HomeMy WebLinkAboutApplication and WC ; - ������/��
��°' TOWN OF YARMOUTH BOARD OF=,�E�Ii,TH
APPLICATION FOR LICENSE/PERMIT-201 '� � �(��6
` *Please complete form and attach all necessary docum�n by Detentber l6 2 16. �
Failure to do so will result in the return of your a�p' ation packet. �qLT
HDE
PT.
ESTABLISF�NT NAME: ' 7 . _ —�
110'� � �'�LOCATION ADDRESS. 5. 4ti VvtfTR�.Ls vVt 1�' Z TEL.#: S��- —Q�!°`I S
� MAILING ADDRESS: O 0 X " ?�0 '� Z !
E-MAIL ADDRESS: � Yy.
OWNER NAME:
CORPORATION NAME IF APP�,IC LE)c �
MANAGER'S NAME: 1 O 1� �/l 1 TEL.#: 0 � 3 —O R�} S
MAILING ADDRESS: �- a �1 r Z,
POOL CERTIFICATIONS: l ,,':.
The pool supervisor must be certified as a Pool Operator,as reqaired by State law. Please list the designated �'"�`
Pool Operator(s)and attach a eopy of the certification to this form.
L � � �- - 2.
Q`��
Pool operators must list a minimum of two employees currenfly certified in standard First Aid and Community ,,,s� ;--
Cardiopulmonary Resuscitation(CPRJ,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 wi11 not use past
years'records. You must provide new copies and maintain a file at your place of business.
1. �f �V�- ��-_
, 2� �r,
3. 4.
1 �
F�OD PROTECTION MANAGERS-GERTIFICATIONS: 64 � �
All food service establishments are required to have at least one fuil-time employee who is certified as a Food �" N '
Protection Manager,as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. p �Q i
Please attach copies of certification to this applicaUon. The Health Department wilInot use past years'records. � ,
You must provide new copies and maintain a file at your estabGshment.
1. 2.
PERSON IN CHARGE:
Eac food establishment must have at least one Person In Charge(PIC)on site during hours of operation.
1. �>'�D..� 9� "t..✓��. 2.
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ALLERGEN CERTIFICATIONS: '
Ail 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 540.009(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.
1• 2. '
HEIMLICH CERT'IFICATIONS: i
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 Deparhnent will not use past years'records. `
You must provide new copies and maintain a file at your place of business.
�. NI ►9 2.
3. 4. ,
RESTAURANT SEATING: TOTAL# '
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OFFICE USE ONLY �
LODGING:
LIC�NSE REQUIRED FEE PERM[T# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �
_B&B a55 CAB[N S55 MOT'EL S1i0
I� $55 =SWRv1MING POOL S110ea.
_LODGE S55 =TRAILERPARK $105 WHIRLPOOL $110ea
FOOD SERVICE:
LICENSE REQ UIItED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERtviIT#
0-100SEATS a125 _CONTINENTAL $35 NON-PROFTT 530
>l00 SEATS $200 _COMMON VIC. S60 —WHOLESALE S80
RETAII,SERVICE:
—RESID.KITCHEN $80 i
LtCENSE REQUII2ED FEE PERMIT# LJCENSE REQUIRED FEE ERMIT# LICENSE REQUIRED FEE PERMIT# '
<50sq� a5� ( >25,000 ft. 5285��� VENDING-FOOD S25 i
_<25,OOOsq.R $ISO =FROZEN�ESSERT$40 �TOBACCO a110 �� 4
NAME CHANGE: SI5 AMOUNT DITE _ $ 3 L '�J•O� I
I
"':**FLEASE TURN OVER AND COMPLETE O'1 NER SIDE OF FORM"+•"* �
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ADMINISTRATION
I
Under Chapter 152,Section 25C,SubsecUon 6,the Town of Yarmouth is now required to hold issuance or renewat
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
AFF'IDAVIT 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 CHEGK
APPROPRIATELY IF PAID:
YES � NQ
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 tetm occupancy,ordinarily and customarily associated with motel andhotel 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)8ays,and
an aggregate of noYmore 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,shalT generally be considered'Transi�nt.
POOLS
POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected 'I
by the Health Department prior to opening. Contact the Hea1th Department to schedule the inspectian three(3)
days prior to opening.PLEASE NOTE;People aze NOT allowed to sit in the pool area until the pool has been '
inspected and opened.
POOL WATER TESTING: T'he water must be tested for pseudomonas,total coliform and standazd 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 ar 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 wha caters within the Town of Yannouth must notify the Yarmouth Health Department by filing the
reqwred 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.varmouth.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 Departrnent. Failure to do so will result in the suspension or revocation of your Frozen
Dessert Permit until the above tem�s have been met.
OUTSIDE CAF�S:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must haue prior approval from the Board of Health.
i
j Oi7TDOOR COOHING: ,
; Outdoor cooking,prepararion,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. TT IS YOUR RESPONSIBILITI'TO RETURN
�
TI�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 i '
i EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR M
TO CONIIv�NCEMENT. RENOVATIONS MAY REQUIRE A STI'E PLAN.
' DATE: IZ-` I.'' j �0 SIGNATURE: _ ''
PRINT NAME&TITLE: I� (, � -�t.�C. �S 0 C��
Itev.10/17J16
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� The Common�vealth of Massachusetls
Department of Industrial Accide�its
". O�ce of Investigations
' 1 Congress Street,Suite 100
Boston,MA 021I4 2017
www.mass.gov/dia _
Workers' Compensation Insurance Affidavit: General Busine�ses
Auplicant Information Please Print Le�iblv
Business/Organization Name: ��`'��-S ��^ V��,� � ''1�4�Z
Address: l ( U� V�.�G 2� �,� �
City/State/Zip; � , ������"� � C7�— ��j'� —'_�9`� �
vr� o e#:
Are you a mployer?Check the appropriate bog: Business , (required):
1. am a employer with � )d�employees(full and/ - 5. etail
or part-time).* 6. ❑ RestaurantlBar/Eating Establishment
2.❑ I am a sole proprietor orpartnership and have no �, � Office and/or Sa1es(incl.real estate,auto,etc.)
employees working for me in any capacity.
[No workers'comp.insurance required] 8. ❑Non-profit
3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment
their right of exemption per c, 152,§2(4),and we have 10.❑Manufacturing
no employees. [No workers' comp. insurance required)* 11.� Health Care
4.❑ We are a non-profit organizatian,staffed by volunteers,
with no employees. [No workers' comp.insurance req.j 12.� Other ,
"`Any applicant that checics box#1 must also fill out the secdon below showing their workers'compensation poliey information.
**If the corporate officeis have exempted themselves,but the corporation has other employees,a workers'compensation policy is required aad such an
organization should check box#L
I am an employer that is providing workers'compensation insuranee for my emp[oyees. Below is the policy information.
Insurance Company Name:
Inswer's Address:
City/State/Zip:
Policy#or Self-ins.Lic.# Expiration Date: ,
Attach a copyof the workers' compensation policy declaration page(showing the policy number and ezpiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can,lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
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 cer ' , �der the pains a enalties ofperjury that the information provided above is true and correct.
�
Si ature: Date: (2 ' /_I � I
n ,� i
Phone#: '1N� �JQi — � � ?j�
Official use only. Do not write in this area,to be completed by cily or town official ,
City or Towns Permit/License#
�ssuing Authority(circle one): ;
1.Board of Health 2.Building Department 3.City/Town Cierk 4.Licensing Board 5.Selectmen's Office
6.Other
Contact Person• Phone#•
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-.wvx.*„�.cs.govldia �
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��� .�� � C����FII,dA�� OF����Li�L1TY ���<J��J-\���. � DATE(MM/DDIY1'1'Y). .
O6/a2l2016 �
THlS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATlON ONLY AND CONFERS NO RIGHTS UPQN THE CERT[FlCATE HOLDER. TWS
CERTIF)CATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMENQ, EXTEND OR ALTER THE COVERAGE AFFQRDED 8Y THE POLIC[ES
BELOW. THtS CERTIFICATE OF INSURANCE DOES NOT CONST7TUTE A CONTRACT BETWEEN THE ISSUING tM1tSURER(S}, AUTHORtZED p
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. �
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1NIPORTANT:If the certificate holder is an ADDfT10NAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions orbe endorsed.if "
SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endarsement A statement on this °'
certificate does not confer rights to the certificate holder in lieu ofsuch endorsement(s). —
PRODUCER � � CONTACT � . N� �
NAME: � � � � D �
AOn RlSk insurance Services west, InC. � � �
PHONE ($66) 283-7122
san Francisco CA Office �ac.ao.exc): �No : C800) 363-0105 d
425 Market Street E-�ua� a
� SIJItE 2800 � � � . � ADDRESS: � � � � p��
San Francisco CA 94105 USA =
� .� � � - - . � � . ����� INSURER(5)APFORDING�COVERRGE NAIC# �
���INSURED � � . � WSURERA ACE AiilE'1'lCdn I�ISI1�df1Ce CORI�7dI1}� zz((� � .
New Albertson's Inc. � � .� � � �Nsu�Ra: ACE Property & fasualty Ittsurance Lo. 20699 �
including All affiliated Subsidiaries &
associated Companies . iNsuReR c �
250 E. Parkcenter Blvd.
�� � � BOlSE ID 83�OG USA . . . . � INSURERD: � . � � . . . . .
. � � . . �� INSURER E: . .. . . � .
