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HomeMy WebLinkAboutApplication and WC *-"1"------ TOWN OF YARMOUTH BOARD OF HEALTH Nr APPLICATION FOR LICENSE/PERMIT-2019 - � complete* re MITI eIketion A / Q NOTE:�Please LOORLI SSS ET FOYPOVE MBER i will ESTABLISHMENT NAME: 1,/Af 7iv Par-A ES rt AN TAX ID: LOCATION ADDRESS: 54 R. GA Vilterioarf/Peer TEL.#: TOA-3 6.9-7977 MAILING ADDRESS: .54.415_ E-MAIL ADDRESS: .S I VAtiu ( C at:IG¢S7 . i[/xT OWNER NAME: --7-1A1 v. .AIOC CORPORATION NAME(IF APPLICABLE): "TC)CA L L.l MANAGER'S NAME: IAA GiJJ/2. &niuG 4 iiZ.S TEL.#:So$-3!'007-747 ► MAILING ADDRESS: 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 a copy of the certification to this form. 1. A/ 4 2. = z DC:0 (t ]iu 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 = inn employees below and attach copies of their certifications to this form.The Health Department will not use past 0 years'records. You must provide new copies and maintain a file at your place of business. m � IR 1. /0.74- 2. 7-1 co 0 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. -41 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. -40 L b1/14 ITQ t tiA,VD 2. IAM( 1J €. 60.uG,41-vES N , a PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. CA C.N. S I. t)t/N,Tt21 /Q K 2. WA G-NS12- GON(.ALVE S •;'', 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)(3Xa). 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. p 1. DIM i 1 i .. .t/44.,cti C 2. tit!4GI)£2— GYC►NGA[.L1t 1 g T 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. I You must provide new copies and maintain a file at your place of business. 1. I.v46-1t►Ei2- CrcaivGALI/LS 2._ . DQLy & C LlJR_ U1 3. ALLY A►ULI—ANL)I 4. RESTAURANT SEATING: TOTAL# 3 I OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT it LICENSE REQUIRED FEE PERMITS LICENSE REQUIRED FEE PERMIT S B&B $55 CABIN $55 MOTEL $110 INN $55 —CAMP $55 SWIMMING POOL S110ea. _LODGE $55 =TRAILER PARK $105 WHIRLPOOL $110ea. FOOD SERVICE:RFU[LIREQUIRED L0�-100 SEATS�D $12 Ar O LIC ONNTI ENTAALL D $35 PERMIT# LICNON P OF T FEE PERMIT# >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 S <50 ..ft. $50 >25,000ft. $285 VENDING-FOOD $25 =Q5,'0 6 sq.R $150 FROZEN DESSERT $40 =TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE = S IBS.06 PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM ADMINISTRATION Under Chapter 152,Section 25C,Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR CERT.OF INSURANCE ATTACHED }t$ OR WORKER'S COMP.AFFIDAVIT SIGNED AND ATTACHED J/ 5 Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES 1/ 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 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 my 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)sdays 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 wwwyarmouth.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., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE ASS 14, . DATE: ///9/b$ SIGNATURE: ..• PRINT NAME&TITLE: 4 . e r • . Rev.10/23/18 The Commonwealth of Massachusetts .,—_ _ Department of Industrial Accidents J. = ,.='/ Office of Investigations _ �..,,,_ _4 1 Congress Street,Suite 100 _'— Boston,MA 02114-2017 . :' www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Analicant Information Please Print Legibly Business/Organization Name: �pGA I L C l a,4 - y,4&wr.r,i/ i7Zel al/ ! ()4A1 Address: SS? i2-r-('i4 City/State/Zip: Y,ewm.,u-Tli Pair /1'I,4. 0a615 Phone#: So B - 36a- 79?'7 Are you an employer?Check the appropriate box: Business Type(required): 1.❑ I am a employer with employees(full and/ 5. 0 Retail or part-time).* 6. 0 Restaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7, ❑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 1q.❑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.❑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: Insurer's Address: City/State/Zip: Policy#or Self-ins.Lic.# 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 ' ' "" -, of perjury that the information provided above is true and correct. '••1 s__r L. �'r'" Date: i/1?//8 Phone#: , 608 — 36a— ?9iJ17 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 Yarmouth Pizza By Evans List of managers Dimitri Ivanof Wagner Goncalves Maria Montesserat A ® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 11/07/2018 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:ACT Linda Sullivan DOWLING & O'NEIL INSURANCE AGENCY (p�/CONN,Ext). (508)775-1620 FAX (A/C,No): E-MAIL AODREss: Isullivan@doins.com 973 IYANNOUGH RD INSURER(S)AFFORDING COVERAGE NAIC# HYANNIS MA 02601 INSURER A: TRAVELERS INDEMNITY CO OF AMERICA 25666 INSURED INSURER B: JOCA LLC DBA PIZZAS BY EVAN INSURER C: INSURER D: C 0 BOTSINI CORP 450 STATION AVENUE INSURER E: SOUTH YARMOUTH MA 02664 INSURER F: COVERAGES CERTIFICATE NUMBER: 335238 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 SUBR POLICY EFF POLICY EXP LIMITS LTR NASD WVD POLICY NUMBER (MMIDDJYYYI) (MM/DWYYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCEDAMAGE TO RENTED $ CLAIMS-MADE OCCUR PREMISES Ea occurrence) $ MED EXP(Any one person) $ N/A ,PERSONAL&ADV INJURY $ GE 'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY(Per accident) $ O HIRED AUTOS _ AUT SWNED (PRer ace de DAMAGE UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY 0••• STATUTE ER EACH ACCIDENT $ 500,000 A OFFICER/MEMBEREXCLUDED?ECUTIVE WA WA WA 6HUB7H82900617 12/30/2017 12/30/2018 E.L. (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more apace is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 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/Iwd/workers-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION 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 CCy,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD � NOTICE - � NOTICE , r ;. TO _ TO _ EMPLOYEES - EMPLOYEES 7 0� 14 s..4%1♦ The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 1 Congress Street, Suite 100, Boston, Massachusetts 02114 — 2017 617-727-4900 — http://www.state.ma.us/dia • As required by Massachusetts General Law,Chapter 152. Sections 21, 22&30, this will give you notice that I (we) have provided for payment to our injured employees under the above mentioned chapter by insuring with: THE TRAVELERS INSURANCE COMPANIES NAME OF INSURANCE COMPANY P .O. BOX 1450 MIDDLEBORO. MA 02344-1450 ADDRESS OF INSURANCE COMPANY (6HUB-7H82900-6-17) 12-30-17 TO 12-30-18 POLICY NUMBER EFFECTIVE DATES DOWLING & ONEIL INS AGC 973 IYANNOUGH RD HYANNIS MA 02601 NAME OF INSURANCE AGENT ADDRESS PHONE# affli JOCA LLC DBA PIZZAS BY EVAN 559 ROUTE 6A 0== YARMOUTHPORT EEE MA 02675 EMPLOYER ADDRESS EMPLOYER'S WORKERS COMPENSATION OFFICER(IF ANY) DATE MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the services a provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably = connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the NAME OF HOSPITAL ADDRESS TO BE POSTED BY EMPLOYER 00C932 W20P1G15