HomeMy WebLinkAboutApplication and WC TOWN OF YARMOUTH BOARD OF HE ���� �S NE
�' � �� APPLICATION FOR LICENSE/PE ,. � �2 ^ G�u C;) �O 5 I
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* Please com plete form and attach all necess a r y d�me�3 ¢`ce� er Fi DEPT.
Failure to do so will result in the return of your application pac .
ESTABLISHMENT NAME: � LU T ID• ��- �
LOCATION ADDRESS: TE Z � TEL.#:
MAILING ADDRESS: D � 2" z
OWNER NAME: �Y�IE'E i
CORPORATION NAME(IF APPLICABLE):
MANAGER'S NAME: ��CNA 5q")M 1G1"f('.hFA TEL.#: 47 �y�J 7
MAII.ING ADDRESS: ��{- �f7uTc. 2X �Jv�ST f�c2N1nL1Tr1 { : J� �)ZEi�I 3
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 form.
1. 2.
Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid
and Community Cardiopulmonary 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:
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 establis6ment.
1. 7L iJb'L�lK I�F_CXAM PD 2.
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Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
i.�'IN �K DFDC�M f�D 2.
HEIMI.ICH 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 uained 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.
�. y�� ��.�K ��c;�N�Po 2. �r�c;rl� so���-rr��.cn.�
3. 4.
RESTAURANT SEATING: TOTAL# J�
OFFICE USE ONLY
LODGING:
LICENSE REQUII2ED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_B&B $55 _CABIN $55 _MOTEL $55
_INN $55 _CAMP $55 _SWIMMINGPOOL $SOea
_LODGE $55 _'fRAIC,ERPARK $105 _WHIRLPOOL $80ea
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIl2ED FEE PERMTT# LICENSE REQUIRED FEE PERMIT#
�.0-]00 SEATS $85 � _CONTINENTAL $35 _NON-PROFiT $30
_>]00SEATS . $160 I COMMONVIC. $60 .�1��'0. ..� _WHOLESALE $80
RETAII.SERVICE: —RESID.KI'I'CHEN $80
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 AMOLJNT DUE _ $ /�S.O6
s*#*sPLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM+R**•
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 ATTACFIED STATE WORKER'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR
CERT. OF INSURANCE ATTACHED
OR
WORKER'S COMP. AFFIDAVTI' SIGNED AND ATTACHED
Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PI.EASE CHECK
APPROPRIATELY IF PAID:
YES ✓ NO
I�SSOTELS r�`73 OTI-IER i.s'3dDGI:+iG ESTr�,'LY�HM"�"1'3
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 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 OPEIVING: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 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 Department,or from the Town's website at www.varmouth.ma.us under Health Department,
Downloadable Forms.
FROZEN DESSERTS:
Frozen desserts must be tested by a State cert�ed 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 Pernut until the above terms have been met.
OUTSIDE CAFES:
-- C�r�i�e�e�{�-,�et3esf seati.�g:eittt u�aiter/fvaitress s�rv:ce),must have prior appr�v�from the Boad afHeail-i.
OUTDOOR COOKING:
Outdoor cooking,prepazation,or display of any food product by a retail or food service establishment is prohibited.
NOTICE:Permits mn annually from January 1 to December 31. IT IS YOUR RESPONSIBILITI'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[#ND APPROVED BY THE BOARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY REQUII2E A SITE PLAN.,
DATE: SIGNATURE: � ' �n
.1� J_ � 1; ry.!
PRINT NAME&TITLE: � iN �F i i i F
Rev. 10/25/11
, , �
�"� The Commonwealth of Massachusetts
DePartment of Indush3a!AcciJentc
N�CINi1�1tlIMs
600 Washingtoe Sdee; 7`"'Floar
Boston,Maxs. D2111
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work siM location lfull addressl:
❑ I�a 6omeowner perFocming all w�k myself.
❑ I arn a sole propridor and have no one working in any capaciry.
