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HomeMy WebLinkAboutApplication & WCTOWN OF YARMOUTH BOARD OF HEALTH APPLICATION FOR LICENSE/PERMIT - 2019 * Please complete form and attach all necessary documents by December 15, 2018. NOTE., ALL BUSINESSESWITHLI UORLICENSESMUSTRETURNFORMSBYNOVEMBERl5-. /1 Failure to do so will result in the return of your application packet. ESTABLISHMENT NAME: S • © - - LOCATION ADDRES TEL.4:509 374 043 MAILING ADDRESS: 1 ' E-MAIL ADDRESS: �llZA,YtV1e.. KesteePrek OyslnsSserVfr._S,COIrA OWNER NAME: -1"N9 ` in3 SVIOD �1Z�rvV1[1 i�,o „Tt.tt� CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: 'FbU I 'U2a7, TEL.#: 508 394 0g3l MAILING ADDRESS: i3WI ►t+O Ct '6t (0t inn MA 0-111A POOL CERTIFICATIONS: MIN The pool supervisor must be certified as a Pool Operator, as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. 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. You must provide new copies and maintain a file at your place of business. 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. Younm, usit provide new copies and maintain a file at your establishment. 1. t'UA•U lowe2 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. n 1. lu DeSQa,Z 2. 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. HEIMLICH CERTIFICATIONS: M� 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. 4. RESTAURANT SEATING: TOTAL # FOOD SERVICE: LICENSE REQUIRED FEE PERMIT # 0-100 SEATS $125 >100 SEATS $200 RETAIL SERVICE: LICENOSssEqq 8 QUIRED FEE OPERMIT # -<25,000sq.ft. $150 LICENSE REQUIRED FEE PERMIT # _CONTINENTAL $35 _COMMON VIC. $60 LICENSE REQUIRED FEE PERMIT # _NON-PROFIT $30 WHOLESALE $80 —RESID. KITCHEN $80 LICENSE REQUIRED FEEEg1�T LICENSE REQUIRED FEE PERMIT # I >25,000 ft. $285 XMIJ J VENDING -FOOD $25 —FROZEN DESSERT $40 TOBACCO $110 f NAMECHANGE: $15 AMOUNT DUE= $ 3g5.O0 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** D C i n L -d 00 Ig OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT # B&B $55 $55 $110 —INN $55 _CABIN CAMP $55 _MOTEL SW24NGNG POOL $110ea _LODGE $55 TRAILER PARK $105 _WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT # 0-100 SEATS $125 >100 SEATS $200 RETAIL SERVICE: LICENOSssEqq 8 QUIRED FEE OPERMIT # -<25,000sq.ft. $150 LICENSE REQUIRED FEE PERMIT # _CONTINENTAL $35 _COMMON VIC. $60 LICENSE REQUIRED FEE PERMIT # _NON-PROFIT $30 WHOLESALE $80 —RESID. KITCHEN $80 LICENSE REQUIRED FEEEg1�T LICENSE REQUIRED FEE PERMIT # I >25,000 ft. $285 XMIJ J VENDING -FOOD $25 —FROZEN DESSERT $40 TOBACCO $110 f NAMECHANGE: $15 AMOUNT DUE= $ 3g5.O0 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** D C i n L -d 00 Ig 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 CLOSING: Every outdoor in ground swimming 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 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. OUTDOOR COOKING: Outdoor cooking, preparation, or display of any food product by a retail or food service establishment is prohibited. TOBACCO PRODUCT PERMIT CAP A tobacco permit holder who has failed to renew his or her permit within thirty (30) days of the previous year's permit expiration date is considered an expired license, and the tobacco license cap is reduced. 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 15, 2018. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY QUI TE LAN. DATE: IlLo 1 i g SIGNATURE. PRINT NAME & Rev. 1023/18 The Commonwealth of Massachusetts Department of Industrial Accidents u6AOffice of Investigations a I Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: The Stop & Shop Supermarket Company LLC Address: 1385 Hancock Street City/State/Zip: Quincy, MA 02169 Phone #: 800-288-8415 Are you an employer? Check the appropriate box: 1. ❑■ I am a employer with 100+ employees (full and/ or part-time).* 2. ❑ I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required] 3. ❑ We are a corporation and its officers have exercised their right of exemption per c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required]** 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] Business Type (required): 5. ❑■ Retail 6. ❑ Restaurant/Bar/Eating Establishment 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 10. ❑ Manufacturing 11. ❑ Health Care 12. ❑ Other *Any applicant that checks box #I must also fill out the section below showing their workers' compensation policy information. **If the corporate officers have exempted themselves, but the corporation 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: Indemnity Insurance Company of North America Insurer's Address: PO Box 1000 City/State/Zip: Philadelphia, PA 10105-1000 Policy # or Self -ins. Lic. # WLRC65437740 Expiration Date: 10/01/2019 Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration 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 ce,gy, under ffie%pcyinv'and penalties of perjury that the information provided above is true and correct. Phone #: 07 770 9708 Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # f190 // 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: www.mass.gov/dia Phone #: Page 1 of 2 A�g"tom` �,J CERTIFICATE OF LIABILITY INSURANCE DATE 27/2018 o9/27/201e 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 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 certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, 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 Willis of North Carolina, Inc. c/o 26 Century Blvd P.O. Box 305191 CONTACT NAME: PHONE 1-877-945-7378 FAX No): 1-888-467-2378 IC No Ext): AIC (AIC, E-MAIL certificates@willis.com ADDRESS: INSURERS AFFORDING COVERAGE NAIC# Nashville, TN 372305191 USA INSURERA: ACE American Insurance Company 22667 INSURED INSURER B: American Guarantee and Liability Insurance 26247 INSURER C: Indemnity Insurance Company of North Ameri 43575 The Stop and Shop Supermarket Company LLC INSURER D: ACE Fire Underwriters Insurance Company 20702 1385 Hancock Street Quincy, MA 02169 INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: W8226394 REVISION NUMBER: 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 POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL IN D SUER WV POLICYNUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM/DD/YYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 F�71 CLAIMS -MADE OCCUR TO ES( RENTED PREMISES Ea occurrence $ 2,000,000 PREMI MED EXP (Any one person) $ A &ADV INJURY $ 2,000,000 HDO G71210650 10/01/2018 10/01/2019 GEN'L AGGREGATE LIMIT APPLIES PER: -PERSONAL GENERAL AGGREGATE $ 2,000,000 J ROT X POLICY ❑ PRO ❑ LOC PRODUCTS - COMP/OP AGG $ 2,000,000 $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 10,000,000 Ea accident BODILY INJURY (Per person) $ X ANY AUTO A OWNED SCHEDULED AUTOS ONLY AUTOS ISA H25268349 10/01/2018 10/01/2019 BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ Per accident HIRED NON -OWNED AUTOS ONLY AUTOS ONLY $ B X UMBRELLALIAB X OCCUR EACH OCCURRENCE $ 5,000,000 AGGREGATE $ 5,000,000 EXCESS LIAB i CLAIMS-MADE AUC08249868-07 10/01/2018 10/01/2019 DED X I RETENTION$ 10,000 $ C WORKERS COMPENSATIONPER AND EMPLOYERS' LIABILITY ANYPROPRIETOR/PARTNER/EXECUTIVE Y / N OFFICER/MEMBEREXCLUDED? (Mandatory in NH) NIA - WLR C65437740 10/01/2018 10/01/2019 OTH- X STATUTE ER E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1,000,000 D Workers Compensation -WI SCF C6543782A 10/01/2018 10/01/2019 E.L. Each Accident $1,000,000 Per Statute E.L. Disease -Ea Empl $1,000,000 E.L. Disease-Pol Lim $1,000,000 DESCRIPTION OF OPERATIONS/ LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) This Voids and Replaces Previously Issued Certificate Dated 09/26/2018 WITH ID: W8128287. Umbrella policy follows underlying in regard to Additional Insured and Waiver of Subrogation wording. SEE ATTACHED The Stop & Shop Supermarket Company LLC L,ANkA=LLA I IUN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD SR ID: 16804499 BATCH: 885616 I. 4wRet,'ell Business Services IF YOU HAVE ANY QUESTIONS OR CONCERNS REGARDING THIS PAYMENT PLEASE rnNTArT- Suzanne Kester - Coordinator I, Licensing (617) 770-8708 suzanne.kester@retailbusinessservices.com or Susan Fox — Coordinator I, Licensing (617) 770-6010 susan.fox@retailbusinessservices.com FAX: 717-960-1932 . PLEASE FORWARD ANY CORRESPONDENCE & LICENSES/PERMITS TO THE FOLLOWING ADDRESS: RETAIL BUSINESS SERVICES, LLC An Ahold Delhaize Company LICENSING DEPARTMENT 1385 Hancock Street Quincy, MA 02169