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Home My WebLink AboutApplication and WC • __ + i _ _ �,. _ y TOWN OF YARMOUTH BOARD OF HI:ALTH � ' APPLICATION FOR LICENSE/PERN�F6x` 1R� � c��+� � � ��t i j *Piease complete form and attach all necessary documen� •`�T ` Failure to do so will result in the return of yo�r$pp icahon . _�s ESTABLISHIv1ENT NAME: I�"5/L 7H�-i C v! S i�� 82rAx ID: LOCATION ADDRESS: '9 �/S /•v S T ti..,�S 7 �/�/�•-ro v7/t T�I..#: 5��'— � 9p— !9�'�" MAII.ING ADDRESS: S q S` �"r.a! �w�5 J' ��ri,r�r,a v'"f��sy 2 � OWNER NAME: 7 w 2 E � `� 7 7Ft G p9 '� 77 ti"� / � . CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: o ""� � C s� K o� n/ q sr C s� TEL.#: 'QY' ' 2��/- MAILII+IG ADDRESS: � M d I ^� �^'R Rr K /`' 0 V T�y ^''�+ 0 Z POOL CERTIFICATIONS: The pool supervisor must be certiYted as a Pool Operator,as required by State law. Please list the designated Pool Operator(s)and attach a copy of the certification to tius form. 1. 2, Pool operators must list a minimtun of rivo employees currently certified in basic water safety,standard First Aid and Community Cardiopulmonary Resuscitation(CPR). Please list these employces below and attach copies of employee certifications to this form.The HealtL Department will not use past years'records. You must provide new copies and maintsin a tile at your place of business. 1. 2, 3. 4. POOD PROTECTION MANAGERS -CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Ptotection Manager,as defined itt the State Sanitary Code for Food Service Establishmenis,105 CMR 590.000. Please attach copies of ceriification to this application T6e Health Department will not use past years'records. You must provide aew copies and maintaiu a file at your establishment, h 1. � i� a► �� r< p�6 �srrr Pd' 2 PERSON IN CHARGE: Each food estabiishment must have at}east one Peisnn In Charge(PTC)on site during hours of operarion. � i. 7iN � G � K p�Oc �.�, po 2 HEIMLICH CERTIFICATIONS; All food service establishments with 25 seats or more must have at least one employee h�ained in the Heimlich Maneuver on the premises at all times. Please list yow employees trained in anti-chokmg procedures below and attach copies of employee certificarions to tlris form. The Health Depardment will not use past years'reiwrds. You must X provide new copies and maintain a ffie at your place of business. 1. � RCl� �' SO�"r K/ �'CIfiA ttO,�N 2 y/n/0. LA f� p�OCfr-MPff 3. 4. RESTAURANT SEATING: TOTAL# 3 7 wncnvc: OFFICE USE ONLY LICENSE REQU[RED FEE PERIvllT p L[CENSE REQUIliED FEE PF,RMIT# LICENSE REQUIRED FEE PERMiT p _B&B S55 �CABIN S55 TMOI'ET. S55 _1NN S55 _CAMP $SS _SWAdk7INC,POOL S80ea. _IADGE S55 _TRAILERPARK 5105 WfIIRLpOpL SBOea. POOD SERVICE: LICENSE REQUIRED FEE PERM(T# LdCENSE REQU[RED FEE PERMIT# LdCENSE REQUIRED FEE PERM[T# I 0.1005EATS §85 ��s _CONTINENTAL S35 _NON-PROFTT S30 _>100SEATS 5160 ,LCOMMONVIC. S6Q I��/O _WHOGESALE ZBO �T`�S$g��: . —RESID.KITCHEN S80 LICENSE►tEQUIRBD FEE PERMIT# LICENSE REQUIltED FEE PERMII'# IdCENSE REQU[RED FEE PERMlT ti _G50 aqR S50 _>25,Q00 sq.& 5225 _VENDING-FOOD S25 _Q5.000 scl.R- S80 _FROZEN DESSERT S40 _TOBACCO S95 x.+nificauvcE: sis AMOUNTDUE � 5��,�ri.�a """PLEASB TURN OVER AND COMPLETS OTI{ER SIDE OF FORM*•••• AD114fINISTRATION � • • Under Chapter 152,Section 25C,Subsution 6,the Town of Yarmouth is now req�ired to hold issuaace ot ronewal of any license or parmit to operate a business if a pason or company does not have a Certificate of Worker's CompensatioII Inswana. THE ATTACFIED 5TATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR CERT. OF INSURANCE ATfACHED OR WORKER'S COMP.AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRLITELY IF PAID: YES NO M01'ELS 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 demonsh�ate that they maintain a principal plxe of resideuce elaewhere. Trensient occupancy shall generally refer to continuous occupancy ofnot 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 shell not be considered tcansient. 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,shatt generatty be considered'Fraasient. POOLS POOL OPENING:A11 swimmmg,wading and wturlpools wlrich have been closed for tha season must be"w)spected by the Health De artmentpnor to opemng. Contact the Heaith Department to schedule the inspecrion thne 3 iiyspnor �opening. P . E NOTE: People are NOT allowed to sit in the pool area until ihe pool has been inspecbed and POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State ce�tified lab, and submitted to the Health Depmtment thrce(3)days prior to opening, and quarterly thereafter. POOL CI.OSING: Every outdoor in ground swimming pool must be drained or wvered within seven (� days of closing. FOOD SERVICE SEASONAL FOOD SERVICE OPENIlVG: Ail food service establislunents must be inspected by the Heaith Departrnent pdor to opening. Please contact the Heahh Department to schedule the inspection three(3)days prior to opening. CATERING POLICY: Anyone who catecs witlrin the Town of Yarmouth must notify the Yarmouth Heslth Department by film' gthe required Tempotary Food Service Application form 72 hours prior to the catered event These forms can be obtained at the Heatth Department, or from the Town's website at www.varmouth.ma,us under Heatth I3epartment, I3ownloadable Forms. FROZEN DY:S5ERTS: Frozen desserts must be tested by a State certified lab prior to opening and monthly thereafter, with sample results submitted to the Heahh Department. Failure to do so will result in the suspens�on or revocation ofyvur Fmzen Dessert Permit untii the above teRns hsve been rnet OVfSIDE CAF�S: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have ptior approval fiom the Boaz+ci of Health. OUTDOOR COOKING: Outdoor cooldng,preparation,or display of any food product by a retail or food service establishment is prohlbited. NOTICE: Permiffi run annually&om January 1 to December 31. IT I5 YOUR RESP(3N5IBII.ITY TO kETURN Tf�COMPLETED RENEWAL APPLICATION(S)AND REQITIKED FEE(S)BY DECEMBER 15,2010. ALL RENOVAITONS TO ANY FOOD ESTABLISHMENT, MOT'EL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR TO CdIVIlVIENCEMENT. RENpVATIONS MAY REQUIItE A SITE PLAN. DATE: SIGNATURE: PRINT NAME&T1TLE: �.m,mni . ' NOTICE OF ASSiGNMENT EMPLOVER: _� COMBO I.D. STATUS OF EMPLOYER TWEEKIAT THEERAATWEP DBA BASIL THAI CUISINE 000846594 Individual 594 MAIN ST � WEST YARMOUTH, MA 02673 COVERAGE GROUP 0891469 Coverage under this assignment The Waiver of Our Right to applies to Massachusetts Recover from Others Endorsement operations only. For coverage is available on Pool policies. outside of Massachusetts, contact Contact your agent for details. the appropriate Pool or Plan for that state. ----� -- AGENT KERRY INS AGENCY INC IINSURANCECOMPANV: OR p O BOX 1945 GRANITE STATE INS CO PRODUCER: N EASTHAM, MA 02651 RESIDUAL MARKET OPERATZONS P 0 BOX 909 PARSIPPANY, NJ 07059-0909 (800) 695-2259 ACaENCV FEIN: CLASSIFICATION OF OPERATION CLASS ESTIMATED RATE ESTIMATED CODE TOTAL ANNOAL PREMIUM REMONERATION ----------------------------------------- ----- ------------- ---------- ---------- RESTAURANT NOC 9079 $15, 000 1. 07 $161 EMPLOYERS LIABILITY 100/100/500 9845 STANDARD PREMIUM $161 LOSS CONSTANT 0032 $20 EXPENSE CONSTANT 0900 $159 TERRORISM CHARGE 9790 $5 TOTAL POLICY MINIMUM PREMIUM 5216 TOTAL ESTIMATED PREMIUM $395 DIA ASSESS. 5.9� S9 TOTAL EST. PREMIUM PLUS ASSESSMENT $359 INSTALLMENT BASIS: Annual DEPOSIT PREMIUM: $359 . ___ _ _ _ _ _ __ ___THIS_13NOTABILL.___ e COMMENTS Coverage effective 12:01 AM on 09/02/11 Subject to 12/16 Anniversary Rate Date. Coverage under this Notice of Assignment applies to the captioned entity only. If coverage is required for an additional entity, the employer must submit an application, check, and an ERM to the Pool for the additional entity. DATEOFNOTICE: 09/19/11 PREPAREDBY: Paulette Hoffman EXT 519 The Workers' Compensation Rating and Inspection Bureau of Massachusetts 101 Arch Street• Boston, MA 02110 (617)439-9030 • FAX�b17)439-6055•www.wcribma.org