIFICATIONS:
All food service establishments 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
certifica6on to this application. The Health Department will not use past years' records. You must provide new
copies and maintain a file at your establishment.
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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 £ile at your place of business.
i. T�,ler -r K ..1� �uar-l� a. �� `Tl�oMr� an
3�� i7nnnc. oMa c�lli 4.�� h . 7� �t r-�-e�
RESTAURANT SEATING: TOTAL# .3h
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT# L[CENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
B&B $55 CAB[N $55 _MOTEL $55
INN $55 CAMP $55 _SWIMMINGPOOL $80ea
LODGE $55 _TRAILERPARK $105 _WHIRLPOOL $80ea
FOOD SERVICE: �
LICENSE REQUIRED FEE ERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
t 0-100 SEATS $85 �lµ_d43 CONTINENTAL $35 NON-PROFIT $30
>100 SEATS $160 �COMMON VIC. $60 -iy_nZ�i =��DEKITCHEN $80
RETAIL SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
<50 sq.ft. $50 >25,000 sq ft. $225 VENDING-FOOD $25
=Q5,000 sq.ft. $80 _FROZEN DESSERT $40 _TOBACCO $95
NAME CHANGE: $15 AMOUNT DUE _ $ I'-F5•OO
"***"PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM'**•*
/ `
ADMINISTRATION _
Under Chapter 152, Section 25C, Subsection 6,the Town of Yannouth is now required to hold issuance or renewal of
any license or permit to operate a business if a person or company does 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 Yannouth tases and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES NO
MOTELS AND OTHER LODGING ESTABLISHMENTS
- - �.,. _ _
TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use, 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 elsewhere.
Transient occupancy shall generally refer to continuous occupancy of not more than trurty(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 shall
not be considered transient. 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.
POOLS
POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected by
the Health Department prior to opening. Contact the Health Department to schedule the inspection three (3) days
prior to opening.PLEASE NOTE:People are NOT allowed to sit in the pool area until the pool has been inspected and
opened.
POOL WATER TESTING: The water must be tested for pseudomonas,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 CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven (7) days of
closing.
-- _ - - - ____ _ - -
FOOD SERVICE __ _ . . _ _ , _ _ _
SEASONAL FOOD SERVICE OPENING:
All food service establishments must be inspected by the Health Department prior to opening. Please contact the
Health Departsnent to schedule the inspection three (3) days prior to opening.
CATERING POLICY:
Anyone who caters within the Town of Yannouth must notify the Yarmouth Health Department by filing the required
Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the
Health Department, or from the Town's website at www.yarmouth.ma.us under Health Department, Downloadable
Forms.
FROZEN DESSERTS:
Frozen desserts must be tested by a State certified lab prior to opening and monthly thereafter, with sample results
submitted to the Health Department. Failure to do so wili result in the suspension or revocation of your Frozen Dessert
Permit until the above terms have been met.
OUTSIDE CAFES:
Outside cafes (i.e., outdoor seating with waiter/waitress service), must have prior approval from the Boazd of Health.
OUTDOOR COOHING:
Outdoor cooking, preparation, or display oF any food product by a retail or food service establishment is prohibited.
NOTICE: Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 13, 2013.
ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO
COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
DATE:_ i 1-/�}�� SIGNATURE: ���,,����,��
PRINT NAME&TITLE: �� � >�� �yi�E,�
Rev. 10/08/13
� . . � The Commonwealth ofMassachusetts
Department of Industrial Accidents
. Offtce of Investigations
� 1 Congress Street, Sudte I00
Boston, MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Aftidavit: General Businesses
Applicant Information Please Print Leeiblv
Business/Organization Name: �N A! �!- �l7,1.Y1�c Il i fchen
Address: �'}'� � � �,�
City/State/Zip: w� `/�rMa �► �� G�,� �hone#: S'6,S''� 77� 7 7 7�
Are you an employer? Check the appropriate box: Business Type(required):
1.� I am a employer with .5 employees (full and/ 5. ❑ Retail
or part-time).* 6. [✓7RestaurantBaz/Eating Establishment
2.❑ I am a sole proprietor or partnership and have no 7, � Off'ice and/or Sales (incl. real estate,auto,etc.)
employees working for me in any capacity. g � Non-profit
[No workers' comp. insurance required]
3.❑ We aze a corporation and its officers have exercised 9. ❑ Entertainment
their right of exemption per c. 152, §1(4),and we have 10.❑ Manufacturing
no employees. [No workers' comp.insurance required]* 11.❑ Health Care
4.❑ We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp. insurance req.] 12.❑ Other
*My applicant that checks box#1 must also fill out the section below showu�g their workers'compensation policy information.
*"If the colpotate officers have exempted[hemselves,but the cotporation has other employees,a workers'compensa[ion policy is required and such an
organization should check box#1.
I am an employer that is providing workers'compensarion!insurance for my employees. Below is the policy information.
Insurance Company Name: � ��� I_�r� �� �n -
Insurer'sAddress: �.�5 dr�P,G.f1S�_�u�Gl.11�- � � �"11��nn'��iN.S
City/state/zip: 6�r70'//�0/
Policy#or Self-ins. Lic.# IA�.��1(Ln Expiration Date: o `� 9��/
Attach a copy of the workers' compensation policy declaration page(showing t6e policy number and eapiration date).
Failure to szcure cuverage as required under Section 25A of biGL c. 152 can lead to the imposition of criminai penal6es oi 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 forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify, under the pains and pena[ties of perjury that the information provided above is true and correM.
S�ature 1��i�Q �S�'�A/t'�A Date• /I"I�J' /�
Phone#: �
Officia!use on[y. Do not write in this area,to be completed by city or town officiaL
City or Town: yR2MOUTl� Permit/License#
I ' on ' cle one):
1. Board of Health 2 Building Department 3. City/Town Clerk 4.Licensing Board 5. Selectmen's Office
Contact Person:
Phone#: 5"0.4- � 3 44- 223� X 12�f1
www.mass.gov/dia
' �� blUu�GY. :�:�UL IOY
WORKERS COMPENSATION POLICY
RENEWAL POLICY
NA TAXPAYER ID N0: XXXXX6510
' NCCI N0: 32247 PRIOR POLICY N0: WC 001010
WC 001010 06/27/2013 06/2]/2014 QUINLY MUTUAL FIRE INSURANCE COMPANY 00116
1 .TTDK LLC HUDSON ELDRIDGE INS. AGENCY
DBA ANN E FRAN'S KITCHEN 265 ORLEANS RD
36 STONEY HILL DR NORTH CHATHAM MA 02650-1161
SOUTH YARMOUTH MA 02664
(508) 9k5-0446
NAMED INSURED IS: LIMITED LIABILITY CO (LLC)
OTHER WORKPLACES NOT SHOWN ABOVE: ON SCHEDULE ATTACHED IP APPLICABLE.
FEDERAL ID N0: RISK ID N0: 0043308
2. POLICY PERIOD: FROM 06/27/2013 TO 06/27/2014
12:01 AM STANDARD TIME AT THE INSURED'S MAILING AODRESS.
3.A. WORKERS COMPENSATION INSURANCE: PART ONE OF THE POLICY APPLtES TO WORKERS
COMPENSATION LAW OF THE STATES LISTED HERE: MA
3.B. EMPLOYERS LIABILITY INSURANCE: PART TWO OF THE POLICY APPLIES TO WORK IN EACH
STATE LISTED IN ITEM j.A. THE LIMITS OF OUR LIABILITY UNDER PART TWO ARE:
BODILY INJURY BY ACCIDENT 5100,000 EACH ACCIDENT
BODILY INJURY BY DISEASE $500,000 POLICY LIMIT
BODILY INJURY BY DISEASE $100,000 EACH EMPLOYEE
3.C. OTHER STATES INSURANCE: PART THREE OF THE POLICY APPLIES TO THE STATES, IF ANY,
LISTE� HERE: ALL STATES EXCEPT ND, OH, WA, WV, WY.
COVERAGE REPLACED BY ENDORSEMENT WC 20 O3 O6 B
3.D. THIS POLICY INCLUDES THESE ENDORSEMENTS AND SCHEDULES:
wc o0 00 0o a wc 20 03 02 A wC zo 03 03 D wc zo 06 0l a wC o0 03 lo
wc o0 04 zo wC 2o QM ot wc 20 ot ot wC zo 03 oi wc 20 04 05
wC 20 06 04
4. THE PREMIUM FOR THIS POLICY WIL� BE DETERMINED BY OUR MANUAL OF RULES,
CLASSIFICATIONS, RATES AND RATING PLAN. pLL INFORMATION REQUIRED BELOW IS
SUBJECT TO VERIFICATION AND CHANGE BY AUDIT:
PREMIUM BASIS RATE PER
TOTAL ESTIMATED $100 OF ESTIMATED
CLASSIfICATI0N5 CODE ANNUAL REMUNERATION ANNUAL
NO REMUNERATION PREMIUM
(SEE EXTENSION OF INFORMATIQN PAGE)
TOTAL ESTIMATED PREMIUM $1 ,226.00
DIA ASSESSMENT ( 4.200$) $41 .00
TERRORISM RISK INSURANCE CHARGE ( 3.000$) 9740 $29.00
MINIMUM PREMIUM $216.00 TOTAL ESTIMATED LOST $l ,zgb.00
DEPOSIT PREMIUM $1 ,296.00
COUNTERSIGNED BY AUTHORIZED REPRESENTATIVE: 05/06/2013
WC 00 00 01 B CONTINUED ON NEXT PAGE
INSURED COPY