HomeMy WebLinkAboutApplication and WC .; TOWN OF YARMOUTH BOARD OF HEALTH ������D
APPLICATION FOR LICENSE/PERNIIT-20i0�,� _: NOV 2 O ZOQ9
* Please complete form and attach all necessazy doeuqtbirts�g�Dece� � L3IGMSUtt'i .
Failure to do so witi resuk in the return pfyou�appl�ca"�on p< .
NAME OF ESTABLISHMENT: f}�I N+ �r'an�� K, �rl,P y� TEL. # �0�-775'- 777/
LOCATIONADDRESS: y1/. ur v M oa
MAILING ADDRESS: �
OWNER NAME: ; (�_� �p,r TAX ID �FEIN or SSNI�
CORPORATION NAME (IF APPLICABLE): TT'D K, LC-C
MANAGER'S NAME: i�ebru � TEL. #;SDd'�-35�- 7y�G
MAILING ADDRESS: �C� 4h r,� i� /�-j'// 1�r S.y a rn�r�/�� ,/� 0�2(0 �3/
POOL CERTIFICATIONS:
The pool supemsor must be certified as a Pool Operator,as required by State Iaw. Please list the designated
Pool Operator(s) and attach a copy of the certificarion 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 Cardiopulmonary Resuscitarion(CPR). Please list these employees below and attach copies of employee
certificarions 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.
�. a.
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
Protecrion Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000.
Please attach copies ofcertificarion to this application. The Health Department will not use past years' records.
You must provide new copies and maintain a file at your establishment.
i.__I Ylex- �v��'� 2. � �Q �v�c.r�
PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
i.TU le� d�i/a,�'-(c— z. �br�� ✓.�u�c�'c�,
HEIMLICH CERTIFICATIONS:
All food service establishments with 2S 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 anri-chokmg procedures below and
attach copies of employee certificarions to this form. The Health Department will not use past years' records.
You must provide new copies and maintain a t"ile at your place of business.
1._ �rc� �uL�r� 2.
3. 4.
RESTAURANT SEATING: TOTAL # � 6
OFFICE USE ONLY
LODGING:
LICHNSE REQUIRED FEE PERMIT# LICENSE REQiTIRED FEE PERMIT# LICENS&REQiJIRED FEE PERMIT#
_B&B $55 _CABIN $55 _MOTEL S55
�iNN S55 _CAMP S55 �SPJIMr�IING POOL �80en.
_LODGE $55 �TRAILERPARK $105 _WHIRI,POOL $SOea.
FOOD SERVICE:
LICENSE REQUIRED FEE P6RM1T# LICENSE REQSIIRED FEE PERMIT# LiCENSE REQUIRED FEE PERMIT#
LaioosEaTs $85 �Gn"63o _CONTINENTAL $35 _NON-PROFIT $30
>I00 SEATS $160 �COMMON VIC. $60 0 I G TWkIOLESALE $80
RETAI[,SERVICE: —RESID.KITCHEN S80
LICENS£REQUIItED FEE PERMIT# LICENSE REQUIltED FEE PERMIT# . LIC£NSE REQIJIRED FEE ��PERMIT#
_<50 sq.R. S50 _>25,000 sq.R. 5225 VENDING-FOOD $25
_QS,OOOsq.ft. $80 _FROZENDESSERT $40 TOBACCO $55
NAMECHANGE: S15 AMOLTNTDUE _ $ /5<6.00
"","«pLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM»"•**
�,
. •.
AD1�II1�iISTRATiON
Under Cliapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal
of any license or pemrit 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 COMI'. AFFIDAVIT SIGNED AND ATTACHED✓
Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY 1F PAID:
YES � NO
MOTELS AND OTHER LODGING ESTABLISHMENTS
Ti2ANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be
limited to the temporary and short term occupancy, ordinarilq and customarily associated with motel and hotel use.
Transient occupants must have and be able to demonstrate that they maintain a principal place of resid�ce eLvewhere.
Transient occupancy shall generally refer to continuous occupancy of not more than t]rirty (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 whiripools which have been closed for the season must be insp�
by the Health Department prior to opening. Contact the Heaith Departmern to schedule the inapection thr�(3)days
pnor to opening. PLEASE NOTE:People aze 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,totat 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 coveted within seven(7)d�ys of
closing.
FOOD SERVICE
CATERING POLICY:
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health 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
Health Department.
FROZEN DESSERTS:
Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health
Department. Failure to do so will resuk in the suspension or revoca6on of your Frozen Dessert Pemut 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 Board ofHealth.
OUTDOOR COOIaNG:
Outdoor cooking,prepararion,or display of any food product by a retail or food service establishment is prohibited.
NOTICE:Pernvts run annually from 7anuary 1 to Decembet 31. TT IS YOUR RESPONSIBILITY TO RETURN
Tf�COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15, 2009.
ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
DATE: l J Jl Sl� SIGNATURE: �� p� �� �1��
PRINT NAME&TITLE: �f�n„ I.J��r� r�u�n�r
09/25/09
� �\ The Commonwealth of Massachusetts
Department of Industria/Accidents
NIW.YN�
600 Washing7on Street, �"`Floor
Boston,Mass. 011ll
Workers'Compeesation Iroaraam AftidavN.Baildieg/Plom6ieg/Ekctrical Coatrsctors
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wark site lacation(full addiessY - �d�������7��
❑ I am a hom�wcer perfomring all wock myself. Project Type: ❑New Const�ucaon QRanodei
❑ I azn a sole�pro�ietor and have ao oce wodcing in anY capacity- �❑Building Addition
� I am an�ployer�xoviding wockeis'compeasation for my empioyees working on t6is job.. .
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the followmg wodceis'comPensatiou Pulices: . . .
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VYORKERS CON URANCE POpLICYEhIN ORMATION PAGE
i
6
POLICYNO: WCK77O1N
-,SURER:
::3M SNSURANCE COMPANY �W gUSINE55
=501 TOUCHTON ROAD SAST 16322
SUITE 3400 NCCIC::"-�'� �•_
3ACKSONVILLE, FL 32245-6000 qccoun� `.= 43308
AGENCY NAh1E AND ADDRESS:
ITEM t.NAMED INSURED AND MAIUNG ADURESS� MCSHEA T_NS��NCE AGENCY INC
TTDK LLC
DBA ANN & FRAN' S RITCHEN �qg Mp,ZN S-REET SUITB H
471 MAIN ST OSTfiRVI��r, M7� 02655
WEST YARMOUTH MA 02673-4843
AGENCY PHONE NO.: (508) 420-9011
AGENCY NO.: 200140
LEGALENTITY: LIMITED LZABILITY COMPANY _ _�,�ation Schedule)
OTHER WORKPLACES NOT SHOWN A��� (See Worke�s C."�='__' -`
ITEM2. P�UCYPERIOD: From: 06-27-2009 To: 06-27 -�0=-
Effective 12:01 A.M. Standard Time at the Insured s ma ^= �=�"-»
ITEM 3. COUERAGE:
A. Workers Compensation Insurance: Part One of the oo' =. �= _= �- �-
_ ;^;�rkers Compe�sation Law of the states
listed here:
I�SA
g. Employers' Liability Insurance: Part Two of the policy apG�E� '- '•="^ � =ach state listed in Item 3.A. The limits of
liability under Part Two are:
100 , 000 ea=' accidem
Bodity Injury by Accident: $ , ,�mit
BodilylnjurybyDisease: $ 500, 000 �- -.
Bodily Injury by Disease: $
100, 000 =�-" `r`'p1Oy�
Other States Insurance: Part7hree of the policy app�ies to -n= s-�-._: ` a�y. listed here:
y al!states except: ND, OH, WA, D7V. WY
and states designated in ITEM 3A of the informatfon page.
= This Policy includes these Endorserr�nts and Schedules:
See Schedule of Forms and Endorsements.
�?Eh1 a. PREMIUM: The premium for this Policy will be determined by =-' �^=��a�sf cation Schedule s suti�ecit o �d
Rating Plans. All information required on the Workers Comce^sa' -"
verification and change by audit. Please see Class'rficTto a1 Es'^'a'e-
•��mimum Premium: $
218 Annuai P'e'" �"'_ S 750
A.;tlit Period: ANAILIAL � ( !
r \ i .
, ; �.. � :"_t:�
=a.= 06-23-09 Countersigned oy
Paqe 2 of 4