�I am an empbyer providing worke�s'compensation fa my employees wodcing am this job.
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❑ I arn a sole praprietor,geoeril e�traetor,or 6omcowner(carrle uue)and have hired the contractas listad below who�have
the folbwing wmkers'compensation polices: � .
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" � NOTICE OF ASSIGNMENT
EMAI.OYER: ' COM60I.�. STATUS OF EMPLOYER
TWEEKIAT THEERAATWET OBA SASIL THAI CUZSlNE 000998599 Individ�al
594 N➢AIN ST
WEST YARMOUTH, MA 02673 COVERAGE6ROUP
0891489
Coverage under this assignment
� The Waiver of Our Ri.9hr to appiies to Massachusetts
Recover from Others Endorsement operations only. E'or coverage
is available on Pool policies. outside of Massachusetts, contact
Contact your aqent for details. the appropriate Pool or Plan far
that state.
A(iENT� KERRY INS AG6NCY INC � INSURANCE COMPANY:
OR P 0 BOX 1945 GRANITE STATE INS CO
PRODUCER: N EASTHAM, MA 02651 RESIDUAL MARKET OPERATIONS
�iP O 80X 909
'�. PARSIPPANY, NJ C7054-09Q9
'�i (B00) 645-2259
AGENCY FEIN:
CLASSIFICRTION OF OPERATION��� �� - �� � - -- �� - �� �CLASS ES'PIMATED RATE - ESTIMATED �
CODE TOTAL ANNUAL PREMIUM
REMUNERATLON
RESTAURANT NOC 9079 515,000 1 .07 5161
EMPLOYERS LIABILITY I00/100/500 � 9895
STANDARD PREMIUM $161
LOSS CONSTANT OD32 $20
EXPF.NSE CONSTANT u90u 5159
TERRORISM CkAR6E 9790 55
TOTAL POLICY MINIMUM PREMIUM $216
TOTAL ESTIMATED PREMIUM 5395
DIA ASSESS. 5.9� $9
___"'_
TOTAL EST. PREMIUM PLUS ASSE$$MENT $354
INSTALLMENTBASIS: Annual . DEPOSITPREMIUM: $359
- . _ . _ _ _ . . 7HIS IS NOT A BILL _
COMMENTS
Coveraqe ePfective 12:01 AM on 09/02/11
Sub�eCt to 12/16 Anniversary Rate Date,
Coverage under this Notice of Assignment applies to the captioned entity only. If
coverage is required £or an additional entity, the employer musC submit an application,
check, and an ERM to the Pool for the additional entity.
DATEOFNOTICE: 09/19/11 pREPAREDBY: Paulette Hoffman
EXT 519
The Wadcars'Compertaation RaNng and Inspeetion Bureau of Massaehusetts
101 Arch Street�Boston, MA 02110
(617�439-9030• FAX(817y439.6655•www.wcribma.org
Dec-OB-11 12:O6pm From- T-248 P.001/002 F-971
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az� ::r, n:Y� �y s:tY' �:���.... .;» ,,'^�M + x..,«_..�, n....�Mar x..�«::. ..�c`',:rry:. k y.:;:-:.
�,^.:tY+�;:y;9M.',e.",:�M'�'HI;F'•HM�'^�:::'.:«�'r.5'.Y.:::i:4�a:.'i•'.r".ry�«n..lahr•�rv�$i:.���."°�'.'.w"°G>a'^�Ka"w*^'rivM!`;r..a^,em^.1....'.`.a^'"a'.:',r:.n✓1..':�'"°t... ..... eM`^t:..:w"
�HIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGH7S UPON THE
� ERTIFICRTE HOLDER.THIS CEI2TIFICATE DOES NOT AMEND, EXTEN�OR ALTER THE COVERAGE AFFORDED
Y THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BE7WEEN
HE ISSUING INSURER S ,AUTHORIZED REPRESENTA7IVE OR PRODUCER AND THE CERTiFICATE FIOLDER.
