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HomeMy WebLinkAboutApplication and WC ^ � � L�pGELS f aEYGa]D �GQ62�$S TOWN OF YARMOUTH BOARD OF HEALTH [���[�O�I C�DD APPLICATION FOR LICENSF./P�RNIIT-20i0 * Please complete form and attach all neceS�'�ry documents by D emri�Y I3�2�OD� Failure to do so will result in the return of your applicaUo p �I H ucr i . NAME OF ESTA$LISHMENT:_ �� � �� TEL. # � 7�d`�� LOCATION ADDRESS:_,_,��'j �,��,�� _�—��� �,3 7;,� MAILING ADDRESS: OWNER NAME: TAX ID (FEIN or�Nl• CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: url ✓A-tNc, TEL. # , ' � MAILING ADDRESS:_ // (�1.�}'ii.J W � M �}-02to 7'i POOL CERTIFICATIONS: T'he pool supervisor must be certitied as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certificarion to tlris form. 1. 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standazd First Aid and Communiry 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 maintafn a file at your place of business. 1. G-�st1< < 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 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 T�e at your establishment. 1.- __ t�v� �/� 2. PERSON IN CHARGE: - - - - _ __ Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. �A Uf (GLc� 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the He'vnlich Maneuver on the premises at all times. Please list your employees mained in anti-chokmg procedures below and attach copies of employee certificarions to this form. T6e Health Department will not use past years' records. You must provide new copies and maintain a t"ile at your place of business. , L 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FE£ PERMIT# LICENSE REQUIRED FEE PERMIT# _B&B $55 _CABIN $55 _MOTEL S55 �]NN $55 _CP.IvL° $55 �SWIDRvIINGPOOL S80ea. _LODGE $55 _TRAILERPARK $105 _WHIRI,POOL $80ea. FOOD SERVICE: LICENSE REQUTRED FEE P$RM1T# LICENSE REQUIRED F£E PERMIT# LICENSE REQUIRED FEE PERMiT# �0-100 SEATS S85 �� _CONTINENTAL S35 �NON-PROFIT S30 _>100 SEATS $160 _COMMON VIC. $60 _WHOLESAL£ 380 RETAII.SERVICE: —RESID.KITCHEIV 580 LICENSE REQiJIILED FEE PERMII'# LICENSE REQUIl2ED FEE PERMIT# L[CENSE REQUIRED FEE � PERMIT# _<50 sq.ft S50 �>25,000 sq.ft. 5225 `VENDING-FOOD S25 „_QS,OOOsq.R � � $80 _FROZENDESSERT $40 TOBACCO S55 NAMECHANGE: SIS AMOUNTDUE = S 85-06 '*"""PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*"«�• AD1�III�TISTRATION Under Chapter 152, 5ection 25C, Subsection 6,the Town of Yazmouth is now required to hold issuance or renewal of any license or peimit 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 taYes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LODGING ESTABLIS�NTS TRANSIENT OCCUPANCY: For purposes of the limitarions of Motel or Hotel use,Transiettt occupancy shall be limited to the tetnporary 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 ofresidence 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 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 which have been closed for the season must be insp¢�� by the Health Department�pnor to opening. Contact the Health Departmem to schedule the inapection tbree(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,total coliform and standazd plate count by a State certified lab, and submitted to the Health Depaztment 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 CATERING POLICY: Anyone who caters witkrin the Town of Yarmouth must norify the Yarmouth Heaith Depaztment by Sling 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 result in the suspension or revocation of your Frozen Dessert Pernrit 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 COOHING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishmeirt is pro6ibited. NOTICE:Permits run annually from January 1 to December 31. TT IS YOUR RESPONSI$ILI7'I'TO RETURN TI� COMPLETED RENEWAL APPLICATION(S) AND REQUIILED 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 APPROVEDBY TI�BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SI'T'E PLAN. DATE: � G`� SIGNATURE: 't PRINT NAME&TITLE: .