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HomeMy WebLinkAboutApplication and WCTOWN OF YARMOUTH BOARD OF HEALTH APPLICATION FOR LICENSEJPERMIT - 2019 *Please complete form and attach all necessary documents by December 15.2018. NOTE. ALL BUSINESSES WITHLI UOR LICENSESMUST RETURNFORMS BYNOVEMBER I5`". Failure to do so will result in the return o your application packet. ESTABLISHMENT NAME: Z ID: LOCATION ADDRESS ♦. 0 3 MAILING ADDRESS: -yl E-MAIL ADDRESS /_ ., 1.... : /� ., . _ t_ J _ 11 ( OWNER NAME:' CORPORATION NAME APP CABLE): 3. MANAGER'S NAME:LA,�_DTEL.#: 5D i�- 9 r] / -(o l8'3 MAILING ADDRESS: e !S POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator, as requirby State law. Please list the designate Pool Operator(s) and attach a copy of the certification to this form. OFFICE USE ONLY 1. 2 m Q Pool operators must list a minimum of two employees currently certified in standard First Aid and Comuni Cardiopulmonary Resuscitation (CPR), having one certified employee on premises at all times. Please list the C-,) = employees below and attach copies of their certifications to this form. The Health Department will not use past n CABIN $55 —CAMP $55 years' records. You must provide new copies and maintain a file at your place of business. m o 1. 2. --1 00 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: LICENSE REQUIRED FEE 0-100 SEATS $125 All food service establishments are required to have at least one full-time employee who is certified as a Food LICENSE REQUIRED FEE PERMIT # Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. _CONTINENTAL $35 —COMMON VIC. $60 Please attach copies of certification to this application. The Health Department will not use past years' records. RETAIL SERVICE: You must provide new copies and maintain a file at your establishment. —RESID. KITCHEN $80 I.—TV\0C,h,-- Se–%J PERMIT # LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT # T<25,000 sq.ft. $150 PERSON IN CHARGE: a Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. n; 1. V\ �10Vn0SD 0 �,it 777, ALLERGEN CERTIFICATIONS: OF FORM***** 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. l 1. 71% HEEVILICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich I 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. 3. 4. i RESTAURANT SEATING: TOTAL # LODGING: OFFICE USE ONLY LICENSE REQUIRED FEE B&B $55 PERMIT # LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT # INN $55 CABIN $55 —CAMP $55 MOTEL $110 —SWIMMING POOL $110ea _LODGE $55 TRAILER PARK $105 _WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE 0-100 SEATS $125 PERMIT # LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT # _>100 SEATS $200 _CONTINENTAL $35 —COMMON VIC. $60 NON-PROFIT $30 _WHOLESALE $80 RETAIL SERVICE: —RESID. KITCHEN $80 LICENSE REQUIRED FEE <50 sqy.ft. $50 PERMIT # LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT # T<25,000 sq.ft. $150 >25,000 sq.ft. $285 FR07,EN DESSERT $40 VENDING -FOOD $25 _[TOBACCO $110 j Z NAME CHANGE: $15 AMOUNT DUE = $ Z60. 00 ! *****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 O 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 ofthe 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.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 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,, PA,\ ING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BYTHE �BO OF HE TH PRIOR TO COMMATE:ENCEMENT—RENOVATIONS CNC ,RENOSIGN ON�S� Y REQUIRE��a��! 1� PRINT NAME & TITLE: Richdrd FOurnie Rev. 1023/18 Tax Manager r-, The Commonwealth of Massachusetts T TIA-ii" Department of Industrial Accidents I Congress Street, Suite 10Boston, lkiA 02114-2017 www. inass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE F11,ED WITH THE PERMITTING AUTHORIT V. Applicant Information Please Print Leibl, Business/Organization Mame: Cumberland Farms, INC Address: 165 Flanders Road City/State/Zip: Westborough, MA 01581 Are you an employer? Check the appropriate box: LZ I am a employer with 3,434 employees (full and/ or part-time).* 2.0 I 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 requiredj* 4. We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] Phone -t:508-270-1400 Business Type (required): 5. [DRetail 6. ®Restaurant/Bar/Eating Establishment 7. [] Office and/or Sales (incl. real estate, auto, etc.) 8. ® Non-profit 9. 0 Entertainment 10.® Manufacturing 11.0 Flealth Care 12 [1 Other I nn:. appncant ma! enec[s x 4 I mutt a;ya til( cut the :cctior) below shohina their workers' compensation policy infonnauon -If the corporate officers have exempted iheinsclvcs, but ths- corporation has other employees, a workers' compensation pal;cy a required and such an organization should check box r t I am an employer that is providing workers' compensation insurance for m}y employees, Belo K, is the policy information, Insurance Company Name;ACE American Insurance Company Insurer's Address: 33 Arch Street,Suite 2900 City State/Zip: Boston, MA Policy z or Self -ins. Lic.: SCFC64787901 —Expiration Date, 04/0112019 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 fame of a STOP WORK ORDER and a fine of up to 5250.00 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. 1 do hereby cer ' lin"I pains acrd penalties of perjury that the information provided ab ve is rue and correct 5i nature: ��� Date: Phone H: 508 270 1417 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: r Phone #: ® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDNYYY) 03/26/2018 1 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 Aon Risk Services Northeast, Inc. Providence RI office CONTACT NAME: PHONE (866) 283-7122 FAX 800-363-0105 (A1C. No. Ext): A1C. No. 100 Westminster Street, 10th Floor Providence RI 02903-2393 USA E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURED INSURER A: Indemnity Insurance CO Of North America 43575 CUMBERLAND FARMS, INC. 165 Flanders Road INSURER B: ACE American insurance Company 22667 INSURER C: Westborough MA 01581 USA INSURER D: PRODUCTS-COMP/OPAGG INSURER E: AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED AUTOS NON -OWNED ONLY AUTOS ONLY INSURER F: COVERAGES CERTIFICATE NUMBER: 570070523136 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. Limits shown are as requested INSR LTR TYPE OF INSURANCE ADDL INSD SUBR WVD POLICY NUMBER POLICY EFF MMIDDNYYY POLICY EXP MMIDDIYYYY LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS -MADE ❑ OCCUR EACH OCCURRENCE DAMAGEORENTED— PREMISES Ea occurrence MED EXP (Any one person) PERSONAL& ADV INJURY GEMLAGGREGATE LIMIT APPLIES PER: POLICY ❑ PRO F—] LOC JECT OTHER: GENERAL AGGREGATE PRODUCTS-COMP/OPAGG AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED AUTOS NON -OWNED ONLY AUTOS ONLY COMBINED SINGLE LIMIT Ea accident BODILY INJURY ( Per person) BODILY INJURY (Per accident) PROPERTYDAMAGE (Per accident) UMBRELLALIAB EXCESS LIAB HOCCUR CLAIMS -MADE EACH OCCURRENCE AGGREGATE DED RETENTION A B ORKS SCOMPPBELSYTION AND WORKERS YIN ANY PROPRIETOR/ PARTNER /EXECUTIVE OFFICERIMEMBER EXCLUDED? N (Mandatory in NH) If s, describe under DESCRIPTION OF OPERATIONS below N 1 A WLRC64787871 SCFC64787901 04/01/2018 04/01/2018 04/01/2019 04/01/2019 X PER ETH E.L. EACH ACCIDENT $2,000,000 E.L. DISEASE -EA EMPLOYEE $2,000,000 E.L. DISEASE -POLICY LIMIT $2,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) The insurance afforded by the policy described herein is subject to all terms, exclusions and conditions of such policy. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of Yarmouth AUTHORIZED REPRESENTATIVE Town Clerk 1146 Route 28 South Yarmouth MA 02664 USA Q 6�- p 9OG� ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD