HomeMy WebLinkAboutApplication and WC � � °° � TOWN OF YARMOUTH BOARD OF HEA�H t'^! � � '�'� t�Nys
APPLICATION FOR LICENSE/PEI�IIKT ' � ��
�� * Please complete form and attach all necessary docy en `'' � pte�eber �
Failure to do so will result in the retum of your application p `� -c''T�
ESTABLISHMENT NAME:� /'an S ��"Gttel� TAX
LOCATION ADDRESS:ti1[_,C����afMDd7Y� � MI� D1L7�?TEL #: . D�''y= '7I)/
MAILING ADDRESS: ���i�a.l.a (�j 11 l�' S u.f'IVJGi'rL, M� �� lolr y
OWNERNAME: �r��, Di�i''-F�— _' '
CORPORATION NAME (IF APPLICABLE): TT � �,' L
MANAGER'S NAME: (�b 1� TEL.#: 5��'� �
MAILING ADDRESS: `/J , !i
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 forni. .
1. 2,
Pool operators must list a minnnum oftwo employees cunently certified in basic water safety, standard First Aid and
Community Cardiopulmonary 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 must provide new
copies and maintain a 61e at y�our place of business.
l. Z_
3. 4.
FOOD PROTECTION MANAGERS - CERTIFICATIONS:
::ll food service establislunents are required to have at least one fuli-time employee who is certified as a Food
Protection Manager, as defined 'ui 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 �le at your establishment.
�.TvIP�- �,� r�_ z. 1����r,l�
PERSON IN CHARGE:
Each iood establislunent must have at least one Person In Charge (PIC) on site durnie hours of operation.
i._�/er (��/ar-� z. �.c_�ur�..r',�
HEIMLICH CERTIFICATIONS:
All food service establishments with 25 seats or more must have at least one employee n•ained in the Heimlicl�
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 forni. The Health Department will not use past years' records.
You must provide new copies and maintain a �le at your place of business.
i.�T l—er—�va.r-�- 2. '7����T�L1�r�--
3��1u�lara�,ha[�eco ,VJari4 '�_OCi�circt 4.�t nnrue. T1�a el/'
RESTAURANT SEATING: TOTAL # _36
OFFICE USE ONLY
LODGI\G:
LICENSE REQUIRED FEE PER'�III'# LICENSE REQUIItED FEE PER�4Ii# LICENSE REQUIRED FEE PE&'�III'�
_BRB S55 _CABIN S55 _MOTEL S�5
_INN S55 _ _ _Cp,�[p S55 _5��11bL\1INGPOOL 580ea.
_LODGE SSi �IRqII.ERPARK 5105 _R'HIRLPOOL S80ea. �
FOOD SER\'ICE: -
LICENSE REQUiRED FEE PERYIII'# LICENSE REQUIItED FEE PER\11I'� LICENSE REQUIRED FEE PER�III�
�0-100 SEAI'S S85 -�l("Og7 _COIVIINENTAL S35 NON-PROFff S30
>I00 SEATS SI60 I CObLNION VIC. S60 �/I-(F,0 _\y'HOLESALE S80
REI'AIL SER\10E: —RESID.KII'CHEN S80
LICENSE REQUIRED FEE PER'�III'# LICENSE REQUIRED FEE PERYIIT� LICENSE REQU[RED FEE PERYIIT¢ �
_a50sq.ft. S50 >?S,OOOsq.Yt. S2?5 VENDING-FOOD S?i
_<25,000 sq.ft. S80 _FROZEN DESSERT S40 TOBACCO 555
��,�ZE c��cE: sls AMOUNT DUE _ $ ��5. ao
"""**PLEASE'flR\OVER A\D CO�IPLE'IE O'IHER SIDE OF FORVI*""•*
ADNIINISTRATION
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 taaces and liens must be paid prior to renewal or issuance of your pemiits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES ;� NO
1VIOT�LS AND OTHEIt LODGCIV(>ESTABLIS1itVIENTS
TRANSIENT OCCUPANCI': For putposes ofthe 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 elsewhere.
Transient occupancy shall generally refer to continuous occupancy of not more than thitty (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
pnor to opening.PLEASE NOTE: People are NOT allowed to sit m the pool area until the pool has been inspected
and opened.
POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standazd 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 Yazmouth 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 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.,outdoor seating with waiter/waitress service),must have prior approval from the Boazd ofHealth.
OUTDOOR COOHING:
Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited.
NOTICE:Pemuts run annually from 7anuary 1 to December 31. TT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED RENEWAL APPLICATION(S) AND REQLTIRED FEE(S)BY DECEMBER 15, 2010.
ALL RENOVATIONS TO ANY FOOD ESTABLISHI�IENT, 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: //��,3 �/0 SIGNATURE: ;_�.,�JuL,��lktite�p
PRINT NAME&TITLE: �p{,ra. L 171cu_r-It
io�ae�io
�\ The Commonwealth ofMassachuselts
Deparhxent ojlndustria(Accidents
a�e,a�
600 Washington Street, 7`"Floor
Boston,Mass. 011ll
Workers'Compeneatioe Iroorsnce Alfldavit;gaildiog/Plombieg/Electrical Contractors -
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work site location(fiil1 address):
. ❑ I am a homeowner perfocm�ng all work myself. Pro�ect Type: ❑New Constrm;don QRemodel
❑ I am a sole proprietor and have no one working in any capacity. ❑Building Addition
❑ I am an employer providing workers'compensatioa for my employecs working on t6is job.
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❑ I am a sole praprietor,geaeral co�tractor,or 6omeowna�(cirel�onc)and have hired the contractocs listed below who have
the following workers compensalion polices:
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tipy ef tYh+hOemeot e�y he fanurded b tAe Oelec of t�ef Me DIA far c�vera�e vvlanW�.
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Signatum �� Date // /L�//O
Print name__ J—�1'A, L J J /Q,f� Phone 8��rf '�/��7"�^
ef9t1a1 aa oely do no1 wrife h Ihh�raa ta Ae moP��6Y�Y�4wn oHkh� . . . �
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DECIARATION PAGE
� ,� 61UINCY MUTUAL FIRE INSURANCE COMPANY
� s�wa�,in9r«,sheer
Quincy,MA 02169
WORKERS COMPENSATION POLICY
NEW BUS�NESS
MA TAXPRYER ID N0: XXXXX7235
NCCI N0: 3224] PRIOR POLICY N0: NEW BUSINE55
NC 001010 06/2j/TO10 06/27/2011 QUINCY MUTUAL fIRE INSURANCE COMPANY 00116
� • TTOK 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) 945-0446
NAMED INSURED IS: LIMITED LIABILITY CO (LLC)
OTHER WORKPLACES NOT SHOWN ABOVE: ON SCHEDULE ATTACHED IF APPLICABLE.
FE�ERAL I� N0: RISK ID N0: 0043308
2. POLICY PERIOD: FROM 06/27/2010 TO 06/27/2011
12:01 AM STANDARD TIME AT THE INSURED'S MAIIING AD�RESS.
3.A. MORKERS COMPENSATION INSURANCE: PART ONE Of THE POLiGY APPLIES TO WORKERS
COMPENSATION LAW OF THE STATES LISTED HERE: MA
3.6. EMPLOYERS LIABILITY INSURANCE: PART TWO OF THE POLICY APPLIES TO NORK IN EACH
STATE LISTED IN ITEM 3.A. THE LIMITS OF OUR LIRBILITY UNDER PART TMO ARE:
BODILY INJURY BY ACCIDENT $100,000 EACH ACCIDENT
BODILY INJURY BY DISEASE $500,000 POLICY LINIT
BODILY INJURY BY OISEASE $100,000 EACH EMPLOYEE
3.C. OTHER STATES INSURANCE: PART THREE OF THE POLICY APPLIES TO THE STATES, IF ANY,
L�STED HERE: ALL STATES EXCEPT ND, OH, WA, WV, WY.
3.D. TH�S POLICY INCLUOES THESE ENOORSEMENTS AND SCHEDULES:
wt o0 00 0o n wc 20 03 02 n wt 20 03 03 C wC 20 03 06 A wC 20 06 0� A
wC o0 03 to Nc 00 04 2o WC 20 Ot ol WC 20 03 ot wC 20 04 05
wC 20 06 04
4. THE PREMIUM FOR THIS POLICY WILL BE DETERMINED BY OUR MANUAL OF RULES,
CLASSIFICATIONS, RATES AND RpTING PLAN. A�L INfORMATION REQUIRED BELOM IS
SUBJECT TO VER�FICATION AND CHANGE BY AUDIT:
PREMIUM BASIS RATE PER
TOTAL ESTIMATED $100 OF ESTIMATED
CLASSIfICATIONS CODE ANNUAL REMUNfRATIQN ANNUAI
NO REMUNERATION PREMIUM
(SEE EXTENSION OF INFORMATION PAGE)
TOTAL ESTIMATED PREMIUM $666.00
DIA ASSESSMENT ( 7.200$) $32.00
TERRORISM RISK INSURANCE CHARGE ( 3.000$) 9740 S12.Q0
MINIMUM PREMIUM $218.00 T T ES M O5T $710.00
���G�!�61�{{ $710.00
COUNTERSIGNED BY AUTHORIZED REPRESENTATIVE: 06/25/2010
HUB Internationa ew ,