PORTANT: If the Certificate holder is an ADDI710NAL INSURED,the poiicy(ies)must be endorsed. If Sl16ROGATION
WAIVED, suGject to the terms and conditions of the policy,certain policies may require and endorsement A statement
n this certificate does not confer ri hts to the certificate hulder in lieu of su�endorsement.
iPRODUCER
1 Kerty I�ufance AgenCy Inc
, PO Box 1945
: No�1+Easth�n,MA 02651
COMPANIES APFORDING INSURANCE
COMPANY A GRANITE STATE INSU
� INSURED
L�°n�'�s':`��i�``�IL�I o�
� r,�w�c rn�� ��, Q �' 4 G 11
,
� DBA Basil Tha Cuisine
b94 Main St
HEALTH DEPT.
West Yartnw�lh,MA 02673 �
. o � !q� L F. 'Cr.,,. ., '�"t5�:1t:i'+0....�5,a:..�..;:dY,�'•M'a'.;�","«v°"'':<:: .".:�� �.»�'"
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,TIi1S IS TO CERi1FY TFWT THE POLICIES OF INSURANCE LI$7E�BELOW IiAVE BEEN ISSUED 70 THE INSURW NAMED ABOVE FOR
THE POLICY PERIOD INaCATED,NbT WITHSTANDING ANY REQUIREMENT,TERM OR CONDITIa`l OF ANY CONTRAC7 OR O7HER
DOCUMENT W�1'M RESPECT TO WHICH THIS CEiti1FlCATE MAY BE ISSUED OR MAY PEKTAIN,THE INSURANCE AFFOR�ED THE
� POLICIES DESCRIBEp HEREIN IS SUBJECT TO/LLL THE TERMS.EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LiMRS SHOWN
� MAY HA��N REDUCEC BY PAID CLPJMS. �
� � ow P[M.�c1'E%P�+n7lotrDA'�
� lTR TYPEOFINSURAI/C¢ PWCYNUYB� POLM.Y
� p a�xscor,masnnot+ uMrcs
o sNr�ar�s uaeum
' ¢aRONtiErow .n:•_ , ...._.� . m^*:.
C��'�`•x�'^.'" i�"Y°w�'� �..
FFI�CER�CUTNE TAMORYUMRS .����,;+X.
c�o pcc�❑ 9947763 9l02/2011 9/02/2012 '�'�»
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Mdiasmeu.Coerario�ony. �� S tOD,o
i ISEqSEPa1CYLR�R $ �'�
,s�r�E-�,cH�,� s �oo
ESC IPT10N OF OPERA710NSNEFIICIESISPECIAL ITEMS
:7}{E WORKERS COMPENSATION POLICY OOES NOT PROVIDE COVERAGE FOR TWEEKIAT THEERAA7VVET�
1
' CERTIFICATE HOLDER ANCELL.ATfON
TOWNOFYARM�ITN SM�uL0ANY0FTXEABWEOESCRieEDPq,ICIESBECANCFJIEOB�REi1� � .
1148 RT LH EXPIRAnoN DA7ETnEREOF,NoiICE wILL HE OEIMEfiED IN ACCCRDANCE
SOUTH YARMOUTH.MA 02684 wixremernucrvRansror+s.
AUTHORIZED REPRESENTATIVE .
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Dec-DB-11 12:06pm From- T-248 P.002/002 F-971
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CHARTIS
SPEC1'ALTY W�RKERS COMPENSATION
PD 80�409
� pA]{SZppANY,NJ 07054-OA09
I p1TONE: 973-337-8617
F�iX:973-402-A435
� FACSIMILE TRANSM,TTTAL SKEET
; TQ. FROM.' DEBBIE HDOK
I COMPRNX.- DATE:
� FAX NTIMB.ER: ^"
�
T�TA.L NUMBER OF PAG`ES 11VCLUD.TNG COVER:
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