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Home My WebLink AboutApplication and WC , T` / a TOWN OF YARMOUTH BOARD OF HEALTH ��-��g��]V�JC�SDD �� APPLICATION FOR LICENSE/PE `'� ;� ` ,.,. � � r n c "O11 * Please complete form and attach all necessary d 1'S^21�1`l.� Failure to do so will result in the return of a ion pa etHEALTH DEPT. ESTABLISHMENT NAME: �-nlAl + Fra n `5 K��c�er, TAX ID: � LOCATION ADDRESS: h�'/ l�f �-� Y1�. ��t�ihDUTEa. TEL.#: ,�I�`775- J7�/ MAILING ADDRESS: -17J �G OVVNER NAME: �hr� L L �ar'� CORPORATION NAME(IF APPLICABLE): TrnK,�j1-C MANAGER'S NAME: TEL.#: �1��'-�9�- ]��Gs MAII.ING ADDRESS: POOL CERTIFICATIONS: The pool supervisor must be ceriified as a Pool Operator,as required by State law. Please list the designated i Pool Operator(s) and attach a copy of the certification to this form. L 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standazd First Aid and Community Cazdiopulmonary Resuscitation (CPR). Please list these employees 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. FOOD PROTECTION MANAGERS - CERTIFICATIONS: Ail food service establishments aze required to have at least one full-time employee who is cert�ed 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. �Y�P�vU,1'� 2.�,P_tirt� ��if� PERSON IN CHARGE:__ - Each food establishment must have at least one Person In Chazge (PIC) on site during hours of operation. 1. y�rr �t.c�1�� 2. [�br�c l�u�crr'� 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. T6e Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. �. �✓/,�r 7�� a. 7��d rA l��r�� 3� 4. RESTAURANT SEATING: TOTAL# �(S OFFICE USE ONLY LODGING: LICENSE REQUIl2ED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&B $55 _CABIN $55 _MOTEL $55 _1NN $55 _CAMP $55 _SWIMMINGPOOL $80ea _LODGE $55 _TRAII.ERPARK $105 _WHIRLPOOL $80ea � FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMTT# LICENSE REQUIRED FEE PERMIT# �0-100 SEATS $85 �/�'Q.� _CONTTNENTAL $35 _NON-PROFIT $30 _>100 SEATS $160 �COMMON VIC. $60 � —b _WHOLESAL,E $80 RETAII.SERVICE: —RESID.KITCHEN $SO LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $50 _>25,000 sq.ft. $225 _VENDING-FOOD $25 _<25,000 sq.ft. $SO _FROZEN DESSERT $40 _TOBACCO $95 rrnriE cxnrrcE: gis AMOLTNT DUE _ $ 145.DO •*��tPLEASE 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 ta4es and liens must be paid prior to renewal or issuance of your permits. PL.EASE CHECK APPROPRIATELY IF PAID: / YES v NO 1�f03�'ELS ANVD JTi�R i.mDGiPr'G ESTr'ivLISHMENT� 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 thirty(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 uansient. 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 generaily be considered Transient. POOLS POOL OPEIVING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Departznent prior to opening. Contact the Health Department to schedule the inspection three(3)days pnor to opening.PL.EASE 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 Deparunent 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 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 obtauied 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 will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Cats:de c�s�i;,:;a�,:�c3�:seating��ith waiie:lwsi:ress serviee);:nus�§evP g=ier a��ro�al f=.cxn the B�rc��€s Iealth, - _ OUTDOOR COOKING: Outdoor cooking,prepazation,or display of any food product by a retail or food service establishment is prohibited. NOTICE:Pernuts 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, 2011. 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 STfE PLAN. DATE: SIGNATURE: ,�.,e.�,z_��f �v „ �p PRINT NAME &TITLE: L7ehrzt C. �e��i�- o w�err Rev.10/25/11 � The Commonwealth ofMassachusetts Deparhnertt ojlndusrrial AcciJenu N�CaNi�tlf�s 600 Washington Sdeet, ��Flaar Boston,Mass. 011ll Wo�icers'CompeesaHos lusorance Aftimvik � � .-. � ... .. .. - AmlkaN i�hrmatlM: Plea�e PRWf kd6h ' t � �: �N -r Fa.�ro'S .krtzklt� d�CSg: ciN statr. � zio: o6me k work site location(futl add�essl: ❑ I�a 6omoowmer perfomting all wwic mysciL � ❑ I mn a sole proprietor and have no a�e working in any capxity. � ❑ I am an dnployer Faoviding workecs'compensation for my employees wocking on ihis job. i _ � comouv nne• . . .. . . . . - -.. ._- � --. - - t -r�. ad�pssr N: inna�ce ee. oaNer M ��: ❑ i am a sole proprie[or,geoeral co�traetor,or 6omeow�a(arele oru)and have hirod ihe contracWcs listed below who�have the following workers compensation polices: rnmmev u�e- addrm- � cNv' nAaee M: ieav��ce ee. edlev 8 . t000aer ume: �' cih• o�o�eM• . .. ---- - � - _. . _ _ . . . _ . _._ ._ . ._- ..___. - - ---- . inva�eeca � - odiev8 w�r.++wrwer,.e...f FaYve r atevs wm�e u�eqded udv Sec1W TSAd MCL 132 ni kad p Ne dpiW�taiNW peuMe d a mt q b S1dKM�Ml�r o�e ynn'I�rhw�eet a�d a dN penMln Is the fir�afa 3TOr WORK OpDSA ud�me N f1M.N a day apimt oe. I mdenhW fYM• capy of tY6 Na0esnl vy 6e firwuded 1s Me Omaa af IavWkuMro K Ue DIA fir arwa`e verMnW�. �/do IYereby rn Me pr/ns !Nv ojperjd Md Ms Infonwmfon proride(e6o�r 6 trre aed rormt / � /' / Signahue 6�T Wrc� � ��-!�� Prim name 1�� D U R��L'7� Phone k ._. .. . . a16ew ox sny . ao nM n.we�.to�.arc,w ee co�Wetcd Ar dtr or rwn.mdd . � . eity or towo: permN/Bceese N ❑Baidme Deparden! ❑eheet Himsemle me b ��k'�°�6 Baard �ePs R9�� SeYetmes9 OfBce ❑Ne1M D�par�t eeotxt penoa: PM�e 6: �Q 1n+�d Sm`mm� � ....., .,,..... ..._..,. WORKERS COMPENSATION POLICY POLICY CHANGE EFFECTIVE 06/27/2011 FINAL AUDIT MA TAXPAYER ID N0: XXXXX7235 NtCI N0: 32247 WC 001010 06/27/2010 06/27/2011 Quincy Mutual Fire Insurance Company ; 00116 � � I .TTDK LLC HUDSON ELDRIDGE INS. AGENCY UBA ANN S fRAN'S KITCHEN 265 ORLEANS RD 36 STONEY NILL DR NORTH CHATHAM MA 02650-1161 SOUTH YARMOUTH MA 02664 (508) 945-0446 NAMED INSURED I5: LIMITED LIABILITY CO (LLC) OTHER WORKPLACES NOT SHOWN ABOVE: ON SCHEDULE ATTACHED IF APPLICABLE. FEDERAL ID N0: RISK Ip N0: 0043308 2. POLICY PERIOD: FROM 06/27/2010 TO 06/27/2011 12:01 AM STANDARD TIME AT THE INSURED'S MAtLING ADDRESS. POLICY CHANGE EFFECTIVE: 06/27/2011 3.A. WORKERS COMPENSATION INSURANCE: PART ONE OF THE POLILY APPL�ES TO WORKERS COMPENSATION lAN OF THE STATES LISTED HERE: MA 3.8. EMPLOYERS LIABILITY INSURANCE: PART TWO OF THE POLICY APPLIES TO WORK IN EACH STATE LISTED IN ITEM 3.A. THE LIMITS OF OUR LIABILITY UNDER PART TWO ARE: BOOILY INJURY BY ACCIDENT $100,000 EACH ACCIDENT BODILY INJURY BY DISEASE $500,000 POLICY LIMIT BOpILY INJURY BY DISEASE $100,000 EACH EMPLOYEE 3.C. OTHER STATES INSURANCE: PART THREE OF THE POLICY APPLIES TO THE STATES, IF ANY, LISTED HERE: ALl STATES EXCEPT ND, OH, WA, WV, WY. 3.D. THIS POLICY INCLUDES THESE ENDORSEMENTS AND SCHEDULES: FORMS FLAG6ED WITH AN * CAN BE FOUND ON A PREVIOUS fNDORSEMENT OR POLICY, fORMS NOT FLAGGED W6TH AN * ARE ATTACHED. *wt o0 00 0o n *wt 20 03 oz a nWC 20 03 03 C *wC zo 03 06 A *Nc 20 06 oi n wC 00 03 lo *wC o0 04 20 *WC 20 0l ol *wC 20 03 0l *WC 20 04 05 *wC zo 06 04 4. THE PREMIUM FOR THIS POLICY WILL BE DETERMINED BY OUR MANUAL OF RULES, CLASSIFICATIONS, RATES AND RATIN6 PLAN. ALL INFORMATION REQUIRED BELOW IS SUBJECT TO VERIFIGATION AND GHANGE BY AUDIT: PRENIUM BASIS RATE PER TOTAL ESTIMATED $100 OF ESTIMATED CLASSIFICATIONS CODE ANNUAL REMUNERATION ANNUAL NO REMUNERAT�ON PREMIUM (SEE EXTENSION OF INFORMATION PAGE) TOTAL ESTIMATED PREMIUM $939.00 DIA ASSESSMENT ( 7.200$) $58.00 TERRORISM RISK INSURANCE CHARGE ( 3.000$) 9740 $22.00 MINIMUM PREMIUM $218.00 TOTAL ESTIMATED COST $1 ,019.00 DEPOSIT PREMIUM $1 ,019.00 WC 00 00 Ol B CONTINUED ON NEXT PA6E INSURED COPY