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Home My WebLink AboutApplication and WC TOWN OF YARMOUTH BOARD OF HEALTH ftepfZ LOfg APPLICATION FOR LICENSE/PFRMI +- 411 * Please complete form and attach all necessary docum,. ,,t ; 'er !l$AEPT NOTE:ALL BUSINESSES WITHLIOUOR LICENSESMUSTI RM : ` `/ r r : ' . Failure to do so will result in the return of your application packet. ESTABLISHMENT NAME: 'tea AA AMA14 0 yolLlc (').A6 e- TAX ID: $' LOCATION ADDRESS: $y S' +f2 ,(rs��un 6 S '1tv math--11 TEL.#: Sa&^ G`i y-- 78.'6 MAILING ADDRESS: '-i (d 6'r�e)5 , M R O Z4 S 3 E-MAIL ADDRESS: v n rvl N,retuA l`{ ( GMA,L , (,, OWNER NAME: M 4V-1n n HALL. CORPORATION NAME (IF APPLICABLE): TbMA.'t#cS ( r &.-6 rave MANAGER'S NAME: M A( INA TEL.#: 7 y- 2-16 -o 460 MAILING ADDRESS: SAn'. 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 not use past yearsrecords. You must provide new copies and maintain a file at your place of business. 1. 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. M A21-11,04; 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. ( 4L1 1-A LL.. 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. 1. YV1 e-T n►A HALL_ 2. 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. 1. N)Ot 2. 3. 4. RESTAURANT SEATING: TOTAL# 80 4e-- t-ZZca OFFICE USE ONLY LODGING: 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$110ea. LODGE $55 TRAILER PARK $105 _WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE P RMIT# - LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 1 0-100 SEATS $125 CONTINENTAL $35 NON-PROFIT $30 >100 SEATS $200 j COMMON VIC. $60 ...4f-I'�O2.5 —WHOLESALE $80 —RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 <25,000 sq.ft. $150 _FROZEN DESSERT $40 TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE = $ i $5. Ir W *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** The Commonwealth of Massachusetts Department of Industrial Accidents eirt _=Ail= Office of Investigations —;:a;! 1 Congress Street, Suite 100 94 ! Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Lezibly Business/Organization Name: --zr, &AS Neto Vo-x A46eu —1/41A contocli Address: B�C (e-T 28' o c -46 City/State/Zip: Seas+ `1Arn 1 roP‘ Phone#: 503-614 —7$i14. Are yo,an employer?Check the appropriate box: Business Type(required): 1. 1E I am a employer with to employees(full and/ 5. 0 Retail or part-time).* 6. []'Restaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7, 0 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. 0 Entertainment their right of exemption per c. 152, §1(4),and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]** 11.❑ 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: 1 L'v\\ CtTy 1 1�r e_ T'rgwzAt4Ca Insurer's Address: 0 nat., 1-44 t 4 ark .et--44 Z-16. City/State/Zip: r,. CT 0 6 I S5*--- Policy#or Self-ins. Lic.# 2-94 S9 Expiration Date: 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 certify,under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: "fit" Phone#: -77(1 - 2 j 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 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(les)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 License#1780862 . C TACT nee.certificates@hubinternational.com HUB International New England PHONE 265 Orleans Road (A/c,No,Eat):(508)945-0446 I FAx (AIC,Noi:(508)945-9136 North Chatham,MA 02650 E-MAIL ADDRESS: (NSURER(S,AFFORDING COVERAGE NAIC q 1 INSURER A:Twin City Fire Insurance Company 29459 INSURED INSURER B: Martina Hall INSURER C: Jomama's Yarmouth 845 Route 28 INSURER D: South Yarmouth,MA 02664 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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 TYPE OF INSURANCE ADDL SUER POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSO wVD IMM/DD!YYYYI (MMIDDIYYYY) A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 1 CLAIMS-MADE f X i OCCUR 08SBAAC6832 1 02/01/2019 02101/2020 DMMGSTOERD e) $oe1,000,000 MED EXP(My one person) $ 10,000 _ PERSONAL Si ADV INJURY 1$ 1,000,000 GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY I l PRO- 11 JECT LOC PRODUCTS-COMPtOPAGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Fcoident)_.__.._ $ ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS pp BODILYRRINJURY(Per accident)S HIRED NON S ONLY _(Per PROPERTY DAMAGE $ ___.$AUTOS ONLY _.. AUTOS 11 I _ N UMBRELLA UAB I I OCCUR EACH OCCURRENCE I$ EXCESS LIAB CLAIMS-MADE _AGGREGATE....._...___. $ DEDJ (RETENTION$ ; WORKERS COMPENSATION PERIOTH AND EMPLOYERS'LIABILITY YIN I STATUTE ER I ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER(MEM$ER EXCLUDEDT _ , N/A ((1M�anddatory n ) E.L DISEASE-EA EMPLOYEE$ If yes,describe under - - DESCRIPTION OF OPERATIONS below i E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS!VEHICLES(ACORD Sol,Additional Remarks Schedule,May be attached it more space is required) Certificate holder is listed as Additional Insured for General Liability when required by written Contract CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Janfra Realty Realty ACCORDANCE WITH THE POLICY PROVISIONS. 559 Cummaquid,MA 02637 AUTHORIZED� " � REPRESENTATIVE Ir11 ACORD 25(2016103) V @ 1988.2015 ACORD CORPORATION. All rights reserved. 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