� � � INSURER F. � . �
COVERAGES CERTIFICATE NUMBER:570062347170 REVISION NUM6ER:
THlS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. Limits shown are as requesfed
�A�D SUBR POUGYNUMBER
LTR TYPE OFINSURANCE WSD WVD � � � PO CY EFF PO CY EXP �
MMIDDIYWY. MMIDDM'YY LIMRS �
A X COMMERCIALGENERALtIABILJTY . � XSLG 7$S40 � 1 1 EACHOCCURRENCE � SZ�OOO,OOO �
cwMsr��,oe X❑occuR SIR applies per policy ter s & condi ions nMn erorx 5500,000
. . . � PREM{SES a ocwrrcnce � � .
� �X Drvggisl Llability Includedd � . . � � MED�EXP p ) � � ��
(Myone arson EXcluded
� � � . � � � PERSONAL d ADV INJURY � $Z�000,OOO n � � .
GEN'LAGGREGATELIMITAPPLIESPER: � � � � GENERALAGGREGATE � $4,000,000 �
. X POLICY �❑PR0.� ❑ � . � . . � � �
JECT ��C � PRODUCTS-CAMpfOpqGG � . S4�OOO�000 N �
m
OTHER: � - . � . tiquorLiah�Tity� � � . � E2�A00�0�0 0 � � � �
A 'AUTOMOBI�Uaa1LITY ' ISA H09042970 06/Ol/2016 06/Ol/2017 coMBINED SING�E LIMR "�
a acciderit 32,000,000
. . x . ANYAUTO . � . � � . � � . � .� � .. . .. BODILYINJURY(Perperson)�� . � � � O . � .
� OWNED � A TOSULED� � � � � �. � � . � � BODILY INJURY(Per aeciden��� � � � � . d �
. � AUTOS ONLY � �
� FpREDALli05 � NON-0WNED� � � � � � � � �PROPERTYDAMAGE . � v � �..
� . oNLY AUTOSONLY. .� : � � . �. � � � � � eracddeM � � � � � ��
. . . . . . . . . . . � � . ,
B. X ��UMBRELLALIAB X �OCCUR �� � . � X00G2]947E1AOO1 . . � 06/Ol/2016 06/Ol/2017 ��{OCCURRENCE � � SS,Q�0,00� V � �
. � � EXCESS LIAB � � CLAIMS-MADE � . . .� AGGREGATE� � � SS,000,D00� � � .� .
. �DED X�RETENTIONS25,000 �� � � . � � � � � . � � � � i !
�� A WORKERSCOMPENSA710NAND�� � WLRC4$OO84SO . O6f01/2016 06/Ol/ZO1T PERSTATUTE. QTH_ � I ��
EMPLOYERS'LJABILITY� � � � � X � � ER �
ANY PROPRIETOR/PARiNER I EXECUTIVE Y/N � � � � � � ' �
� OPFICERIMEM6ER EXCLUDED? . �N I A � � � � . � . � �£L EACHACqDENT � S��OOO�OOO i� �
. (Mandatory in NH) �: . � . . . . � . .. I.
� � � �� ��ELDISEASE•EAEMPLOYEE .� $2,�000„A00 � . . I�-
ICyes,.describe under. � . � . � . � � . . . .
. DESCRIPTION Of OPERATIONS below � � � � - �. E.0 OISEASE-POtICY�L�MIT - �E2,000,000�-
.. .. � . . . . . . . . � � � � . . . . � . .�� � .
�� DESGRIPTION OFqPER.4T10NS I.LOCATIONS!VEHIC�ES(ACORD�0'I,�Additional Remarks Schedule,�may bt attached ii more space is required� . �� � �
elanl<et additional insured for General �iability and waiver of Su6rogation for Ge�eral �iability'staYus extend to those parties �
to whom the Insured has contractually agreed to provide this status. �
�
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CERTlFlCATE HOLDER CANCELLATION �
. �.. - � . . .. �� . ' � � � � � .� SHOULD qNY,OF�THE ABOVE� DESCRIBEO� pOLICfES BE CANCELLEO BEFORE 2HE � � �
� � � . �� � . � � � � � . EXPIR4TION.DA7ETHEREOF, NOTICE�WILLBE DELNERED IN qCCORDANCE iM7H�iHE � ' �
. . .. . . . . �. :� POLICYPROVISIONSr�'� . . � . . . . � . � . . � . . . � i
NeW albertson�5, IfIC.�. � � � . � � AUTHORQEDREPRESENTATIVE � j
And all .affiliated, subsidiary & .
,4ssociated companies
Z50 East Parkcenter Blvd. � � (f, � �,�/' �
soi se I� 83706 U5q �z ✓ J�utrr��aax cJot�•s� ���
I
01988-2t115 ACDRD CORPOFL",TJOP7.A!I rghts r�s�rved.
�CO�D 2:i�2�'=E/G3) T;as t1C0 vD nams a�d logo a�a r9gister�rl marlcs of ACORD �
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