HomeMy WebLinkAboutApplication and WC -B ^: � se� 5r+�� ��, - � � �.,�.� .�'.�' ; .
20WP�f�F YARM(}UTH SOARD L'�'� a �' ,� ; �
APPLIGATIUI�f T'OR LTC�NSEiP� ��� '� ;
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I ' *Please complete form and attach all necess�ry-�cum�ts �2Q1 S. � �
I Failwe to do sv will resutt in fhe ret�m of your applic.�tox�p� �t. . , ,
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F�TABLISHMENT NAIvf� ��rr.� <���,r.� �.�..�A�S•.c TAX 1B� �` - �°�
LC7�ATIt3N ADAR.ESS:�'� �-\w��c•,•�� ,4�V G�S.`t�rr��,�,T'EL:#: �sb- 3�l 4-U��11
MAiLING ADDR.�SS: \c�� �.�c��.��7 '�..ti.�. '�z-. G�c=w..�v��r-"��-12�. �'"�,v���r�C� �/3�-"�(�{1
E-MATLAt�I7RESS: �.c.�,�,r�S�b��'�•\ G�n�
O�NER NAME:
Ct3R1'�RATTON NAI�iE(IF APPLICABLE}: C��� `C�-`�+'`� �"C'
MANAGER'S NAME: ` Cs�r•�=�� TEL.#: � q -U�'"1�
� MAILTNG ADDRESS: C� �� a "c.t� - \ — ��.�5
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� POOL CERTI�ICATIONS:
The pool supervi�or nnust be certified as a Pool Operator,as required by Stat�law. Piease list the designated
Pocil Operator{s)and attach a cQpy of the certi�catian to tins for�a.
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Paol,operators must[ist a cginimum of two er�playaes currer�tly cert��d in standard F��st Aid�nd C��n�ity
Cardiopulrnan�ry Resnscitatinn(�P��,havfnp�one ce�Ya�'i�d smployee an p�ernis�s at�Il t�mes. Pte�se list#��
empla�ees belaw and aitach copies of tl�eir cert�fications tca this farm.The H��IEh Uepartment w�ll not u�se past
y�a�s'r�eords. Y'os���prt►vthde�ev��t►p�.and,n�i�tEaim a�31e at'yaar p'l�ce of hrusin�s.
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Ft7�T)ARt)TF,CTIC?N MAN�CrFRS-GERTIFICA`I`I�NS:
All food seruice establishrnen�s are requir�d t�ha+re ax least one full-time�rn�layee�vho is c�rEifed as�a�'ood ;
Protection Manager,as defined in the State Sani#ary Gode for Food 5en+ice Establishments, lOS CMit S9Q.000. ,
Please at#ach copies t�fcertification to this application, Thc Hcaft[�De�arfmEnt wilt not use past years'records.
Yau must�srovide new copies and maintain a�le at yaur estabGshment.
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P�I2S(3N IN CHARtiE:
Ea�:h food establishment musrhave at least one Persan In Charge(P1C)on site during hours of operatio�. ',
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ALLERGEN C�12TIFT�CATIONS:
Ail fi�+od service sstahlishznezats are reyuir�d ta have�t leasi one full-tim��mplay�e who has Allergen�erfi��ati�n,
as defined in the Sts�te Sanitary Code for Foc�d Service Establishments,145 CMIt 590.U€�9tG}(3}(a). Please attach
capies af certiificatian tc�this applicatio�a, The He�lth Deprartment witl not use past ye�rs'reeorda. Yaa mus#
provide new copiea and mai�tain a�le at y�ur establishm�nt.
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HETMLICI-I CETtTIFTCATIQI*IS: `
All fooci service establishments with 25 seats or more-must have at least one em�loyee trained in the Hei�nlich
M�ne�a�r�=an the prPmice�at ai!t;r��s. nlea�lict ynur emnlc�vees trained in ant�-ch�afctng prncedures below a:nd
aztach copi�s af�mployee certifications tc�this faem. The H+eatth Dep�rtment wiil pot use}�ast years'records.
You musY provide new ea�ies and maint�in a file at your place 4f busine�s.
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RESTAUR,ANT S�A'i"ING: "�"f}TAL#
_� .�___ �_ �.__..�e.�FF�C����4)�iLY ___ ����
LODGING. .. _._...__._ _�,. �,�.. -,
UCENSE REQUiRED FEE PGRMIT# LtC�NSF,REQUIRED 1'EE PERMIT� LIC�NSI�ftEtjUIREt) FEG P�RMIT#
Bc@.F� $55� � CAt3i*1 � $SS � � MQTEL $Y iQ � ��
—INN �55 CAMP $SS SW[M�vtING POf}L St{Oca.
