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HomeMy WebLinkAboutApplication and WCTOWN OF YARMOUTH BOARD OF HEALTH APPLICATION FOR LICENSEIPERMIT - 2019 * Please complete form and attach all necessary documents by December 15 2018. N17T ;ALL BUSINESSES W7THLI UOR LICENSE.SMUST RETURN�i F3YBER 1P. Failure to do so will resit m t ne return o your application packet - ESTABLISHMENT NAME: LOCATION ADDRESS: an MAILING ADDRESS: VOKICLL kLcl E-MAIL ADDRESS: i ,- r e V �l rc r\ . f OWNERNAME: C ` ��fICS Go)r PS CORPORATION NAME (1F APPL�I?CABLE), S thUY� Co r 1 MANAGER'S NAME: C C� (V`\ L� ul� (SbcLLrer EL.#: �b &- O S/ ke f MAILING ADDRESS:_La 3` _ r POOL CERTIFICATIONS: 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. 1. W. /A-. _ 2. 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. I . t V / t&, 2. 3. 4. 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. 1. ipnr--w C"r\ PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. i. C-CktY\� Aa Wl!-OCUO-2 r- 2. 1D(�_kSi�(E-� V`E'_. kA. L\ 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. I . r1/Gt. R �1l (i l: l °r rn, S r LAr;1 in \ AJ 1 I r� VA 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. -txc , av_ cC E � 2 L� `first A i C� . 3. 4. RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LODGING - y 0_100S $125 >100 SEATS D CC -i LICENSE REQUIRED FEE PERMIT # B&B $55 CABIN $55 SC?� -r-i --• _ SWIMMING POOL $ t l0ea —LODGE $55 =TRAILER PARK $105 _WHIRLPOOL S1 10M 0 © ren ao � 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. I . r1/Gt. R �1l (i l: l °r rn, S r LAr;1 in \ AJ 1 I r� VA 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. -txc , av_ cC E � 2 L� `first A i C� . 3. 4. RESTAURANT SEATING: TOTAL # FOOD SERVICE: OFFICE USE ONLY LODGING - y 0_100S $125 >100 SEATS LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT # B&B $55 CABIN $55 MOTEL $110 INN $55 —CAMP $55 _ SWIMMING POOL $ t l0ea —LODGE $55 =TRAILER PARK $105 _WHIRLPOOL S1 10M FOOD SERVICE: LICENSE RE 4RED FEE PERMIT# Q 0_100S $125 >100 SEATS $200 RETAIL SERVICE - LICENSE REQUIRED FEE PERMIT # =QS,000 sq.1 $150 NAME CHANGE: $15 LICENSE REQUIRED FEE PERMIT # —CONTINENTAL $35 _COMMON VIC. $60 LICENSE REQUIRED FEE PERMIT # >25,000 sq.1 $285 FROZEN DESSERT $40 LICENSE RETARED FEE P Tit„ I NON -PRO IT $30 W_ 91 WHOLESALE $80 —WHOLESALE $80 $80 LICENSE REQUIRED FEE PERMIT # VENDING -FOOD $25 TOBACCO $110 AMOUNT DUE = $_ ,pp *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** 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 tern 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 WA'T'ER 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.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 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 waiteriwaitress 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 i 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 REQUIRE A SITE PLAN. DATE: SIGNATURE: PRINT NAME & TInE: Rev. 1023/19 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations I Congress Street, Suite 100 Boston, MA 02114-2017. www.massgovfdia Workers' Compensation Insurance Affidavit: General Businesses &plicant Information Please Print Legiby Business/Organization Name: r i4cT®'�l-' Address: /, 7 �Uti P, ,, /ZT,> City/State/Zip: S IA� eG zv-r/f Phone #: u`-4�� %Z, u — o`76/ Are you employer? Check the appropriate hoz: 1. I am a employer with employees (full and/ or part-time).* 2.0 1 am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required] 3.0 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. 0 Office and/or Sales (incl. real estate, auto, etc.) 8. Nan -profit 9. ❑ Entertainment 10. El Manufacturing 11.1—] Health Care 12.❑ Other *Any applicant that checks box 41 must also fill out the section below showing their workers' compensation policy information. **If the corporate offioers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an organizatiaa should check box #1. I am an employer that is providing workers' compensation insurance for my employees. Below is thepolicy information. Insurance Company Name: 4 Of A-�7� U ,i"dtJ f 1 N� Insurer's Address: City/State/Zip: Q Policy # or Self -ins. Lic. 4 WC I JI.S " SPIP41 — 42 it Expiration Date: 7 �0 Attach a copy of the workers' compensation policy declaration page (showing the policy number add exmtion 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. O);iicial use only. lM not write in this area, to be completed by city or town official City lir Town: Permit/License # Issuing Authority (circle ane): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone #: www.ums.gov/dia ACOR 1 0DATE CERTIFICATE OF LIABILITY INSURANCE (MMIDDIYYYY) 11/28/2018 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 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 CONTNAME: Mary Waishek TELAMON INSURANCE & FINANCIAL NETWORK PAHONE II., N Ext • (617) 614-1222 �C No: E-MAIL ADDRESS: mw@ampllfledinsurance.com INSURERS AFFORD ING COVERAGE NAIC# 30 SW Park INSURERA: LIBERTY MUTUAL FIRE INS CO 23035 Westwood MA 02090 INSURED INSURER B: INSURER C: ROBERT F KENNEDY CHILDRENS ACTION CORPS INC INSURER D: INSURER E: 40 COURT ST STE 410 1 INSURER F: BOSTON MA 021082202 COVERAGES CERTIFICATE NUMBER: 342227 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. !NSR LTR OF INSURANCE ADDLTYPE 10kSU D POLICY NUMBER POLICY EFF MM/DDIIYYYY POLICY EXP MMIDDIYYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS -MADE FIOCCUR DAMAGE 0 —PREMISES (Ea occurrence) $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ N/A GEN'L AGGREGATE LIMIT APPLIES PER: I GENERAL AGGREGATE $ POLICY PRI F7 F7 LOC PRODUCTS - COMP/OP AGG $ $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident BODILY INJURY (Per person) $ ANY AUTO ALL OWNEDSCHEDULED AUTOS AUTOS N/A BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ Per accident NON -OWNED HIRED AUTOS AUTOS UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LAB CLAIMS -MADE N/A DED I I RETENTION $ $ A WORKERS COMPENSATIONFOTH- AND EMPLOYERS' LIABILITY Y / N ANYPROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBEREXCLUDED? NIA (Mandatory In NH) NIA NIA WC231 S381849028 07/02/2018 07/02/2019 X I STATUTE I I 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 N/A DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may he attached if more space is required) Workers' Compensation benefits will be paid to Massachusetts employees only. Pursuant to Endorsement WC 20 03 OS B, no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires, or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued (unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage -Coverage Verification Search tool at www.mass.gov/lwd/workers-compensation/investigations/. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN TOWN OF YARMOUTH ACCORDANCE WITH THE POLICY PROVISIONS. 1146 ROUTE 28 AUTHORIZED REPRESENTATIVE SOUTH YARMOUTH MA 02664 Daniel M. Croiey, CPCU, Vice President— Residual Market— WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD