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Home My WebLink AboutApplication and WC �"`"-' B�wraDi�s Ic,�C2e7aM �� TOWN OF YARMOUTH BOARD OF HEALTH APPLICATION FOR LIC� , ; =�6k� NUV 'L 1 Z013 � * Please complete form and attach a11 heo� �' ts by ec Failure to do so will result in t�ie}�etu�.uf3�o'�r applicat • ESTABLISHMENTNAME: �on�i�' ='c� RE �'- LOCATIONADDRESS: 9�,¢ 0urk 2� �+-n�NaE a,y,}RMov�r+� TEL.#: .S Od'r- (019-3lrlo MAILING ADDRESS: 32 3 cAr RD S�Aits n i� 58�3 E-MAILADDRESS:_'Y1 cc-hal �, �Veri�eM• �1et � �I-s �-ho-Iv @ q'�+-i • Cam, OWNERNAME: Artc � a- �of�P F C�t L CORPORATION NAME (IF APPLICABLE): C' .� E'dT�ER t S � �.�C ' MANAGER'SNAME: NRN� _ e�AyA� TEL.#: �`F-4'S�8- agS MAILING ADDRESS: 3z3 ti-{�,-e eart v,. e a a s vn cF f'l•y. (O a 83 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 tlus form. 1. 2. Pool operators must list a minimum of two employees currently certified in basic water safety,staudard First Aid and Community Cardiopulmonary Resuscitation(CPR),hauing one certified employee on premises at all times. Please list the employees below and attach copies of their certificaflons 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' reeords. You must provide new copies and maintain a file at your establishment. i. J'f�aey �1 . C,�NA �y 2, - PERSON IN CIIARGE: Each food establishment must have at least one Person In Charge(PIC) n site during hours of operation. 1. I�In�tc� �1. CA N A ��` 2. o s�l'�} F� C��a�y ALLERGEN CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who has Allergen certification,as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.009(G)(3)(a). 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 Tile at your establishment. i. I'(RncY 1� - �'A �AL�' a. �1 o s�Ptf ��f1 NA�� HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one em�loyee trained in the Heixnlich Maneuver on ihe premises at a11 times. Please list your employees trained 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. 1, c]OSt"t'N � CAHA�Y �C�/(�LS Z, ( It�ncYA _C�..�HA�Y ACLS/QLS 3. 4. RESTALJRANT SEATING: TOTAL# f C� OFFICE USE ONLY � LODGING: ' LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# BBcB $55 CABIN S55 MOTEL S55 � �A1N $55 CAMP $55 SWIMMINGPOOL $SOea. _LODGE $55 7RA[LERPARK $105 _WFIIRLPOOL $SOea FOOD SERV[CE: � � � LICENSE REQIDRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# I 0-t00SEATS $85 � � �-I� �� CONTINENTAL $35 � NON-PROFIT $30 � � _>100 SEATS $160. � �COMMON VIC. $60 �,J� WHOLESAI,E � �$80 � � . � � . � "�� . —RESID:KITCHEN S80 �� I RETAIL SERVICE: � � � LICENSE REQUIRED FEE PERMI'1'# � LIFENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq.ft. $50 >25,000 sq.ft. $225 VENDING-FOOD $25 <25,000 sq.ft. � $SO � � �FROZEN DESSERT $40 —`COBACCO $95 '��. NAME CHANGE: $15 AMOUNT DUE _ $ �I�S, OO � � •s•r�Y1.EA9E TEJRN OYF�t�AIYD COMPLETE OTI�IER SI@&OB FORM•::.: �', � _ _ . ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yannouth is now required to hold issuance or renew3l 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 V OR � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yazrnouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK � I APPROPRIATELY IF PAID: � YES � NO ' MOTELS AND OTHER LODGING ESTABLISHMENTS � TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use, Transient occupancy shall be lnnited 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 tliirty(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 I 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 inspected by the Health Depar[ment prior to opening. Contact the Health Deparhnent to schedule the inspection three (3) days prior to opening.PLEASE NOTE:People aze NOT allowed to sit in the pool azea until the pool hasbeen 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 nofify 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.varmouthma.us under Health Department, Downloadable Forms. FROZEN DESSERTS: Frozen desserts must be tested by a State certified 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 Permit until the above terms have been met. � I OUTSIDE CAF'ES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. OUTDOOR COOHIIVG: Outdoor cooking,preparation, or display of any food product by a retail or food service establishxnent is prohibited. NOTICE: Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMI'LETED RENEWAL APPLICATION(S)AND REQiJIRED FEE(S)BY DECEMBER 13,2013. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY QUIRE A SITE PLAN. � DATE: � ( I 1 (� I13 SIGNATUftE: Q l � pxn�rr rr.�tE�Trrr;E: I'1 r�n�y A . �ya�y J a�E-a tr F' C'r�y��r -ow�'�ns Rev. 10/OSA3 � � � �� . � The Commonwealth ofMassachusetts Department of Industrial Accddents Of'fice oflnvestigations 1 Congress Street,Suite Z00 Boston, MA 02II4-20U www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses A licant Information Please Print Le 'bl Business/OrganizationName: C'N� L�T�� P2t�t �.LC �SA z-eMt��E's Tc� �RE'�M Address: �� °�'►'�' �"" �ut�7N'(G- � City/State/Zip: �d��,A(ZMotl'Tt�(,_��} �z�G� Phone#: `� �a'- � 19- 3(., lO Are yo n employer? Check the appropriate boz: Business Type(required): 1. I am a employer with �'-�i employees(full and/ 5. ❑ Retail o art-time 6. []'TEestauranUBar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no �, � pffce and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers' comp. insurance required] $• ❑ Non-profit 3.❑ We aze a corporation and its officers have exercised 9. ❑ Entertainment their right of exemp6on per c. 152, §1(4), and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]* 11.❑ Health Caze 4.❑ We aze a non-profit organization,staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.❑ Other �I *Any applicant[hat checks box#1 must aLto fill out the section below showing their workers'compensation policy informatioa. �� "If the cocporete officeis have exempted themselves,but the corporadon has other employees,a workers'compensalioa policy is required and such an �' organizaflon should check box#L � � .. �� . � � � -" . � � . I, I am an employer that is prov^ng workers'compensation insuranc or my employees. Below is the policy information. ' Insurance Company Name: 1��li��R �!f�D��'{l� � GF �ME��CF1 � Insurer'sAddress: �/o ��(�fRSy �RA� .1l'fSURAfPCE /'-tGEN�)' � c;riis�c�iz�p: �o�rE- I 3'�. S'e _ �t-rtn�s (►`1 R (� 2(,6 a Policy#or Self-ins.Lic. # tD �� 8 - SQ -/ � /C7�f - (7 -� 3 Expira6on Date: ��Oz/�� Attach a copy of the workers' compensarion policy declaration page(showing the policy number and eapiration date). � Failure to secure coverage as required under Section 25A of MGL a 152 can lead to the imposi6on of criminal penalties of a ' fine up to $I,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP VJORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwazded to the Office of Investigaiions of the DIA for insurance coverage verificauon. i I do hereb i ,under t e pa�and pen s ofperjury that e information provided above is true and correcd I Si ature: � � I Date: � �� 3 Phone#: C�C.L -1 �y - � J @l �8q � 'i1y-� J'b g.2�S�flAIYCY ' � � Official use only. Do not write in this area,to be completed by city or town offaciaL City or Town: vp�ylTrt{. Permit/License# uin u ' (circle one): I .Board of Health 2.Building Department 3. City/Town Clerk 4.Licensing Board 5. Selectmen's Office 6. Contact Person: Phone#: �$-3QB.