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Home My WebLink AboutApplication and WCi St• l'"'( o p()L. TOWN OF YARMOUTH BOARD OF HEALTH NOV /0 APPLICATION FOR LICENSE/PERMIT`- 19 * Please complete form and attach all necessarydocum b ne+e ' o �t{,� 1PT NOTE:ALL BUSINESSES WITH LIQUOR LICENSES UST RETURN FORMS BY NOVEMBER l St". Failure to do so will result in the return of your application packet. ESTABLISHMENT NAME: YE V/-f' IYlni)d'S Eri.ccoptte chock TAX ID: LOCATION ADDRESS: GI 05 Old. fl1&t(1 SireQ_ - S.k1aVvY101A#�1yo3y)114• 4(p(/ TEL.#: 5-x-19y-/-/aa-O- MAILING ADDRESS: yob E-MAIL ADDRESS: 6A-1c a Sk kvi dS f(ga-2.I * Dyn C- 'S-}-(o i3 a 4 e 4- OWNERNAME: ii CORPORATION NAME(IF AA��PPLICAB E): l MANAGER'S NAME: A"Bret &&j UY( e K TEL.#: ---- MAILING ADDRESS: Ewe_ az (Lko)(2 - POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Operator(s) and r..-- :-eopy vf4hc ierfifEationto-this form. 1. 2. Pool operators must list a mini , . two employees currently certified in standard First Aid and Community Cardiopulmonary Resuscitation :4'R), having one certified employee on premises at all times. Please list the employees below and attach .pies o.their certifications to this form. The Health Department will not use past years' records. You m provide n•w copies and maintain a file at your place of business. 1. . 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments . e required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in h•e State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to is application. The He. 1 1 epartment will not use past years'records. You must provide new copies and ma'i tain a file at yo ' establishment. 1. 2. PERSON IN CHARGE: Each food establishment must have at le. 'one Perso Charge (PIC) on site during hours of operation. 1. 2. ALLERGEN CERTIFICATIO " : All food service establishments are equired to have at least one full-time employee who has Allergen certification, as defined in the State Sanitary Code or Food Service Establis •-nts, 105 CMR 590.009(G)(3)(a). Please attach copies of certification to this applicati$ 4. The Health Dep. - ii ent will not use past years' records. You must provide new copies and maintain a fil• at your estab ' 1 ment. 1. 2. HEIMLICH CERTIFICATIONS: All food service establishments with - seats or ,ore must have at least one employee trained in the Heimlich Maneuver on the premises at all ti • -s. Please list i ur employees trained in anti-choking procedures below and attach copies of employee certif,.tions to this form. ' he Health Department will not use past years' records. You must provide new co I' s and maintain a file at our place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# 6011-e- tb— )33tf—0' 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 PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE P IT it_ , 0-100 SEATS $125 _CONTINENTAL $35 I NON-PROFIT $30 ��-0`=C_) >100 SEATS $200 COMMON VIC. $60 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 = $ 30.00 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** � 1 ® ACC:MD DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE August 9,2018 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 CONTACT NAME: Tracey Parent The Church Insurance Agency Corp PHONE FAX 210 South St,Suite 2 INC.No,Ext):(800)293-3525 (NC,No):(800)557-1395 Bennington,VT 05201 E-MAIL ADDRESS: PRODUCER CUSTOMER ID#: INSURER(S)AFFORDING COVERAGE NAIC II INSURED INSURER A: Liberty Insurance Corp Diocese Of Massachusetts INSURER B: INSURER C: _ 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, s.EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ADDLSUBR POLICY EFF POLICY EXP( TYPE OF INSURANCE INSR WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS GENERALILITY EACH OCCURRENCE OMMERCIAL GENERAL DAMAGE TO RENTED PREMISES(Ea occurrences $ CLAIMS-MADE (OCCUR MED EXP(Any one person) $ _ — --j i PERSONAL&ADV INJURY - GENERAL AGGREGATE IGEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG !!POLICYlL�LIPRO-CT LOC { o i ABILITY !COMBINED SINGLE LIMIT 1 Ea accident) •NY AUTO ! BODILY INJURY(Per person) ,$ LL OWNED AUTOS BODILY INJURY(Per accident) $ CHEDULED AUTOS j � PROPERTY DAMAGE HIRED AUTOS NON-OWNED AUTOS _ I UMBRELLA LIAB I OCCUR ,EXCESS LIAB EACH OCCURRENCE (CLAIMS-MADE •GGREGATE •, 'DEDUCTIBLE !RETENTION $ _----- _T-- . WORKERS COMPENSATION , i WC STATU- 0TH- A AND EMPLOYERS'LIABILITY Y/N Y X WC7625900009018111 9/30/2018 9/30/201b TORY LIMITS -ER! PROPRIETOR/PARTNER/EXEE E.L.EACH ACCIDENT $1,000,000 CU IV rlFFl(`FA/AAFPARFA FXCI I Ir1Ffl, Mandatory in NH) E.L.DISEASE-EA EMPLOYEE •1,000,000 (DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 h i _ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION St Davids Episcopal Church SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 205 Old Main St THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN South Yarmouth,MA 02664-4529 ACCORDANCE WITH THE POLICY PROVISIONS. The Commonwealth of Massachusetts Department of Industrial Accidents =ZVI Office of Investigations _ 1 Congress Street, Suite 100 Boston,MA 02114-2017. .Y., , �" www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly •Business/Organization Name: / '�' �` iS ( _ L V Address: a05- 0\d- Ya,(,t4 q City/State/Zip: S . amol,(- i m)4-• one#: 567 1-q,ac:2-(9-- A • . an employer?Check the appropriate box: Business Type(required): am a employer with Li' employees(full and/ 5. 0 Retail or part-time).* 6. 0 Restaurant/Bar/Eating Establishment 2.U 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. [ ton-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 4.'o employees. [No workers' comp. insurance required]** 11.0 Health Care We are a non-profit organization,staffed by volunteers, with no employees. [No workers' comp.insurance req.] 12.0 Other rikk. r . -- *My *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: -L2 Ch(.1/lat.- .1151A./&t&PJI– ,P.iel (?i p - Insurer's Address: 1 h St U. S1 • � U City/State/Zip: 1f V►Vliln54'0V1 VI-• 6 O 1 Policy#or Self-ins.Lic.# W C 162. ,),_S- 9t b 0 0 9 o ( D l i t Expiration Date: t 13c / I 62/ 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 unto$1,500.00and/or one-year imprisonment,as well as civil penalties in the foul'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 certifQyp ,under the pains and penalties of perjury that the information provided above is true and correct. Signature: ` -S'4–e v • th AA.. Date: 1 111 -1 I • Phone#: 6Thi 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