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Home My WebLink AboutApplication and WC . :_- ., � �� `� TOWN OF YARMOUTH BOARD OF HE.A�.LT�I � � ¢ 'b APPLICATION FOR LTCENSE/PER1V$'��`��Ol t . ��3 ' NOV ? � % �g �� w'?� ' � *Please complete form and attach all necessary @�ocum�ms� ` Dece er D Utr� . � Failure to do so witl result in the retum p�`your applicatton pac NAME OF ESTA�3LISHMENT: � I. �� Z �TEL. # ��J�'�� LOCATION ADDRESS:__��"10 rbv�.- MAILING ADDRESS: OWNER NAME: glockbuster Inc. TA�ID"(FEIN or SSN�� . CORPORATION NAIUI: permits and Licenses M,ANAGER'S NAME:_ p O. Box 8009 TEL. # MAILING ADDRESS:�, McKinney, Texns 75070 POOL CERTIFICATIONS: The poal supervisor must be certified as a Pool Qperator,as reqaired by State law. Please list the designated Pool Operator(s) and attach a co�y of the certification to this form. 1. _ 2. Pool operators must list a f o em oyees currently certified in basic water safety,standard First A.id and Community Cardiapulmo Re u cita ' PR). Please list these employees b�low and attach copies of employee certifications to this form. he H lt epartment will not use past years' records. You must provide new copies and maintain a fil at yo plac of business. �. a. � 3. 4, i �_.,_.�.,._._.,_.�,...�_,.�.._.�......_,__. a � FOOD PROTECTTON�vIANAGERS - 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 S 'tary Code for Food Service Esta li �e�, 0� ;r�� .000. Please attach copies of certification ta t ' pp ' tion. The Heatth Department w � ' �e'ai��ords. You must provide new copies and ma i e at your establishment. ;r1!, --� 1. 2. ��.��' U ;�CE��?� J _ PERSON IN CHARGE: r .�!�,�.�..;�l�S�, I�E�� __ -,�t --- _ _ --- - _ . Each food establishment must have at least one Person In Charge (PIC) on site'` �hours o�operation. I � 1. 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 rimes. Please list your emmployees trained in anti-choku�g procedures below and ' attach copies of employee certifications to this form. The Health Department will aot use past years' records. � You must provide new copies and main in a file at your place of business. 1. � 2. 3. 4. RESTAURA.NT SEAT'ING: TO AL# LODGING: OFFICE USE ONLY ' LIC�IVSE REQUIRED FEE PBRMIT# LICENSE REQUTRED FE$ PERMIT# LJCENS�REQUTRED FEE PERMIT# �B&B $55 iCABIN $55 ,_MOTEL $55 _,_,TNN $55 �CAA2P �55 �SWIMIvIING PO�L �80ea. �LODGE $55 _____TRAILBRPARK $105 +WHtRI,POOL $80ea. FOOD SERVICE: LICENS�REQUIRED FEE PERMIT# LICENSE REQUIRED �'�E PERMIT# LICENSE REQUIRED F�E PERMIT# ____0-100 SEATS $85 _CONTINENTAL $35 �NON-PROFIT $30 >100 SEATS $160 COMMON VIC. $b0 �WEiOLESAL£ $80 RETAIL SERVICE: _ �RESID.KITCHEN �80 LICENSE REQUIItED FEE PERMIT# LICENSE REQUI1tED FEE PERMIT# LIC�NSE REQUIRED FEE PERMTT# 1„<50 sq.R. �50 ��=�o-aal7 >25,000 sq.8. �225 ,_VENDING-FOOD $25 ,_;_QS,000 sq.ft. $80 _FROZEN DESSERT $40 �TOBACCO $SS NAME C,HANGE: $is AMUUNT DUE _ $ 50.op "*"*"PLEASE TURN OVER AND COMPLE'TE OTHER SIDE OF FORM***** t i^ � �"� ADNIINISTRATION Under Cha.pter 152,Section 25C, Subsection 6,the Tawn of Yarmouth is now required to hold issuance or renewal of any license or pemnit to operate a business if a person or company does not have a Certificate of Worker's Cornpensation Insurance. THE ATTACHED STA1'E WURKER'S COMPE ATION INSU1tANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR � CERT. OF INSURANCE ATTACHED '; OR WORKER'S