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Home My WebLink AboutApplication and WC TOWN OF YARMOUTH BOARD OF HEALTH APPLICATION FOR LICENSE/PERMIT-2019 otl_. *Please complete form and attach all necessary documents by December 15.2018. NOTE:ALL BUSINESSES WITH LIQUOR LICENSES MUST RETURN FORMS BY NOVEMBER 15th. Failure to do so will result in the return of your application packet. ESTABLISHMENT NAME: S h A.w'S M 36 9 L WIT): LOCATION ADDRESS: l I0 1 K4. Z 8 i S. Yapenov-i-4, A,9 OI4tEL.#: YOB-711 Y--09/r MAILING ADDRESS: PG So 29094; /as Pi'Csal, "gen;K1 AZ 8)1,38-90 9 C E-MAIL ADDRESS: ,o a.s c..-fro► Ice s 0-'Pe v 4 v . c o e b-N OWNER NAME: C -f-cr /✓I 4.r ked-; Co.•..,any, '6c. CORPORATION NAME(IF APPLICABLE): S 4+a r /.7 a r f e.+s Co,.tip A"y, tee.,c. MANAGER'S NAME: R!c) G//leo. t TEL.#:,S-0 8-3 9'I-0 4{9 S MAILING ADDRESS: //016 z 4.• 2.8 j S. `k.r•e+1 ov'f•1., An,4 O 2.GC. f 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. 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 n i• 7: •,. yearsrecords. You must provide new copies and maintain a file at your place of business. ' _: C t AI 0 3. 4. NOV t)2018 FOOD PROTECTION MANAGERS-CERTIFICATIONS: HEALTH DEPT 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. "i You must provide new copies and maintain a file at your establishment. 1. g ,GAextva 6 I• PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. A i. A '..A,,d G I.'c..1eL 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 , Cr.) 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. l(•..vi.,o,..4' 6:::-/.*C-"A_ 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich P O Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and *'C� r 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. CA CQ 3. 4. 1 1 RESTAURANT SEATING: TOTAL# r. j OFFICE USE ONLY k0 LODGING: %1 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# r B&B $55 CABIN $55 MOTEL $110 INN $55 CAMP $55SWIMMING POOL$1 lOea. LODGE $55 TRAILER PARK $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 >100 SEATS $200COMMON VIC. $60 WHOLESALE $80 —RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LIC SE: • A: i „ T; LICENSE REQUIRED FEE PERMIT# v"7'3,71 <50 ..ft $50 . . tih •„. 4 VENDING- •• 25 =<25,et,sq.R $150 FROZEN•ESSERT$40 NAME CHANGE: $15 AMOUNT DUE _ <' rOJ� q-1,... -rt-ie- 915 ti. PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** as-tn R 0 .341 LaK ti 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 1/— OR 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: 1/-- NO YES 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.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 m 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 COMMEN E NT. RENOVATIONS MAY Q A SITE PLAN. DATE: I I(I i� SIGNATURE: (��(,061arv. PRINT NAME&TITTLE: u Tiffany y Corcoran Rev.10/23/18 Supervisor Tax The Commonwealth of Massachusetts i1v— /. Department of Industrial Accidents _1181 Congress Street,Suite 100 tr =_ �_ Boston,MA 02114-2017 .,,,'( www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Business/Organization Name:Shaw's#3692 Address: 1108 State Rd. City/State/Zip:South Yarmout,h MA 02664 Phone#:508-394-0995 Are you an employer?Check the appropriate box: Business Type(required): 1.E✓ I am a employer with 107 employees(full and! 5. El Retail or part-time).* 6. ❑Restaurant/Bar/Eating Establishment 2.0 I am a sole proprietor or partnership and have no 7. El Office and/or Sales(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,§1(4),and we have 10.❑Manufacturing no employees. [No workers'comp. insurance required]** 11.1:1 Health Care 4.❑ We are a non-profit organization,staffed by volunteers, with no employees. [No workers' comp.insurance req.] 12.0 Other *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 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:Ace American Insueance Company Insurer's Address:5600 West 83rd St.. 8200 Tower, Suite 1100 City/State/Zip: Minneapolis, MN 55437 Policy#or Self-ins.Lic.#WLRC65434623 Expiration Date:8/1/2019 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. Ido hereby certif.,u der the pains and penalties of perjury that the information provided above is true and correct. Signature: 1A17 �4v Date: III tol i F Phone#:623-869- 26 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 AC0 DATE(MMVDD/YYYY) ‘....../ CERTIFICATE OF LIABILITY INSURANCE 07/27/2018 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 5 REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. w 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 w certificate does not confer rights to the certificate holder in lieu of such endorsement(s). c PRODUCER CONTACT a Aon Risk Services Central, Inc. NAME: - Minneapolis MN Office PHONE 066)Ems); C866) 283-7122 FAX No); (800) 363-0105 irr O 5600 West 83rd Street E-MAIL a 8200 Tower, Suite 1100 ADDRESS: O 2 Minneapolis MN 55437 USA INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A: ACE American Insurance Company 22667 New Albertsons L.P. INSURER B: ACE Property & Casualty Insurance Co. 20699 Including All Affiliated Subsidiaries & Associated Companies INSURER C: 250 E. Parkcenter Blvd. INSURER D: Boise ID 83706 USA INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 570072434505 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 ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POUCY NUMBER ((MM/DD/YYYY MM/DDIYYW)) LIMITS A X COMMERCIAL GENERAL UABIUTY XSLG71208886 08/01/201808/01/2019 EACH OCCURRENCE $3,000,000 CLAIMS MADE I (OCCUR SIR applies per policy terms & conditions DAMAGE TO RENTED $3,000,000 PREMISES(Ea occurrence) _ X Druggist Liability Included MED EXP(Any one person) EXCl uded PERSONAL&ADV INJURY $3,000,000 c GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $18,000,000 M X POLICY I PRO- LOC PRODUCTS - h1JECT OTHER: Liquor Liability Included- o A AUTOMOBILE LUIBIUTY ISA H25268313 08/01/2018 08/01/2019 COMBINED SINGLE UMIT $5,000,000 (Ea accident) X ANY AUTO BODILY INJURY(Per person) 0 OWNED —SCHEDULED BODILY INJURY(Per accident) y AUTOS ONLY AUTOS al HIRED AUTOS NON-OWNED PROPERTY DAMAGE V ONLY —AUTOS ONLY (Per accident) 4= 'a a B X UMBRELLA LIAB X OCCUR x00G2794761A003 08/01/2018 08/01/2019 EACH OCCURRENCE $5,000,000 0 EXCESS LIAB CLAIMS-MADE SIR applies per policy terms & conditions AGGREGATE $5,000,000 DED X RETENTION A WORKERS COMPENSATION AND WLRC65434623 08/01/2018 08/01/2019 x PER STATUTE OTH- EMPLOYERS'LIABILITY Y/N ER ANY PROPRIETOR/PARTNER/EXECUTIVE Y E.L.EACH ACCIDENT $2,000,000 OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE S2,000,000 If yes,describe under DESCRIPTION OF OPERATIONS belowEL DISEASE-POUCY LIMIT $2,000,000- ... DESCRIPTION OF OPERATIONS!LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Blanket Additional Insured for General Liability and Waiver of Subrogation for General Liability status extend to those parties 21 to whom the Insured has contractually agreed to provide this status. a•,( 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. New Albertsons L.P. AUTHORIZED REPRESENTATIVE Including All Affiliated Subsidiaries & Assoicated Companies t.. 250 E. Parkcenter8S Blvd �/J ` �f n 9 �� ee�L ate;" Boise ID 83706 USA �..c Iii �,r rJ Blia IN 031988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD