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Home My WebLink AboutApplication and WC, , �j � R�� TOWN OF YARMOUTH BOARD OF HEALTH ,.; ,. � n,,.� � � APPLICATION FOR LICENSE/PERMIT-2017 ��'� , ' '� �� ._. * Please complete form and attach all nece��o�uments by Dece be . pT. Failure to do so will result in the retfir��t�f your app�caD n � e . ,� ESTABLISHMENT NAME: �,� � r�Xc'=%�r C.�Si`} ,-T��L TAX ID: `7�-`�y�ii�G/ LOCATION ADDRESS:� u��nc Dr� �rE ;S' u'�i., :: r in�� /� TEL.#:.��7�'=3��-D?�'/`� MAILING ADDRES S: ' -;D r` _G�� .L�r:� L��-i�r�- ` ; . � L� �.4�`� �V.��' iJ ' E-MAIL ADDRESS: %;L'��5`es�Iabu/n�ci(_CCy`�'� OWNER NAME: CORPORATION NAME (IF APPLICABLE): i%n�j� T ;ir,y�f � � 1,�i`_d MANAGER'S NAME: �-L CGit��t�_� TEL.#: 5�'� =��'-� ��` � MAILING ADDRESS:�.�'Gt��ne-� GGS� 0 0✓� - hJ��=�?�-J`��'' POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated j Pool Operator(s) d attach a copy of the certification to this form. - - - l f'� �� 1 ` � . Pool operators must list a minimum of two employees currently certified in standard First Aid and Community � Cardiopulmonary Resuscitation (CPR), having one certified employee on premises at all times. Please list the � employees below and attach copies of their certifications to this form. The Health Department will not use past ; years' records. ou must provide new copies and maintain a file at your place of business. i � 1• 2• 3. 4. i 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'records. ! You must provide new copies and maintain a file at your establishment. I ; � 1. l�i� � E� 2. 1 ��- ' PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. i 1. �r/ �� 2. 1 � . - _ _ - _ _- -__ -- __ _ - 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 file at your establishment. ; ; 1. (� l 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 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. � � 2. 3. 4. ' RESTAURANT S�AT�FC:--TOTAL # � OFFICE USE ONLY j r nnL'.Int�= __ __ _ __--- _____ ---- -- ----- _—— -- ----_— _ ---- -- LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $110 IT1N $55 CAMP $55 SWIMMING POOL$I l0ea. j _LODGE $55 _TRAILERPARK $105 _WHIRLPOOL $110ea. � FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 ._CONTINENTAL $35 NON-PROFIT $30 =�%t��' >100 SEATS $200 _COMMO:'�ViC. $b0 ZWHOLESALE $80 � RETAIL SERVICE: —RESID.KITCHEN $80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $50 >25,000 sq ft. $285 VENDING-FOOD $25 _<25,OOOsq.ft. $I50 _FROZENDESSERT $40 _TOBACCO $110 NAMECHANGE: $15 AMOUNTDUE _ $ gO•D� *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** $ot�F-IS-(883-02 � ': 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 AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED � OR WORKER'S COMP. 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 AND OTHER LODGING ESTABLISHMENTS � TRANSIENT OCCUPANCY: For purposes of the limitations of Motel 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 prior to opening. PLEASE NOTE: People are NOT allowed to sit in 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. POOL CLQSING: EwPr3�-oatcloor i�ground svw��nixig pool�nust be drained or�overed within seven_(7�days of i 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 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 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. ___�_ __ _ __ _— - _ __ ��KI1�TG: _ _ _ ___ - Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 16, 2016. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUII'MENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOlt TO COMMENCEMENT. RENOVATIONS MAY REQUI�E A SITE PLAN. � � DATE: �Q �"�� =�6��' � SIGNATURE:��k,`�' �/��--' , � � PRINT NAME &TITLE: ��j�-��_, `- �2 Z-� 2d�72o q ' Rev. 10/12/16 � �� i � '' � The Commonwealth of Massachusetts Department of Industrial Accidents ; Office of Investigations � ' ' 1 Congress Streef,Suite I00 � ` Boston, MA 02114-2017 � www.mass.gov/dia '' Workers' Compensation Insurance Affidavit: General Businesses ; � Applicant Information Please Print Legiblv n Business/Organization Name: �i�r1�� er1�S �-��,.� :�;t�• I Address: �'�'7 ��rt��✓l��Or� .�l�Q � I � City/State/Zip: �. �' Y��/"��,��L � Phone #: .5��'';5��_ �� _z�2% -�'�%�5- Are you an employer? Check the appropriate boz: Business Type(required): 1.❑ I am a employer with ,�employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ RestaurantBar/Eating:Establishm��- - - 2.❑ i arri a�ii�proprietor or pa:�tner$hip and have iro �. �Office and/or Sales(incl. real estate, auto, etc) employees working for me in any capacity. [No workers' comp. insurance required] g• ❑ Non-profit � 3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4), and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]* 11.❑ Health Care 4.❑ We are a non-profit organization, staffed by volunteers, I_ p� with no employees: [No workers' comp. insurance req.] 12.