COMP. AFFIDAVTT SI D AND ATTACHED : Town of Yarmouth taxes and liens must be paid prior o renewal or issuance of your pernuts. PLEASE CHECK APPROPRIATELY IF PAID: ' YES N4 MOTEI.rS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purpases of the limitations of Motel or Hotel use,Transient occupancy shall be ' limited to the temporary and short term occupancy, ordinaril�and customarily associated with motel and hotel use. Transient occupants must have and be able to demonstrate that they mairrtain a principal place ofresidence elsewhere. Transient occupancy sha11 generally refer to continuous occupancy of nat more than thirty (30) days, ar�d an aggregate of not more than ninety(90) days within any six(6)manth 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 defined in M.G.L. c. 64Cr or 830 CMR 64G, as amended, sha11 generally be considered Transi�nt. POOLS POUL OPENING:A11 swimmin,g,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. Contact the Health Departmerrt to schedule the inspectionthree(3)days pnor to opemng.PLEASE NOTE:People aze NOT allowed to sit m the pool area until the pool has baen inspected and opened. POOL WATER 1'ES17NG: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, and submitted to the Health Deparkment 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 wit}un the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These£orms can be obtaiiied 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 ar revocation of qour Frazen Dessert Permit untit the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitaress service),must have prior approval from the Board ofHealth. OUTDOOR COOKING: . _4utdo��4oki�g,g_r�paration,or, is lay of any food�product by_a retail or food_serv_ice establishment is prolubited. , NUTICE:Permits run annually from 3anuary 1 to December 31. IT IS YOUR RESPONSIBII.ITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15, 2009. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAZNTING, NEW � EQUIl'MENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR � TO COMMENCEMENT. OVATIONS MAY REQUIRE A SITE PLAN. ; � i DATE: �` ✓ SIGNATURE: f � PRINT NAME&TITLE: I 09l25/09 i 1 • � � �� The Commonwealth of Massachusetts , Department of Industrial Accidents N�Cf Ii�l� 600 Washington Street, 7`�'Floor ' Bostoa,Mass. 0211I + Workers'Comncasation Iasarance A�vit-�Baitdieg/Ptumbieg/Electrical Contractors Aonliwrt le6sree� :,_��. , �_ Blockbuster Inc. _ �J Permits nnd Licer�ses ' -- - ad�s:_ P.O. Box 8009 = . .,. _�, � � " ��y McKinney, Texas 75070 . , �;D_ D�# G��a'1�1�� work site 1«�tio�►rruu ada�ssr ` ❑ I am a homeowner perf'ornung all work myseif. Pro'ect T ❑ I am a sole J YPe= ❑New Construction QRemodel P�Pnetor and have no one working in any caPacih'• ❑Building Addition ; ❑ I am an e.mployer}xoviding w�k 'compensati�for my ployees wo ' g on this:ob. , , -. �N �{ F: �,,,,� : �,. ;: � ,,_ _ oo�a �ame: - tddtess: ,��. 2 ci O _ ]� tns ca � �, � #. L/ �; • , ,, ,,._ � .,...��f��.�,..s': .. .a-:.: � . ,.::: �.'.;•. , ';.'�.: . . .�:� ..'e. ...':: .�.�.--. ,' ..::: ,e-x'. ..,-.>,.-..i .E.:' ,e'2F: S c..,,> ❑ I am a sole prapriefor,g��al cottractor,or 6oeieown�(circle one)and have luc+ed the co�actors lisfsd below who have ' the following workezs' "on polices: ; ; � � d � - i�s�ra�ce ea - � :�:. _ � , _.�: �,�::� �w�'.�{_�' �� ad�- �:. - - - - 1a�.e�, --- - > >---�� _- -- -- _ --- — - ------- • -- . , �..: _ . � x.:s E �. s._s ---�a .�"�:��, >�_�.� Sv ya�s+t._r��.`;_f-'�.,�;�+..: . Fa�e«.aa�e cw��nqa�,ea oaer sectlu.2SA.t MCL ls2 e..ie�a t.iYe�pn�.[ �pma�.ca�e.p�.sl,soa.M a.r/.z �)"p�'�t as wr�as dH pe�dtla i t6e��f a 31'D!'WORIC ORDSR aed a 8ee�[31 N t day aaarymt ate. 1�adm0uid Wat a e�py�t lib atate�wR my 6e f�rwaded�o He Omee�[ a e. �m�t t6e D c�age�aliu. /lo benby certify rrwder tJYe�atws d fdes of ot tlie iw etlo�p ' e�aboae Lc dne awd . � — �O � Date Pcint nantie Phone# � o�idal�x oaly de�at write ia mis uea to be�d 6y.dtY er MRa�.�ciai . dt)'or bw�: , ;.�� t ❑cied�if�ie rt�psme is ieq�ed �Beard �m's O�oe p�,,:�a� PkNe�; �� ACO� DATE(MAA/DD/YYY1� �- � CERTIFICATE OF LIABILITY INSURANCE page 1 of 4 09/30/2009 Paoouc� 877-945-7378 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE willis of Texas, xac. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 26 centuxy slvd. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P. O. Hox 305191 mash.riiie, mrr 3�aso-si9i INSURERS AFFORDING COVERAGE NAIC# INSURED glockbuster. Inc�.. � �. . � � . - INSURERA:The Insuraace C ompaay of the State of Pea 19429-001 1201 Elm Street INSURERB:Commerce and Industr Insuraxice C Renaissance Tower Y omyany 19410-001 Dallas, TX 75270 INSURERC:National Uaion Fire Insurance Company of 19445-002 INSURERD:Illinois Disi.ional Insurance Compaay 23817-002 INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THEINSURED 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 POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR DD' POLICYEFFECTIVE POLICYEXPIRATION � LTR NSR TYPEOFINSURANCE �POLICYNUMBER � DATE M DD/YYY DATE MM/DD/YYY LIMITS A GENERALLIABILITY GL6506380 9/30/2009 9/3O/2010 EACHOCCURRENCE $ 1 �00 �00 � X COMMERCIALGENERALLIABILITY DAMAGETORENTED I _ PREMISES Eaoccurence $ 1 0�� 000 . . .. -�LAIMSM1AADE �OCCIiR -'-�... � :.�.��- ----- � �__ �- �� . . - . ... ^:� MEDEXP.(Any:one�persan) .. .. $.. � PERSONAL&ADVINJURY $ �. OOO OOO GENERALAGGREGATE $ S 000 O00 GEN'LAGGREGATELIMITAPPLIESPER: PRODUCTS-COMP/OPAGG $ S OOO OOO POLICY �E a LOC � A AUTOMOBILEUABILITY AOS CA6647291 9/30/2009 9/30/2010 A X ANYAUTO VA CA6647290 9/30/2009 9/3�/2010 COMBINEDSINGLELIMIT ; (Eaaccident) $ 2�000�000 $ ALIOWNEDAUTOS MA CA6647289 9/30/2009 9/30/2010 gODILYINJURY � SCHEDULEDAUTOS (Perperson) $ j HIRED AUTOS BODILY INJURY 1 NON-OWNEDAUTOS (Peraccident) $ � PROPERTYDAMAGE $ � � (Peraccident) � GARAGELIABILITY � AUTOONLY-EAACCIDENT $ � � ANYAUTO OTHERTHAN �ACC $ AUTOONLY: AGG $ �,' EXCESS/UMBRELLALIABILITY 27471468 9/30/2009 9/30/2010 EACHOCCURRENCE $ 2 �0p �00 ][ OCCUR � CLAIMSMADE AGGREGATE $ a OOO OOO $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION WC STATU- OTH- A ANDEMPLOYEHS•uae�F�v - . _ � AOS WC4289228 .9/30/2009 9/30/2010 X TORYLIMITS � ER '�-Y/N -__ .., . . . . .__.. p� ANYPROPRIETOWPARTNEFVEXECUTIVE� CA WC4289225 9/30/2009 9/30/2010 E.LEACHACCIDENT $ 2 O00 OUO OFFICER/MEMBER EXCLUDED? D (MandatoryinNH) FL WC4289224 9/30/2009 9/30/2010 E.L.DISEASE-EAEMPLOYEE $ 2 000 �0� If yes,describe under SPECIALPROVISIONSbelow E.L.DISEASE-POLICYLIMIT $ 2 OOO OOO OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/FJ(CLUSIONS ADDED BY ENDORSEMENT!SPECIAL PROVISIONS � See Attached CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF�THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION � DATE THEREOP,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 3 0 DAYS WRITTEN .NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON TME INSURER,17S AGENTS OR EvidenCe of Insur8nCe REPRESENTATIVES. ' AUTHORIZED REPRESENT ACORD 25(2009/01) Co11:2820649 Tpl:985555 Cert:1 �1988-2009 ACORD CORPORATION.All rights reserved. The ACORD name and logo are registered marks of ACORD > -� DATE W1��IS CERTIFICATE OF LIABILITY INSURANCE Page 2 of 4 �a9/30/2009 PRODUCER g��_gq5_73�g THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR willis of 'rexas, xnc. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 26 Century Blvd. P. O. Box 305191 Nashvilie, �tmt s723o-5191 INSURERS AFFORDING COVERAGE NA�C# INSURED glockbuster Inc. . INSURERA:The Iasurance ComBany of tha 3tate of Pen 19429-001 1201 Elm Street INSURERB:Commerca aad Industry Insurance Caa�paay 19410-001 Renaissaace Tower Dallas, TX 75270 INSURERC:National Uaion Fire Insuraace C�aay of 19445-OOa INSURERD:Illinois National Iusuraace C�aay 23817-002 INSURER E: DESCRIPTIONOFOPERATIONS/LOCATIONSNEHICLES/EXCLUSIONSADDEDBYENDORSEMENT/SPECIALPROVISIONS �� . � . Worher Compeasatioa: ND, NY. WA, WI, WY Carrier: National IInion Fire Insurance Company of Pittsburgh Policy NY�mber: WC4289227 Policy Effective: 9/30/09 Policy Exgiration: 9/30/10 NAIC-LOC: 19445-001 Workers Compensation: OR Carrier: The Iasura�ce CompanY of the State of Pennsylvania Policy N�mber: wC4289226 Policy E£fective: 9/30/09 Policy Expiration: 9/30/10 NAIC-LOC: 19429-001 Workers Compensation: TX Carrier: New 8ampshire Insurance Company Policy N1�mber: wC4289223 Policy Effective: 9/30/09 Policy Expiration: 9/30/10 ' NAIC-LOC: 23841-001 Excess workers Compensation aad Employers Lisbility: OH Carrier: Illinois National Unioa Insurance Com�any Policy N�mber: WC0910533 Policy Effective: 9/30/09 Policy Expiration: 9/30/10 NAIC-LOC: 23817-002 Workers Compensation: Statutory Employers Liability $2,000,000 Each Accident; $2,000,000 Each Employee for Disease Commercial General Liability is subject to the following provisioas: Additioaal Iasured-Maaagers or Lessors of Premises - "All persons or orgaaizations leasing premises to you" is included as an insured, but only with respect to liability arising out of the ownership, maintenaac� or use of that part of the premises leased to you and is subject to the following � additional exclusion: � 1, Aay �becurrence" which takes place after you cease to be a tenant in that premises; ! 2. Structural alteratioas, new coastruction or demolition operations performed by or on behalf of ; the "persoa or organizatioa leasiag premises to you". Additioaal Insured - Primary - However, coverage under this policy afforded to aa Additioaal � Insured will apply as Primary insurance where reguired by contract, and say other insurance issue �k to such Additioaal Iasured shall apply as excess and Noa-contributory insurance. � Additional Insured - Vendors (CG20150704) Included for coverage; Additional Insured - Volunteer Workers (CG20210798) Iacluded for coverage; Additional Insured-Desigaated Person or Organization (CG20260704) Included for coverage. Commercial General Liability aad Automobile Liability policies are subject to the following provisioas: Additional Insured - Where Required Under Contract or Agreemeat: AaY Persoa or organization to Co11:2820649 Tp1:985555 Cert:13159341 _