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HomeMy WebLinkAboutApplication and WC 1 TOWN OF YARMOUTH BOARD OF HEALTH ii �/ *Please APPLICATION FOR LICENSE/PERMIT-2019 REvLsEN I complete form and attach all neceby documents Dec r 15 2018 NOTE:ALL .` - l�pS RN BYNOVEMBEII'l5'". Failure to do so will resulttm the return of application packet. MAS 201 ESTABLISHMENT NAME: Cape Sands Inn TAX ID: HEALTH DEPT. LOCATION ADDRESS: 149 Main Street,West Yarmouth,MA 02673 TEL.#: 508-775-3825 MAILING ADDRESS: 149 Route 28,West Yarmouth,MA 02673 — E-MAIL ADDRESS: kashemno©gmail.com I 7 7,tT OWNER.NAME: Noushad Kashem CORPORATION NAME(IF APPLICABLE): Two Families Inc MA. 0 I. R15cu�� MANAGER'S NAME: Monzur Khan TEL.#: 508-967-5381 et i;+, MAILING ADDRESS: 149 Rt 28,West Yarmouth,MA 02673 cALTH DEPT. POOL CERTIFICATIONS: ,..1 t The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated :t, Pool Operator(s)and attach a copy of the certification to this form. : ,, 1 Leonard Fabiano 2 Agnes Demoranville 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 the1"4)'"-`1 employees below and attach copies of their certifications to this form.The Health Department will not use past '" yearsrecords. Yon must provide new copies and maintain a file at your place of business. 1 Agnes Demoranville 2. Lenoard Fabiano 3. Monzur Khan 4. Noushad Kashem +; 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. 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. 1. 2. k✓ -:' a' 0 cP ALLERGEN CERTIFICATIONS: 0 0 0 0 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 .o 15 -o r copies of certification to this application. The Health Department will not use past years'records. You must 1 t t I provide new copies and maintain a file at your establishment. - -s' -1 1 1 I NI 1. 2. Va bi L HEIMLICH CERTIFICATIONS: p r -6 N 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. 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# CENSE REQUIRED FEE 'u_ # B&B S55 CABIN $55 MOTEL $110 - - (9-0() —INN $55 CAMP $55 SWIMMING POOL SI1 I ••••11;1 019 _LODGE $55 TRAILER PARK $105 ..LWIIIRLPOOL WON. •-••41 FOOD SERVICE: $FSMREQUIRED LICENSE0-100SEREQULRED FEE PERMIT# LICENSE FEE$35 4t9-.�Q(o3 LICENSEONPROFIT $30 PERMIT# >I00 SEATS11200$200 COMMON VIC. S60 —WHOLESALE $80 —RESID.KITCHEN S80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 ..ft. $50 >25,000 sg.ft. $285 VENDING-FOOD $25 —.:/5,t t i sq.ft. $150 =FROZEN DESSERT S40 TOBACCO S110 NAME CHANGE: $15 AMOUNT DUE = $ 4 75.00 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 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 of the limitations of Motel or Hotel use,Transient occupancy shall be limited to the temporary and short tenn 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.yannouth.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:Pemtits 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 REQ A S LAN. DATE: 03/11/19 SIGNATURE: PRINT NAME& tITLE: Noushad Kashem,Owner Rev.10/23n8 The Commonwealth of Massachusetts ....--.--..=. Department of Industrial Accidents '' _ ,—�/ Office of Investigations =' tI Congress Street,Suite 100 .= Boston,MA 02114-2017 �1+ www mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant InformationPlease Print Leaibty Business/organization Name: Two Families Inc Address: 149 Main Street City/State/Zip: West Yarmouth, MA 02673 Phone#: 508-775-3825 Are you an employer?Check thea propriate box Business Type(required): 1. I am a employer with employees(full and/ 5. 0 Retail or parttime).* 6. 0 Restaurant/Bar/Eating Establishment 2.0 1 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. g 0 Non-profit [No workers'comp.insurance required] 3.0 We are a corporation and its officers have exercised 9. 0 Entertainment their right of exemption per c. 152,§1(4),and we have 10.0 Manufacturing no employees.