�'] Other � ��l t��. ,�/ '�G( O � *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. **If the corporate officers have exempted themselves,but the corporarion has other employees,a workers'compensation policy is required and such an organization should check box#1. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: Insurer's Address: ��.�`,�- ��(��L7�l-e� � City/State/Zip: Policy#or Self-ins. Lic.# Expiration Date: Attach a copy of the workers' compensation policy declaration page(showing the policy number and egpiration date). Failure to secure coverage as required under Section 25t�of MGL a.152 can lead to the imposition of criminal penalties of a finr iir�tn �1 S�LJ��3��L1F � � il�s£:.,:i ..,..,.,.ta:,.,. `...�„F....,. ..1'„ c•m�n�i��nrr�i�rn _�� ._..____1...�i�' '' " .. .... � . a r. . . .�ivi:ia�I—ZC �L1iL'_--__. of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify, under the p ns d penalties of perjury that the information provided above is true and correct. Si ature: � ��-�L�' Date: � • �� /.��' Phone#: � � '_`2<G�c`�x�� (�'G�/ C'� ,��`/� Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3.City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone#• www.mass.gov/dia ,acoRO� CERTIFICATE OF LIABILITY INSURANCE pATE(MMlDDIVYYY) �' 1�31�2017 1/21/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE GOVERAGE 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 certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAlVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER LOCKTON COMPANIES NAMEACT � � ' - 2100 ROSS AVENUE,SUITE 1400 PHONE FAX A/C No: DALLAS TX 7520] E-Mai� ' 2�4-9�i9-6�� ADDRESS: � � �� INSURER S AFFORDING COVERAGB NAIC# —_._ ___ �NsuReR A:ACE American Insurance Com an 22667 INSUREO BBU,[��c,on behalf of itself and iNSURER B:IIICI0111111 Insurance Co of North America 43575 1359436 U.S.subsidiaries including wsuReR c:A ri General Insurance Com an 42757 (see attached addendum) iNsuReR o:ACE Fire Underwriters Insurance Company 20702 255 Business Center Dr. Horsham PA 19044 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 12152765 REVISION NllMBER: XXXXXXX THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTCD BELOW HAVE BEEN ISSUED TO THE INSURED NRMED ABOVE FOR THE POtICY 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, EXCLUSIpNS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUBR POLICY EFF POLICY EXP �TR TVPE OF INSURANCE POLICY NUMBER MM/DDlYYYY MM/DD/YYYY LIMITS A �X COMMERCIAL GENERAL LIABILITY j�J N HDO G27403967 1/31/2016 1/31/2017 EACH OCCURRENCE $ 1 OOO OOO DAMAGE TO RENTED —� ; CLAIMS-MADE � OCCUR PREMISES Ea occurrence $ 1 OOO OOO � MED EXP(Any one person) $ 5�� PERSONAL&ADV MJURY $ 1�OOO OOO � GEN'L AGGREGATE LIMIT APPLIES PER: � � � � GENERAL AGGREGATE � �.$-2 OOO OOO POLICY PRO- � . �JECT ❑X LOC � - �PRODUCTS-COMP/OP AGG� $ 2 OOO OOO OTHER: . � � $ . A AUTpMO61�E LIABILITY j�J N ISAH0886715A I/31/2016 1/31/2017 COMBINED SINGLE UMIT $- Ea accident 5��0�� X ANY AUTO BODILY INJURY(Per person) �$ XXXXXXX __ AUTOS NED qUTOSULED BODILY INJURY(Per accident) S XX '�X�' _._- ---._.__. NON-0 W NED PROPERTY�DAMAGE HIRED AUTOS qUTOS Per accident $ XXXXXXX $ XXXXXXX '_ UMBREILA LIAB OCCUR NOT APPI.ICABLE EACH OCCURRENCE $ XXXXXXX EXCESS LIAB__ _ C�AIMS-MADE AGGREGATE S XXXXXXX DED� RETENTION$ 8 XXXXXXX A ANDEMPSO ERSENsnnTOY N WLRC48597051 CA,MA) 1/31/2016 1/31/2017 X �STATUTE ERH B ANY PROPRIETOR/PARTNER/EXECUTIVE Y�N WLR C48597099�AOS) 1/31/2016 1/31/2017 E.l.EACH ACCIDENT $ ] OOO OOO C OFFICER/MEMBEREXCLUDED? � N�A WI-RC4859�1�g �� 1/31/2016 �/31/2��7 D (Mandatory(n NH) SCF C48597130( I} 1/31/2016 I/31/2017 E.L.DISEASE-EA EMP�OYEE $ 1 Q��QQQ � If yes,describe under DESCRIPTION OF OPERATIONS below � E.L.DISEASE-POLICY LIMIT $ 1 OOO OOO DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Ramarke Schadule,may be attached if more space is required) Policy#HDO G27403967 indudes policy general aggregate of$lOM Evidence of Insurance. CERTIFICATE HOLDER CANCELLATION See Attachment 12152765 BBU,InC. On behalf SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE of itself and U.S. subsidiaries THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1nCILiding(See attaChed adderidUln) ACCORDANCE WITH THE POLICY PROVISIpNS. 255 Business Center Drive Horsham PA 19044 AUTHORIZED REPRESENTATIVE - 7�" � �' � O 7988-2014 ACORD CORPO�ATION. All rights reserved. ACORD 25(2014/01) The ACORD name and Iogo are registered marks of ACORD INSURED: BBU, Inc. on behalf of itself and U.S. subsidiaries inciuding (see attached addendum) 255 Business Center Drive Horsham, PA 19044 USA The fallowing 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 Ea�hgrains Baking Companies, LLC - Earthgrains Distribution, LLC EGR California Region Support Services, Inc. Stroehmann Line-Haul, L.P. ' Wholesome Harvest Baking, LLC The following are Named Insureds under the WC policies: Bimbo Bakeries USA, Inc. Wholesome Harvest Baking, LLC Standard Attachment:BIMBAKUSNI � Master ID: 1359436,Certificate ID: 12152765