�R��` A�'�'K� ��� 09/25/09 <Toname:----> <Tofaxnum:5o87754577> CERTIFlCATE OF INSURANCE irlvso�o HIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE ERTIFICATE 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 Certificate 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 certificate 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 INSURED Jason Carvalho Dba Bagels 8 Beyond 311 Rte 28 W Yarmouth, MA 02673-0000 COVERpGE� . THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LIS7ED 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 MqY PERTAIN,THE INSURANCE AFFORDED THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.IIMITS SHOWN MAY HAVE BEEN REDUCED RY pqip CLqi�Ng co �TR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTNE OATE POLICy Fj(p�pq7pN OATE /� ORKERS COMPENSATION ND EMPLOVERS'LLIBILITY HE PROPRIETOR/ LIMITS ARTNERS/EXECU7NE FFICEftSARE � � . � INCLOEXCL❑ 988646] 'IZIOrJIZOO9 'IZIOSIZO�O TATUTORVLIMITS � THER overege PpPlias to MA Operationy Onty. CHACCIOENT $ IOO,OO ISEASE Pp��CY LIMIT $ 500,00 ESCRIPTION OF OPERATIONSNEHICLES/SPECIAL ITEMS �SEASE-EACM EMPLOVEE $ 100,00 E:THE WORKERS COMPENSATION POLICY DOES NOT PROVIDE COVERAGE FOR JASON CqRVAlHO. CERTIFICATE HOLDER ANCELLATION TOWNOFYARMOUTH SMOULDANYOFTHEABOVEUESCRIBEDPOLICIESBECANCELLE�BEFOHETHE 1146 RT 28 �P��TION DATE THEREOF,NOTICE WILL 8E UELIVERED IN ACCORDANCE SOUTH YARMOUTH, MA 02664 �H7E THE POLICY PROVISIONS. AUTHORIZED REPRESENTqTIVE �,�,�.w � , Jan ,29 10 02: 04p User � � 508-778-6458 p. l I:. ��`�� j . . � . . . . �' � . . �� . . ' � GFYANITE ST�1TE INSl1RANCE COMPA�► �� � � 0072529-00 WC 009-88=6467 13102 �:e: ----- ---013 66=1209-00� JASON CARVALHU CHARTI �6��d�� W�YARMUUTH, MA o2673-0�00 "� '��"J � �'`20�� _ A ChaRis mmpsny � FYceurive orHeEs: � HEALTH DEPT. � �75 Witer Sfroet�. �� � . SEE EX7ENSION OF I7EM 1. OF THE IN _ New Vork, NV t0E13�. � � � - I.Dd "� . -.',. ,�, .�. � � f__ A LOVELETTE INS AGCY INC �� WORKERS COMPENSATION ArO �_�=E 28 LIABILITY POLICV INF011MAT10■ '13h0UTH, MA 02673-4]1 j � INSUNED IS �•'C(1SPOLICYNUMIBEH INUIVI�URL �� =:NEHAL 004 880 OTHER WORKPLACES NOT SHOWN ABOVE. z3.' =� 7HE SNFORNIATION PAGE - WC990610 IiEMa OOLICYVEFIOA@:O�0.MslanderAllmGNrr� .� i: - mem�a+aam. F." �� - -�r/09 ro 12/95/10 �r�� p, Workers Compansation Insurr��1r �a � Me Workers Compensatlon taw of the SWtes listed �era: MA B. Employers Liability Insureno� PIK1� ��e work in euh sWtn fistetl i� item 3,A The IImUs of our Iiability und�r P�t ,�,, � . d r f�f.� Injury by AcrJdent ; 100,000 earli eccident . � �� kyury by Uisa�se S . 500.000 poll�y iimit r'iy ►yury by oisnse S 700.000 ach emolayee Q Other Staties Insuranea Part T1rw� 1e �s, i1 any, listed irerc SEE ENDORSEMENT - WG200�ii D. Th�s poliey includes these F SEE EXTENSION OF ITEM 3A�� �_� - 'NC990812 ihm� The premium tor this polity will be s /�aes, daSsitiWtians, Rrtes and Rating Plans. All intormarion repuired 6dow Is suE�ftr ���ve vy audit. 611melYaTel�l �op� Ez[ImaYtl Pemunenlirn � Gromlu Q�afiliu4s .aO�NumEer OAnnu�l❑3YMr muneratbn �Annual �3.Yur . I SEE EXTENSION OF ITEM 4. OF 7HE INFORW►7� i � TAlCES/ASSESSMENT$/SURCHARGE$ � I SSS I I IXiFllSECONSTpNT�O1tEPTWMEREAPiLICAn9tE8Y5TA7� ..� MINIMVM VREIpIUM .Z�p f�A TOT4L ESfIMATEO VNEMIUM � 042 II I�tliCilBtl bOIOW,mb�iin itljUSimenlf OI O�BTIUT 5��11 0��� � Ssml-Annuany � �u+qa�ly pEPO51TPPEMIUM O1/O9/10 ASSIGNE� .RISK , �t � ' �'' "� L Ixiue Uate . ��a Aul�orimN NeOnisntallvs y,,��.�pl :;' 3996)�Ra�d W i98) , . T .