[No workers'comp.insurance requu+ed]** 11.©Health Care / 4.0 We are a non-profit organization,staffed by volunteers, / / with no employees.[No workers'comp..insurance req.] 12. 4 Other /10�0 ,..4. *Any applicant that checks box#1 must sloe fill out the section below showing their workers'motion palmy • • . "•.' "If the corporate officers have exempted themselves,but the corporation has other employees,*a wcckers'oompmsnion policy is required aid such an organization should check box#1. /am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name- Boynton INsurance Agency Insurer's Address: 72 River Park Street i City/state/zip: Needham, MA 02494 TWC 368481601/05/2020 Policy#or Self-ins.Lie.# 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 MOL 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 certify,under the and ,,. of perjury that the Information provided above is true and correct. Date: 03/11/19 Signature: /71 i Phone#: 212-858-9743 Official use only. Do not write in this area,to be completed by city or town ofiiciat City or Town: Permit/License Issuing Authority(circle one): i 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Licensing Board S.Selectmen's Office i 1 6.Other Contact Person: Phone#: I www.mumgovldis I A v02/20 oo2/20 D CERTIFICATE OF LIABILITY INSURANCE DATE YYYY) 16 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 CONTACT Boynton Insurance Boynton Insurance Agency (A/CNN Ext): (781)449-6786 bac,No): (781)449-4269 72 River Park Street ADDRESS: certificates@boyntonins.com INSURER(S)AFFORDING COVERAGE NAIC II Needham MA 02494 INSURER A: Vermont Mutual Insurance Company INSUREDINSURER B: Technology Insurance Company,Inc. Two Families Inc. INSURER C: American Bankers Insurance DBA:Howard Johnson Motor Lodge INSURER D: 149 Route 28 INSURER E: West Yarmouth MA 02673 INSURER F: COVERAGES CERTIFICATE NUMBER: CL1811912875 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. INSA ADDL LICY EXP LTR TYPE OF INSURANCE NSD SWVD POUCY NUMBER (MUER M DDIIYYYY) (UCY EFF MM/DD /YYYY) LIMITS X COMMERCIAL GENERAL LIABILITYEACH OCCURRENCE $ 1'000'000 DAMAGE l 0 RENTED 50,000 CLAIMS-MADE XI OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 5,000 A Y BP11050289 01/27/2018 01/27/2019 PERSONAL&ADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 1POLICY PRO- Ti LOC _ PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ - AUTOMOBILE UABILITY COMB aBINED)INGLE LIMIT $ Included (Ea — ANY AUTO BODILY INJURY(Per person) $ A OWNED SCHEDULED BP1105028901/27/2018 01/27/2019 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED X NON-OWNED PROPERTY DAMAGE $ X AUTOS ONLY ^ AUTOS ONLY (Per accident) _ $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 3,000,000 A EXCESS LIABCLAIMS-MADE Y CU11003952 01/27/2018 01/27/2019 AGGREGATE $ 3,000,000 DED X RETENTION$ 10,000 $ WORKERS COMPENSATION X STATUTE ETH AND EMPLOYERS'LIABILITY Y/N 1,000,000 B ANY PROPRIETOR/PARTNER/EXECUTIVE N/A TWC3684816 01/05/2019 01/05/2020 ( E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? 1,000,000 (Mandator/ In In NNH) ThiE.L.DISEASE-EA EMPLOYEE $ If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ Building $350,000 Flood C 99058622232018 04/09/2018 04/09/2019 Contents $150,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Re:Howard Johnson Inn(HOJ 15349 West Yarmouth,MA),149 Route 28,West Yarmouth,MA 02673. Certificate holders are endorsed as additional insureds;30 days notice of cancellation to additional insureds. Umbrella Liability follows form as permitted by policy terms,forms,conditions,and exclusions. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Howard Johnson International,Inc. ACCORDANCE WITH THE POLICY PROVISIONS. 22 Sylvan Way AUTHORIZED REPRESENTATIVE Parsippany NJ 07054j rr_, ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD