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Home My WebLink AboutApplication and WC . . A� - �� TOR'N OF YARMOUTH BOARD OF HEALTH ti� � ��C/< <�, _ �¢. , APPLICATION FOR LICENSE/P�RMiT -201 DEC O 4 2012 �` � V * Please complete form and attach all necess cu�epE��d� �� r IS 2012. Failure to do so will result in the return�your apphcation pack t. H DEPT. ESTABLISHMENT NAME: ANN r Fi'Y.�n S �C�-1z1�e� TAX ID: �• .; LOCATION ADDRESS: '�?! R�. .2 S� TEL.#: Sb�-7'7S- 7 77J MAILINGADDRESS: Y� yAcfMti��Th ,��'Z3 OWNERNAME: �,E�r� T�t��r-l� CORPORATION NAME (IF APPLICABLE): —f`T K MANAGER'S NAME: � TEL.#: D - - MAILING ADDRESS: 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 copv of the certification to this form. 1. 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standazd First Aid and Community Cardiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Deparhnent 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. L ��rcL, �Ua,f� 2. ) Y �� 1.7vtt,r � FER.;�:`d .TP: �I�ARG�: __ _ _ ___ _ . -- -_ Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. �.�� 'l��cet�-�e. 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. IJ.YhYG � 1V ��' � �(�i �a �G,1'f� 2. �.�u ll�ontii'JSa�, 3. �Or'1 ilQ�hawt�t 4�il;�— 4. �S' � �,�cj' RESTAURANT SEATING: TOTAL# '�(� OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQIDRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 _MOTEL $55 INN $55 CAMP $SS _SWIMMING POOL $SOea LODGE $55 TRAILERPARK $105 _WHIRLPOOL $SOea. FOOD SERVICE: � LICENSE REQUIRED FEE PERM[T# LICENSE REQUIRED FEE PERMIT# LICENSE REQUtRED FEE PERMIT# I 0-100SEATS $85 /.J– —CONTINENTAL $35 _NON-PROFIT $30 >100 SEATS $160 I COMMON VIC. $60 .�-/3�USI _WHOLESALE $80 RETAIL SERVICE: —RES[D.KITCHEN $80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<SOsq.ft. � $50 >25,OOOsq.ft. $225 _VENDING-FOOD $25 <25,000 sq.ft. $80 —FROZEN DESSERT $40 _TOBACCO $95 NAME CHANGE: $15 AMOUNT DUE _ $ /N5. 00 ***"*PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM****• 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 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 Yarmouth ta�ces and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES � NO lYIOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient 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 able to demonstrate that they maintain a principal place of residence elsewhere.Transient occupancy shall generally refer to continuous occupancy of not more than thiriy(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 Deparhnent to schedule the inspection three(3)days prior to opening.PLEASE NOTE: People aze NOT allowed to sit in the pool azea 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 Department to schedule the inspection three (3) days prior to opening. CATERING POLICY: Anyone who caters within the Town of Yarmouth 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 Depariment,or from the Town's website at www.varmouth.ma.us under Health Deparhnent, 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 will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside-cafes(i.e_,qutdoarseatin�with�raiter/waiYress service),must havE pri�r anproval from tUe Bnacd ofHealth.- OUTDOOR COOHING: Outdoor cooking,prepazation,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 15, 2012. 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 REQ RE A SITE PLAN. DATE: /��/ Z SIGNATURE: �� ,�.�� PRINT NAME & TITLE:�� L• d�u4✓�e - �,„„� e�--- Rev. 10/09/12 � The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Auulicant Information Please Print Leeiblv Business/Organization Name: NI�yF I'(l,tP�S �ja�� _ Address: City/State/Zip: Phone#: Are you an employer?ChecJc the eppropriate box: , _ Business Type(require�): , 1.❑ I am a employer with employees(full and/ 5. ❑ Retail or part-tune).� 6. ❑RestauranUBaz/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 aze a corporarion 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]* 11.0 Health Caze 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 t!1 must also fill ou[the sec[ion below showing their workers'compensation policy infortnation. "*If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organiza[ion should check box#1. . I am an employer that is providing workers'compensation insurance for my employees. Be[ow is the policy information. Insurance Company Name: Insurer's Address: CiTy/State/Zip: - Policy-#-orSelf-ms.Lic.# � _-- --- _ _ Ex�atiar,�ata: - — - Attach a copy of the workers' compensatiou policy declaration page(showing the policy number and espiration date). Failure to secure coverage as required under Secrion 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 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 the pains and penalties of perjury thai the informaHox provided above is true and correct. Sienature: Date� Phone#: OJficial use only. Do not write in this area,to be completed by city ar town o�cial City or Town:_ /A{LINOU77}- Permit/License# Iss ' 'rcle one): .Board of Health 2 Building Department 3.City/Town Clerk 4.Licensing Board 5. Selectmen's Office ther ContactPerson: Phone#: �OS—.398-a,3� X l'�"y� � . � � � � - � � - www.m9ss.gov/dia . .. . � . DECIARATION PAGE - L �� 62UINCY MUTUAL GROUP � 57 Washington Sfreet D i r ec t B i 1 1 9ulncy,MA 02769 N i ne Pay BUSINESSOWNERS RENEWAL BO 107485 10/08/2012 10/08/2013 QUINCY MUTUAL FIRE INSURANCE COMPANY 00116 TTDK LLC HUDSON ELDRIDGE INS. AGENCY ANN AND FRAN'S KITCHEN 265 ORLEANS RD 38 STONEY HILL DRIVE NORTH CHATHAM, MA 02650-1161 S0. YARMOUTH, MA o2664 (508) 945-0446 IN RETURN FOR THE PAYMENT OF THE PREMIUM, AND SUBJECT TO ALL THE TERMS OF THIS POLICY, WE AGREE WITH YOU TO PROVIDE THE INSURANCE AS STATED IN THIS POLICY. POLICY PERIOD 12:01 A.M. STANDARD TIME AT YOUR MAILING ADDRE55 SHOWN ABOVE. BUSINESS DESCRIPTION Form of Business : OTHER ORGANIZATION Insured's Business: LUNCHEONETTE DESCRIBED PREMISES PREM BLDG 001 001 471 MAIN ST, W YARMOUTH, MA 02673 � s E Terrorism Premium (Certified Acts) $5 � Businessowners Extension Plus Endorsement Equipnent Breakdown Enhancement Endorsement ' t 1 LIA8ILITY AND MEDICAL EXPENSES � i Each paid claim for the following coverages reduces the amount of insurance we provide during the applicable annual period. Please refer to Section II - � Liabitity in the Businessowners Coverage Form and any attached endorsements. Limit Liability and Medical Expenses $1 ,000,000 Per Occurrence Medical Expense $10,000 Per Person Damage to Premises Rented to You $300,000 Any One Prem. ' Other Than Products/Canpleted Operations Aggregate $2,000,000 Products/Compteted Operations Aggregate $2,000,000 Employee Related Practice Liability Cov. - Defense Only $5,000 PROPERTY COVERAGE BY LOCATION PREMISES:001 BUILDING:001 471 MAIN ST, W YARMOUTH, MA 02673 Occupancy of Premises: Restaurant,Whlsale, All Other ' Deduetibles: Property Deductible : $1 ,000 Optional Coverage/Glass Deductible : $500 Building - Autanatic Increase: 2$, Replacement Cost $223,900 Business Personal Property $10,000 Continued on Next Page INSUREU � � DEGLARATION PAGE ;: 6�UINCY MUTUAL GROUP , �� 57 WashingTon Sfreet D i r ec t B i 1 1 '� Quincy,MA 02169 N i ne Pay BUSINESSOWNERS RENEWAL BO 107485 10/08/2012 10/08/2013 QUINCY MUTUAL FIRE INSURANCE COMPANY 00116 TTDK LLC HUDSON ELDRIDGE INS. AGENCY ANN AND FRAN'S KITCHEN 265 ORLEANS RD 38 STONEY HILL DRIVE NORTH CHATHAM, MA 02650-1161 50. YARMOUTH, MA 02664 (508) 945-0446 Mortgage Holder: ILLUSION PROPERTY TRUST 370 WEIR RD YARMOUTHPORT, MA 02675 LIABILITY COVERAGE BY LOCATION PREMISES:001 BUILDING:001 471 MAIN ST, W YARMOUTH, MA 02673 Occupancy of Premises: Restaurant,Whlsale, Al1 Other TOTAL ANNUAL PREMIUM FOR POLICY: $1 , 197.00 THIS IS AN ADVANCE PREMIUM SUBJECT TO AUDIT FORMS AND ENDORSEMENTS Forms and endorsements made part of this policy at time of issue: BP0003 0106 BP0108 1008 BP0143 0106 BP0159 0808 BP0412 0106 BPo417 0702 BP04t9 0106 BP0439 0702 BPo446 0106 BP0492 0702 BP0501 0702 8P0515 0108 BP0517 0106 BP0523 0108 BP0542 0108 BPo577 oto6 BPo6o6 0107 BPo698 0906 BPiooS o7oz eP1oo6 0702 BP8002 0106 BP8110 0106 BP8119 0310 BP8190 0106 BP9018 0106 TDESPP 0106 �. ` � �jl��.�i�,v �� 1 /2012 Countersigned Authorized Representa ive 'u8 international New E giand, LLC INSURED