_LOI}GE 553 ,_TRAi1:ERFARK' $fUS _WH[RLNOOL $]lfka.
�`OPD S�RYtC�r
I,IGGNSEREQ[1iR�D FEE PGRMIF# t,iCET�i3��REQUtREIJ P��� PEKI�t13"!1 LTCENSER�QUIEtL'[) �FEE FEI�Pv$T# �
0-100 SEATS 5125 _CONTiTVENTAL �35' NOA(-PROFCI' $3Q !
�100 SGATS $2U� CQMM()N�/IC. �6U �1�NC)LGSAL,C 6�i0 �p?�O `
RETAtL SERYICE; � � —��SID.KI7'CHEN 580 !
I,ICENSERF,QIJtRED FEE PG T'� LICENSE LTT `��'�:�tMiTfY L10E1�{S�REQUlR�.17 FP,E PERIvtJT`#
sq >25,OQ V E1dDfNG-f`O1717 525�
<25,pOfl sq.ft. $1�50 ,�FRO�I. {} ' iTOBACCQ $1 IO
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NAME CMANG�: �$15 +��ULTNT IIU�.r. '� �,�„Q;�S�: '�
**"'"�A1,EASE T11RN UVER ANU COMPLGTCa OTHER$IDE OF FORM*""**
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� ADMINISTRATION
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� Under Chapter 1 S2,Section 25C,Suhsection 6,the Town of Yarniouih is now xecluixed to hald issuance or renewal
j of any license or permi#to operate a 6usiness if a person or company does not have a Certificate of Worker's
� Compensation Insurance. T�T� ATTACHED STAT� WORKER'S COMP�NSATT�N TNSURANCE
I AFFIDAVIT MI}ST B�CUMPLETED AND SXGN�D,OR
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CERT.C�F INSURANCE ATTACT�ED +�
OR
WORKER'S COMP.AFFIDAVIT SIGNED AND ATTACHED
Town of Yarrnouth taxes and Eiens must be paid prior to renewal or issuance of yauc permits. PLEASE CHECK
APPROPRIATELY IF PATD:
YES v� NO
MOTEL,S AND�THER LODGING ESTABLIS�IMENTS
TRANSIENT OCCUPANCY: i=or purposes of the limitatians of Motel or 1-Iotel use,Transient occupancy sha41 be
limited to the temporary and short t$rm occupancy,ordinArily and customarily associaied with motel and hote[use.
Transient occupants must have and be a61e to demor�strate that they maintain a principal place of residence
elsewhere.Transient occupancy shall generally refer to continuous occupancy of not more than thirry(30)days,�nd
an aggregate of not more than ninety(90)days withitt any six(6}nionth period. Use of a guest unit as a residence or
dwelling unit shall not be considered Yransient. Occupancy that is subject to th�collection of Room Occupancy
�xcise,as defined in M.G.L.c..64G or 830 CMR 64G,as an�ended,shall g�nerally be considered Transient.
roo�s
POOL UPENING:Ail swimming,wading and whirlpools whicii have been closed for the season must be inspected
Uy the Health Departrnent prior to opening. ConCact the Heal�h Dep�rtment to schedute ti►e inspection threc(3) ,
days prior to opening.PLEASF NOTE:People are NOT al�owed to sit in the pool area until the pool has been
inspected and opened.
POOL WATER TESTCNG: The water must be tested for pseudomonas,total coliform and standard plate coupt
Uy a State certifed lab,vid submitted to the Healti�Department three (3) days prior to opening,and quarterly
tl�ereafter. '
PDOL C�.OSING:Every outdoar in ground swimming pool nn�st be drainec!or covered ravithin seven(7)days of
closing.
FOOD SERVICE
SI'.ASONAL FOOD S�RVICE t}PENING:
All food service establishmenis xnust be inspected by the Heaith Department prior to apening. Please contact the
Health Department to scheduie the inspection three(3)days prior to opening.
CATERING P�LICY:
Anyone who caters within tlte Town of Yarmouth must notify the Yarmouth Health Department by filing the
ren�ured Te�nporary I�aod Service Application form 72 hours prior to the catered event. These forms can be
obtained at the�-Iealth Department,or from the Town's website at www.yartnouth.ma.us under Health Department, �
Downloadable Forms.
FROZEI�I DESS�I2TS:
Frozen desserts musE be tested by a State certifieci 3ab prior to opening ana mont�hly t�;ereafter,wit;�sample iesu;ts
submitted to the Health DepartmenG Failui�e to do so will result in the suspension or revocation o.f your Frozen ;
Dessert Permit untif the above terms have been met. �
OUTSiDE CAFL+SS: �
Outside cafes(i.e.,outdoar seatin�with waiter/waitress seevice),mc�st have priorappraval from#he Boazd of HeaEth.
OUTDOOR COOKING: '
Outdoor cooking,prepacation,or display of a�iy food product by a retail or food service estabiishmenE is proh9bited. '
NOTICE:Permits run annuaI[y fiotn January 1 to December 31. YT IS YOUR R�SP(3NSIBILITY TO ItETURN
1'HE COMPL�TED RENEWAL APPLICATION(S}AND RGQUIRED FEE(S)BY DECEMBER 15,2Q15.
ALL RENOVATIONS TO ANY FOOD ESTABLISHM�NT, MOTEL OR POOL (i.e., PAINTfNG, N�W �
�QUIPMENT,ETC.),MUST BE REPORTED T4 AND APPRO'VED$Y THE BOARD QF HEALTH PRtOR i
TO COMMBNCEMENT. RENOVATIONS MAY R�QUIRE A SIT�PLAN. F
DATE: //— 3"' � SIGNAT1J12E: Me-�tr �[1���'�-�-� i
PR1NT NAME& E: �� �'r'� ,- Y��
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Rev.10l01/15 � '
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_ t� The Commonwealth ofMassuchusetts
Department oflndustrial Accidents
Offce ofinvestigations
1 Cangress Street,Suite 100
Bostnn,MA 02114�2017
www.mas�gov/dia
Workers'Compensatiou Insnrance Affidavit:General Basinesses
Apnl�cant Information Please Print Le�ibiv
Business/Organization Name: ��YY�,v'�d �`�-'��� ���i��C '
Address:�'�" ��`����l��t�� �� e—
G�
City/State/Zip:S• �{�'M d"�� Phone#: '�c.`��— 3`�7�-} —O�-`�� �$'- a-a.i_
e yo n employer?Check ihe approgriate box: Bnsiness Type(reqaired): G ' ""
1 a employer with�_employees(£ull and/ S. ❑Retail
or part-time)* 6. ❑Restaurant7Bar/Eating Establishment
2. .{T'..I i 8rii a sate praprietnr ar pactnership.and have no ry; ��ffice andlor SaIes(incl.real estate,auto,etc.)
employees working for me in any capacity.
[No workers'comp.insurance required] x• ❑Non-profit
3.❑ We are a corporation and its officers have exercised 9. []Entertainment
their right of exempCion per a I52,§1(4),and we have 10.�Manufacturing '
no emptoyees.[No workers'comg.insur�nce required]"` �1.0 Health Care
4_❑ We are a non-profit organization,staffed by volunteers, 1 � ���)�cr���Q (�.���`� �vv�S
with no employees.[iYo workers'comp.insurance req.]
�Any applicant shat checks boz#1 must also filf oui We sed3on below showklg��'���s'compensatioa policy infosmation.
*tIf the corporate officers have exempted themselves,but the cotporation has ather employees,e workers'compensation poliey is required and such an
orgaaizatioa should check box i1L
I am an employer that is providing workers'cnmpe»sation insurttnce for my employees. BeIow is[he policy informatton.
Insurance Company Nazne:
Insurer's Address:
City/Stata/Zip:
Policy#or Self-ins.Lic.# Expiration Date:
Attach a copy of the vuorkers'compensation policy declaration page(showing the policy aumber and ezpiration date).
Failure to secure coveraoe as required under Section 25A of MGL c.152 can lead to ihe imposition of crisninal penalues of a
firie up to$I,�60.�?0 and/or one-Yeaziinprisocunac�-aswell•areiail panxltiesin tke f�rm.of a STOP WORK•ORBER art�s f�
of up to$250.00 a day against the violator. Be advised that a copy of fliis statement may be forwarded to the Office of
Investigations of the DIA for insurance caverage verification.
I do hereby certify,und ins and penalties of perJury that the informafion provided above is true and correcb
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1 --�'6��� � `�a. -c�-�`'1� -e-7� -j d�i�
Officia!use only. Ao not write ix this area,to be co»rpieted by eity or town officia� �
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City or Town: Pe�mitlLicense#
Issaing Authority(circle one): �
1.Board of Heaith 2.Bnilding Bepartment 3.CifylTown Clerk 4.Licecsing Board 5.Select�ten's Of�ce �
b.Other
ConEac#Person: Pl�one#: :
www.mass.govldia
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A�!e�` CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDMfW)
2/1/2016 1/27/2015
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS '
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATNELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES ,
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT:If the ceRificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to I
the terms and conditions of the policy,certain policies may require an endorsement A statement on this certiTicate does not confer rights to the
certificate holder in lieu of such endorsement(s). '
PRODUCER LOCKTON COMPANIES � ��
2100 ROSS AVENUE,SUITE 1400 a No EXt: ac No:
DALLAS TX 75201 E-MAIL
214-969-6700
R
wsur�aa: ACE American Insurance Com an 2266�
INSURED ggU,Inc.on behalf of itself and INSURER B: �d0mi11t insurance Co of North America 43575
1359436 U.S.subsidiaries including iNsur�R c: A i General Insurance Com an 42757
(see attached addendum) . ACE Fire Underwriters Insurance Com an 20702
455 Business Center Dr.
Horsham PA 19044
RER F:
COVERAGES CERTIFICATE NUMBER: 13323158 REVISION NUMBER: XXXXXXX
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED.NOTWITHSTANDING 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 BY THE POlIC1ES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
. EXCLU�Oh`S AND CORfDITIOIdS C�SUCH PBtielE�`s'tiMliS�uHAWidfaiAY HAVE SEEN REDUCED 9l'?hfB CL-&!M3:— _"-- - -- '
INSR ADDL SUBR PQLICY EFF POLICY EXP LIMITS
TYPE OF INSURANCE �N POLICY NUMBER M/
A X COMMERCIAL GENERAL LIABIIITY N. N Hp0 G27341652 2/UZO15 2/I/2016 EACH OCCURRENCE 1 OOO OOO
CLAIMS-MADE�OCCUR . �REM ES F_a ocwEven� 1 OOO OOO ;
� MED EXP An one erson 5�0� �
PERSONAL&ADV INJURY $ 1 OOO OOO '
GEN'LAGGREGATELIMITAPPLIESPER: GENERALAGGREGATE $ ZOOOOOO �
POLICY❑jEa a LOC PRODUCTS-COMP/OPAGG $ 2 OOO OOO �I
OTHER $ I
A AUTOMOBILE LIABILITY N N ISAH08852479 2/I/2015 2/1/2016 EOM�BI deDtSINGLE LIMIT $ S OOO OOO �
X ANY AUTO BODILY INJURY(Per person) S XXXXXXX �
AUTOS NED qUTOSULED BODILY INJURY(Per accident $ X}�}{XX}� .
HIREDAUTOS AONOSWNED P80a�RTYDAMAGE $ XXXXXXX �
$ XXXX}�X �.
UMBRELLA LIAB OCCUR EACH OCCURRENCE $ XXXXXXX
EXCESS LIAB CIAIMSMADE NOT APPLICABLE AGGREGATE $ XXXXXXX
DED RETENTION$ $ �
WORKERS COMPENSATION '
A AND EMPLOYERS'LIABILITY N WLR C48144871 CA,MA� 2/1/2O1$ 2/1/ZO16 X STATUTE TH- .
B ANVPROPRIETOR/PARTNER/EXECUTIVE Y�N �RC48144883�AOS� ZII�ZOIS Z�1�ZO�6 E.L.EACHACCIDENT $ 1 OOOOOO �
C OFFICER/MEMBER EXCLUDED? N❑ N�A WLR C481462ll TN� 2Il I2O�S Z/II2.OIC7 1 �
D (MantlrtoryinNH) SCFC48144895( n 2�1�2��5 2�1�2��6 E.I.DISEASE-EAEMPLOVEE 1 �0���� ��.
DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT 1 OOO OOO . ',
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 701,Additional Remarks Schedule,may be attached if more space is required)
Policy#HDO G27341652 includes policy general aggregate of$l OM !
CERTIFICATE HOLDER CANCELLATION See Attachment
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SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE �
THE EXPIRATION DATE THEREOF, NOTICE WILI BE DELIVERED IN j
ACCORDANCE WITH THE POLICY PROVISIONS. �
13323158 AUTHORIZED REPRESENTATIVE f
Evidence Of Coverage
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ACORD 25(2014/01) 01988-2014 ACORD CORPORATION.All rights reserved �
The ACORD name and logo are registered marks of ACORD
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INSURED:
BBU, Inc. on behalf
of itself and U.S. subsidiaries
including (see attached addendum) ,
255 Business Center Drive
Horsham, PA 19044 USA
The following are Named Insureds under the GL and Auto policies:
Advantafirst Capital Financial Services, LLC
Arnold Sales Company LLC
Bimbo Bakeries USA, Inc.
Bimbo Bakeries Distribution Company, LLC
Bimbo Foods Bakeries Distribution, LLC
Earthgrains Baking Companies, LLC
Earthgrains Distribution, LLC '
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EGR California Region Support Services, Inc. '
Stroehmann Line-Haul, L.P.
Wholesome Harvest Baking, Inc.
The following are Named Insureds under the WC policies: �
Bimbo Bakeries USA, Inc.
Wholesome Harvest Baking, Inc. ,
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Standard Attachment:BIMBAKUSNI
Master ID: 1359436,Certificate ID: 13323158