The URL can be used to link to this page

Home My WebLink AboutApplication and WC � T3AGEL5 + }"3E-yoNP � TOWN OR YARMOUTH BOARD OF H&.�LT� ��'� � APPLICATION FOR LICENSE/P�1t11�1T-2010 ��]I �(� * Please complete form and attach all necessary{tci�umerit"s by Dec 2 9. Failure to do so will result in the return of your applicataon ac . `'��7 NAME OF ESTABLISHMENT: G . LOCATION ADDRESS: i,J `1,� � �Zf�27' MAILING ADDRESS: OWNER NAME: _ _ �f:C�— 'AA.vv�� - TAX ID (FEIN or SSN): CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: �,��,,� Ca.-vz/rro TEL. # !�?J�-7�—�fw MAILING ADDRESS: 2,�1 W1, -fLi J t,J -a M,i9- OZ(o'7'� 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 certificarion to tlus form, 1. 2. Pool operators must list a ' ' um of two emplo ees currently certified in basic water safety, standazd First Aid and Community Cardiopulmo ary Resuscitation(CP Please list these employees below and attach copies ofemployee certificarions to this form. The Health De en will not use past ecords. You must provide new copies and maintain a fil at your p 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 Protecrion Manager, as defined in the State 5anitary 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 provi e new copies and maintain a file at your estab6shment. 1. �5.� �A�w q-ua> 2. PERSON IN CHARCiE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. `1 �cS Y-. �R�R-�r� 2. 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 flst your enployees trained in anri-cholang procedures below and attach copies of employee certifications to tlris form. T6e Health Department will not use past years' records. You must provide new copies and m intain a file at your place of business. �. ,�� 2. 3. 4. RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQIJIRED FE£ PERMI'1'# LICENSE REQUIRED FEE PERMIT# _B&B S55 _CABIN $55 _MOTEL $55 �INN $55 _CAMP $55 �SWIIvL'�IlNGPOOL SSOea. _LOD4E S55 ,TRAILERPARK $105 _WI�IIRLPOOL S80ea. FOOD SERVICE: LICENSE REQUIltED FEE PERM[T# LICENSE REQAIRED FEE PEFtMIT# LiCENSE REQIJIRED FEE PERMIT# �0-100 SEATS S85 �10—(� _CONTINENTAL 835 TNON-PROFIT $30 >I00 SEATS $160 I COMMON VIC. $60 ��J�J _WHOLESALE $80 RETAII.SERVICE: —RESID.KITCFIEN 380 LICENSE REQiJIItED FEE PERMI'C# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _a50sq.8. $50 >25,OOOsq.ft. 5225 _VENDING-FOOD $25 ,QS,OOOsq.ft. $80 _FROZENDESSERT $40 TTOBACCO $55 NAMECHANGE: $t5 AMOUNTDUE _ $ 1�f5.0� •*""•PLEA5E TURN OVER AND COMPLETE OTHER SIDE OF FORM»««.. � ADMINISTRATION Llnder Chapfer 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 COMI'. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CI�CK APPROPRIATELY IF PAID: YES� NO MOTELS AND OTHER LODGING ESTABLISffi1�NTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transieirt occupancy shall be limited to the tetnporary 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 ofresidence eLcewhere. Transient occupancy shall generally refer to continuoua 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 sha11 not be considered transient. Occupancy that is subject to the collection of Room Occupancy Excise, as de6ned 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 wlilch have been closed for the season must be ins�� by the Health Department prior to opening. Contact the Health Depardmem to schedule the inspectiott three(3)days pnor to opening.PLEASE NOTB: People aze NOT allowed to sit m the pool area until the pool has baen inspected and opened. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform attd standazd plate count by a State certiSed lab, and submitted to the Health Department three (3) days prior to opening, and quarterly thereafter. POOL CI.OSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Departmern by Sling the Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtainedr�th Health Department. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified tab. Test results must be sent 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: Outside cafes(i.e., outdoor seating with waiter/waitress service),must have prior approval&om the Board ofHealth. OUTDOOR COOHING: Outdoor cooking�pre�ararion,or di�lay of any food product by a retail or food service establishmern isprohibited. _ NOTICE:Permits run annually from 7anuary 1 to December 31. TT IS YOUR RESPONSIBI[�1TY TO RET[JRN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIltED FEE(S)BY DECEMBER 15, 2009. ALL RENOVATIONS TO ANY FOOD ESTABLISHIv1ENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND A.PPROVED BY TI�BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A 3TfE PLAN. DATE: r'/ G SIGNATURE: PRINTNAME&TITLE: �I/�rt CAiLv�tto �kUAJr/�— 0925/09 <Toname:----> <Tofaxnum:5087754577> C'ERTIFICATE OF INSURANCE u�vso�o HIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN HE ISSUING INSURER(S , AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the Certifcate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require and endorsement. A statement n this certiticate does not confer ri hts to the certificate holder in lieu of such endorsement. PRODUCER Marshall K Lovelette Ins Agcy Inc 396 Route 28 West Yarmouth, MA 2673 COMPANIES AFFORDING INSURANCE COMPANY A GRANITE STATE INSURANCE COMPANY WSURED Jason Carvalho Dba Bagels 8 Beyond 311 Rte 28 W Yarmouth, MA 02673-0000 COVERAGES THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOT WITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN . MAY HA10E BFEN REQUGEO BY.PAID-CLAIMS- -� � -- to LTR TYPE OF INSURANCE POLICV NUMBER VOLICY EFFECTNE DATE POLICY E%PIRAiION DATE �{ ORKERS COMPENSATION N�EMPLOYERS'LIABILITV LIMITS HE PROPRIETOR/ .. � � PARTNERS/EXECUTNE FFlCERSARE: . � INCL O EXCL❑ 9886467 12/05/2009 12/05/2010 TATUTORY LIMRS � THER overage Applies to hW Operations Only. ACH ACq�ENT $ 1 OO,OOO OISEASE POUCV LIMIT S SOO,OO OISEASE-EACHEMPLOVEE S �OO,OO DESCRIPTION OF OPERATIONSNEHICLES/SPECIAL ITEMS RE:THE WORKERS COMPENSATION POLICY DOES NOT PROVIDE COVERAGE FOR JASON CARVALHO. CERTIFICATE HOLDER ANCELLATION TOWNOFYARMOUTH SHOULOANVOFTHEABOVEOESCRIBEOPOLICIESBECANCELLEOBEFORETHE EXPIRATION DATE TMEREOF,NOTICE WILL BE DEIIVERED IN ACCORDANCE 1146 RT 28 WIHTE THE POLICV PROVISIONS. SOUTH YARMOUTH, MA 02664 AUTHORIZED REPRESENTATIVE . �^�-/ `- I 'I.�/ . . . �/ ��an 29 10 02: 04p User 508-778-6458 p. 7 � I I � l . � � :� .. • �. • � ' � � ; GRANITE STATE INSl1RANCE COMPArf -'- � 0072529'00 WC 009-88-5467 i 31 o z =X. .+__ ------- - ------------- .�,. . ---0�3-66-izo9-oo 1S. "S pi . _: •. : ' � C�C�OMCD � JASON �CRRVALHO C H A R T�I S W�YARMOUTH, MA 02673�-0000 y ` �--�� A CM1artis company �currve oFF�ees: HEALTH DEPT. SEE EXTENSION OF ITEM 1. OF THE IN � 175 Water SVeet . New Vork, NY 10038 I.D,f � •• � iy+'' _rf__ K LOVELET7E INS AGCY INC WORKERS COMPENSATION A/� :_�=e 28 � LIABIUTY POLICY INPORMATlOw � - '1�hOUTH, MA 02673-4713 INSUHED IS �•�1SPOLIGVNUM9EF INOIVI�UAL R.°NENAL 004 880 OTHER WORKPLACES NOi SHOWN AB01fE .3 ' � 7HE 1NFORMATION PAGE - WC990670 REMx POLiCTiERI00itAlAMslandaMlimeat�er� . . ma�rnyaaaress ;.._'::�= .y �� -_ _��Oj ro 12/Orj/10 R�� A, Workers Compensacion Insura�K.c 11� a�a � Ne Workers Compensation Law af the states listed �ere: MA �� B. Employers Liability Insurano� P�t'�� a �e work in each state Iistetl in item 3,A. The limits of our Iiabllity undar P�ti� - t ff.� kqury by Actitlent $ 100.000 each accident . � rfq- kqury by Disease S SOO..ODO policy limit r'i� c+jury 6y Oisease $ 100.000 eaCh amployee C. OtM1er States Insurencr. Part Thrae�i �� . �f any. listed here SEE ENDORSEMENT - WG200�i� D. This palicy i�clutles these -`� SEE EXTENSION OF 17EM 3A�! �4ac - WC990612 ��m� The premium tor th�s pc�ley will De a lass. dassitiw[ions, Rrtes and Rating Plans. All iMormation requi�ed bHow is wE��r -�ile T' �dit. Es�imataeTmal 1�y tePer Estim��etl dasailic�6as .�ae Numner Remune.efion S1d00f Rr Pmmlum � Annuel �3 Vear Tu0¢rdUOn �Annual ❑3 T�ai I SEE EX7ENSION OF ITEM 4. OF THE INFORWI7O . i TAXES/ASSESSMENTS/SURCHARCES I S55 I I ppENSECONSTPMT�IXGEPTWHFAEAVPLIGAoBIFBYSTA7Q � MINIMUM VREMIUY .2�p MA TOT4l ESTIMATEO PpEMIUM I O4 P 11 indiwmd below, mt�rim atljustmann o�prem�um s�al�t��W � Semi-nnnuairy � �uvietlY OEPOSITPPEMIUM O1/09/10 ASSIGNED RISK � � � Issue Date �'� Aul�or'ved R¢Oreaentalive W�00 90 01 i R 399s11Aov'a wia61 �S � ; '..