-��J ,p/2�� www.mass.gw/dia i _ ,� , : . TRAVELERS J WORKERS COMPENSATION � AND � EMPLOYERS LIABILiTY ppLICY TYPE AR INFORMATION PAGE WC 00 00 01 ( A) POLICYNUMBER: (sHU6-5690104-0-13) NEW-13 I ��S�R� �'t-� FRAS�'fCEi25 I4�g1EtdJITY COMPANY OF AMERICA t•E ( i ;• NCCI CO CODE: 13439 tN��' PRODUCER: �Fk1 �N�TER?RISES LLC ROGERS & 6RAY INS AGENCY 323 �A7�IGOTE ROAD ROUTE 134 SCkRSflALE NY 105g3 SOUTH DENNIS MA 02660 lnsured i5 A LZMITED LIABILITY COMPANY Other work piaces and fdentffication numbers are shown in the schedule(s) attached. 2- Fhe poticY period is from o4-02-13 to 04-o2-i a 12:01 A.M. at the insured's mailing address. 3• k• WQRKERS COMPENSATION INSURANCE: Part One of the poticy applies to ihe Workers Compensation Law of the state(s) listed here: � MA m� m� „� B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state Iisted in = Rem 3.A. The IimRs of our liabi�lty under Part Two are: _-= Bodtly Injury byAccidern: $ s0o000 Each Accident � B�ily Injury by Disease: g 500000 paicy Limit o= Bodily Injury by Dlsease: S 500000 Each Employee _ C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, 'rf any, listed here: � COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06A � �� m� '� D. This policy includes these endorsements and schedules: ti_ ' a� SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE o� , � � 4. The premium for this policy will be determined by our Manuals of Ruies, Classifications, Rates and Rating � Plans. All required irrtormation is subject to ver'rfication and change by audit to be made ar�M�pLtv. DATE OF ISSUE: 04-23-13 BP OFFICE: ORLANDO INDUS AFF 161 ST ASSIC�1: MA PRODUCER: ROGERS & GRAY INS AGENCY 237XR aovea 1 � �� I �� ' ��itv�c.��s'�'' WORKERS CQMPENSATION � AND E�p�DYE�LlABILITY POLICY TYPE AR INFORMATIOM PkGE W�pp pp p� � A� POLICY NUMBER: (6HUa-5B9oi oa-o-�3} CWSStF{CATION SCHEDULE: PREMIUM BqSIS ESTIMqTED RATES CLASSIFICATIONS T�TA�ANNUAL PER$100 OF ESTIMATED CODE NO REMUNERATION REMUNERATION ANNUAL PREMIUM SEE EXTENSION OF INFORMATION PAGE - SCHEDULE(5) SIC-CODE: 5812 I -------------- --------- ----------- ----- ----------- OTAL ESTIMATED ANNUAL STANDARD PREMIUM $ STANDARD PRER9IUM DISCOUNT 21� 0900-20 EXPENSE CONSTANT NONE TERRORISM 250 TOTAL ESTIMATED PREMIUM 5 TAXES AND SURCHARGES 486 ' DEPOSIT AMOUNT DUE � ' 493f� A/R (WCIP) # Minimum Premium; g 21 g EMPLOYERS LIABILITY MINIMUM: $ 50 DATE OFISSUE: 04-23-t3 Bp ST QSSIGN: MA OFFICE: ORLANDO INpUS AFF 161 PRODUCER: ROGERS & GRAY INS AGENCY 237XR —`, - _ -- .,�---- � �p . TRA�(F�.E�IS� woR►ceas ca�+PeNsanoN AND EMPLOYERS UABILlTY POLICY EXTENSION OF INFO PAGE-SCHEDULE WC 00 00 01 ( A) POLICY NUMBER: (6HU6-5B90104-0-13) �T�R: T}E TRAVELERS INDEMNIN COMPANY OF AMERICA 13439-MA ��p•5 NAt� : CNJ EN7ERPRISES LLC RA� gUREAU ID: 000974767 PREMIUM BA5I5 ESTIMATED RATES ESTIMATED TOTAL ANNUAL PER $100 OF ANPHIA� CLASSIFICATION CODE REMUNERATION REMUNERATION PREMIUM E£3GATI�f 001 Ot FEFN ENTITY CD 001 ' CNd ENTERPRISES LLC 928 ROUTE 28 S YARM6UTH, MA 02664 RESTAURANT NOC 9079 15000 1 .07 161 .�. � m� �C � o� a� o�- m� , �� _ _ ____'_ ___'_'_ ', m� = 1 .00% EMPL. LIAB. SNCREASED LIMITS(9807) $ 2 ,.= ADD FOR INCREASED LIMITS MINIMUM (984$) 48 NONE a� MERIT RATING/EXPERIENCE MOD: NONE MODLOSSDCONS�TAN�T Zd °— TOTAL ESTIMATED ANNUAL STANDARD PREMIUM 2�1 ' = EXPENSE CONSTANT(0900) 250 � 0.0300 TERRORISM (974�) 5 � 4.20% MA WC SPECIAL FUND AND TRUST FUND � � TOTAL ESTIMATED PREMIUM 493 DEPOSIT AMOUNT DUE 493 DATE OF ISSUE: 04-23-13 BP ST ASSIc�1: MA SCHEDULE NO: 1 OF LAST oone