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Home My WebLink AboutApplication and WCf �• TOWNOFYARMOUTHBOARDOFHEALTH, I �� =�� , � -�,�� APPLICATION FOR LICENSE/PERMIT- � � � � � � (�C: ��i0 * Please complete form and attach all necessary docu,m s by�ce e EPT. Failure to do so will result in the return of your appJi��'t�on p ESTABLISHMENT NAME: /✓� TAX ID: LOCATION ADDRESS: c`J TEL.#: � ) —� �� MAILING ADDRESS: I� OWNER NAME: (�/ ��( C9-( CORPORATION NAME (IF APPLICABLE): /�/ ,S' , C . MANAGER'S NAME: �� TEL.#: MAILING ADDRESS: ��^e POOL CERTIFICATIONS: The pool supervisor must be certi�ed as a Pool Operator, as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certificatiou to this form. 1. 2, Pool operators must list a minimum of two em loyees cuirently certified in basic water safety, standard First Aid az�d Commwiity Cardiopulmonary Resuscitation(�PR). Please list these employees below and attach copies ofemployee certifications to this form. The Health Department will not use past y�ears' records. You must provide new copies and maintain a Gle at your place of business. 1. 2 ' �� 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establisluneuts are required to have at least one full-time employee wl�o is certified as a Food Protection Manager, as defined 'ui the State Sazutary Code for Food Seivice Establislunents, 105 CMR 590.000. Please attach copies of cei7ification to this applicatiou. The Health Department will not use past years'records. You must provide new copies and maintain a 61e at your establishment. 1.��1� �l�N �^J/a'N(n 2. lav �l�/� �l(�"° PERSON IN CHARGE: �.ach iood estabGsiunent must have at least one Person In Charge (PIC) on site durnie hours of operation. \ �. ��Id'�l f.fl�✓� z. HEIMLICH CERTffICATIONS: 1 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 yom� employees tranied in anti-choknig procedures below and attach copies of employee certifications to this forni. The Health Department��ill not use past years' records. You must provide new copies and maintain a file at your place of business. �. �(��(�fi✓ � z. 3. 4. RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LODGI\G: LICENSE REQUIRED FEE PERYIII'd LICENSE REQUIRED FEE PER�IIT� LICENSE REQUIRED FEE PERNIIT a _B&B S55 _CABIN S55 _b10?EL S» _INN S» ----- _CtLYfP 5�5 _S��i�?MING➢OOL S8nea. _LODGE S55 _1-RAII,ERPARK S105 _\L-HIRLPOOL S80ea. FOOD SER�'ICE: LICENSE REQLIIRED FEE PERVIIT= LICENSE REQLIIRED FEE PERIIIT€ LICENSE REQUIRED FEE PERi�11T= I 0-IOOSEATS S85 '��(�Q((o _CON"IINENI"AL S35 NON-PROFIT 530� _>l00 SEAI'S 5160 I CO_YLYION VIC. S60 #l1—ali _\y'HOLESALE S80 RE'I:�IL SER�ICE: —RESID.KITCHEN S80 LICENSE REQUIRED FEE PER'�fIT# LICENSE REQUIRED FEE PER\-fIT# LICENSE REQOIRED FEE PER�IIi# _<50 sq.d. S50 _>25,000 sq.8. 5225 VENDING-FOOD S25 _<25,OOOsq.ft. S30 _FROZENDESSERT Sd0 TOBACCO 555 �a�e cxa�cE: sis AMOUNT DUE _ $_�y5 •00 ""**"PLEASE'IL'R\OVER A\D CO�IPLEI'E OTHER SIDE OF FOR�i"""** ADMINISTRATION 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 ATTACHED STATE WORKER'S COMPENSATION INSURANCE ; AFFIDAVTP MUST BE COMPLETED AND SIGNED, OR ; CERT. OF INSiJRANCE 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 CHECK , APPROPRIATELY IF PAID: ! YES NO - MOTELS Al�,"D t1THER i,t7DGING ESTABLIS�I�TENTS TRANSIENT OCCITPANCY: For purposes ofthe limitations ofMotel 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 OPENING: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 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 standard plate count by a State certified lab, and submitted to the Health Department three (3) days prior to opening, and quarterly thereafter. i POOL CLOSING: Every outdoor in ground swirruning 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 Deparhnent to schedule the inspect�on three (3) days prior to opening. CATERING POLICY: Anyone who caters within the Town of Yazmouth 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 i Health Department, or from the Town's website at www.yarmouth.ma.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. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. OUTDOOR COOHING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. i NOTICE:Pernuts run annually from January 1 to December 31. TT IS YOUR RESPONSIBILITY TO RETURN ; THE COMPLETED RENEWAL APPLICATION(S) AND REQLJIlZED FEE(S)BY DECEMBER 15, 2010. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW I� EQUII'MENT,ETC.),M[IST BE REPORTED TO AND APPROVED BY THE BOARD OF FIEALTH PRIOR ' TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE FLAN. DATE: SIGNATURE: ' PRINT NAME&TITLE: I 10-06'10 � ; Public Service Mutual Insurance Company i ' ' One Park Avenue . . . I New York,NY 10016•5807 WORKERS COMPENSATION AND EMPLOYER'S LIABILITY INSURANCE POLICY INFORMATION PAGE NCCI Company No:16152 Prior Polky Number: WC 072209 09 RENEWAL Policy Number: WC 022209 10 1. Named Insured and Mailing Addresa: Producer and Mailing Address: Fine Asian Cuisine, Inc. Richard Soo Hoo Insurance Agency, Inc. 981 Main St, Route 28 1148 Washington Street South Yarmouth, MA 02664-5642 Boston, MA 02118 TeL (617)33&8188 The Insured:Corporation Other workplaces not shown above: Named Insured:Fine Asian Cuisine, Inc. 2. The policy period is from 5/30/2010 to 5/3W2071 72:01 A.M. Standard Time at your mailing address shown above. 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers' Compensation Law of the states listed here: Massachusetts B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident $ 500.000 each accident Bodily Injury by Disease $ 500.000 policy limit Bodily Injury by Disease $ �00'000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: D. This policy includes the following endorsements and schedules: See Extension of Information Page 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Premium Basis Rate Per Estimated Loc. Code Total Estimated $100 of Annual Classifications St. No. No. Annual Remuneration Remuneration Premium See Extension of Information Page $351 Loss Constant: $20 Expense Constant Charge: $250 Minimum Premium $218 Deposit Premium $607 Total Estimated Annuai Premium: $601 Premium Adjustment Period: Annually Servicing Office: New England Branch �� Countersigned 3/29/2010 at New York, N.Y. by _ Auttwrized Representadve THIS INFORMATION PAGE WITH THE WORKERS COMPENSA770N AND EMPLOYERS LIABILJTY INSUflANCE POLICY AND ENDORSEMENTS,�F ANY,ISSUED TO FORM A PART THEREOF,COMPLETES THE ABOVE NUMBERED POLICY. EdNion 10/97 CopyrigM, 1987 Natio�al Council on Compensadon Insurance Page t of 5 INSURED COPY