Loading...
HomeMy WebLinkAboutApplication and WC UUL7'./L Uvw RECEIVED GFTe1- 74, 18 —ecl = E NOVO 9 2018TOWN OF YARMOUTH BOARD OFIL+`AI, H "6q ►� APPLICATION FOR LICENSEIPER1VtI *2U -40 t , *(nEALTH DEPT. it TAX AC*COUNTING 1-v,1. : , Please complete form and attach all necessary docets be r 15.2018. NOTE:ALL BUSINESSES WITH LIQUOR LICENSES MUST RETURN FORMS BY NOVEMBER 15'h. Failure to do so will result in the return of your application packet. ESTABLISHMENT NAME: jV4h(G MAID Paves 1 t 9c,, TAX ID: LOCATION ADDRESS: 44L(1 $itaInteN TEL.#: 50$-2-92.- 1030 MAILING ADDRESS: PO $i's pp a (It*:((alt info 110 Ppan)KQ, 1/4 vias(•7,110 E-MAIL ADDRESS: Sa144E4' 4 9trrfj bnc.(pwi OWNER NAME: CORPORATION NAME (IF APPLICABLE): tutelar 5 f ormJ LOwt P ut I k MANAGER'S NAME: TEL.#: S t(b -3(02,-ill(( MAILING ADDRESS: POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated - - Pool e:_ . - - .R_; ; _. _ 'Hie-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. 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. 1. 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. 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. 2. 3. 4. RESTAURANT SEATING: TOTAL# (go'h - ✓--(339 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 PERMIT# 0-100 SEATS $125 _CONTINENTAL $35 NON-PROFIT $30 >100 SEATS $200 COMMON VIC. $60 WHOLESALE $80 RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE P R11IT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# j.<50 sq.ft. $50 I7-O >25,000 sq.ft. $285 VENDING-FOOD $25 <25,000 sq.ft. $150 =FROZEN DESSERT $40 TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE = $ SO.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 AFFIDAUT MUST BE COMPLETED AND SIGNED,OR RECEIV • 4''9 ��,, CERT. OF INSURANCE ATTACHED. • . � • OR TAX ACcouto l`! 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 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.yarmouth.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 CAFÉS: 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 A SITE PLAN. DATE: $ SIGNATURE: fay/CAA, Ate, PRINT NAME& TITLE: 04r Rev. 10/23/18 io CNK nl -7'7; GF The Commonwealth of Massachusetts mow..._ T�epa,'tmentoflndustrialAccidents RECEIVED - :141- E „P Office of Investigations ..1 Congress Street, Suite 100 NOV 0 9 2018 RECE�vED Boston,MA 02114-2017. TAX ACCOUNTING www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: A-4v4vue Avtio Pots Address: 14141 5ta b Oh ANk/ City/State/Zip: Phone#: 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. 0 Office and/or Sales(incl.real estate,auto, etc.) employees working for me in any capacity. [No workers' comp.insurance required] 8. 0 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]** 4.ElWe are a non-profit organization,staffed by volunteers, 11.❑ Health Care with no employees. [No workers' comp. insurance req.] 12.0 Other *My 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: jdt., 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 STOO' .� :_ Kan ane 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 1(' Signature: S �/1/1.� Date: 15`� Phone#: 513.414 414441 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 • 1ka9 AGENCY CUSTOMER ID: J32008 LOC#: Richmond AR ADDITIONAL REMARKS SCHEDULE Page 2 of 2 AGENCY NAMED INSURED Marsh USA Inc. Advance Stores Company,Incorporated 5008 Airport Road POLICY NUMBER Roanoke,VA 24012 CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance Workers'Compensation Policies: Policy Number:WLRC64789685(AOS) Carrier.Indemnity Insurance Company of North America Effective Date:06/01/2018 Expiration Date:06/01/2019 Policy Number:SCFC64789727(WI) Cartier:ACE Fire Underwriters Ins.Co. Effective Date:06/01/2018 Expiration Date:06/01/2019 Policy Number:WLRC64789715(TN) Carrier Agri General Insurance Company Effective Date:06/01/2018 Expiration Date:06/01/2019 Policy Number.WLRC64789703(AZ,CA,GA,MA,PA) Cartier:ACE American Insurance Company Effective Date:06/01/2018 Expiration Date:06/01/2019 Policy Number WCUC64789673(OH) Cartier.ACE American Insurance Company Effective Date:06/01/2018 Expiration Date:06/01/2019 SIR:$500,000 Policy Number WCUC65225992(FL,NC,VA) Cartier.ACE American Insurance Company Effective Date:06/01/2018 Expiration Date:06/01!2019 . SIR:$750,000 ACORD 101 (2008/01) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD I -, ® 1��V A�to CERTIFICATE OF LIABILITY INSURANCE DATE(M 8D/YYYY) 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 Marsh USA Inc. NAME: Three James Center (A/C No.Ext): FAX No): 1051 East Cary Street,Suite 900 E-MAIL Richmond,VA 23219 ADDRESS: Attn:AdvanceStores.CertRequest@marsh.com INSURER(S)AFFORDING COVERAGE NAIC# J32008--GAWU5-18-19 INSURER A:ACE American Insurance Company 22667 INSURED INSURER B:ACE Property And Casualty Ins Co 20699 Advance Stores Company,Incorporated 5008 Airport Road INSURER C:See Additional Page Roanoke,VA 24012 INSURER D: INSURER E: • INSURER F: COVERAGES CERTIFICATE NUMBER: CLE-005663746-16 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 ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS A X COMMERCIAL GENERAL UABILITY XSLG71094704 06/01/2018 06/01/2019 EACH OCCURRENCE $ 1,500,000 CLAIMS-MADE X OCCUR DAMAGE TO RENTED 1,500,000 PREMISES(Ea occurrence) $ X Self-Insured Retention 500,000 MED EXP(Any one person) $ _ PERSONAL&ADV INJURY $ 1,500,000 GE 'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 10,000,000 X POLICY 2C07 LOC PRODUCTS-COMP/OP AGG $ 3,500,000 OTHER: $ A AUTOMOBILE LIABILITY ISAH25157515 06/01/2018 06/01/2019 COMBINED SINGLE LIMIT $ 5,000,000 (Ea accident) X ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY AUTOS ONLY AUTOS (Per accident) $ X HIRED X NON-OWNED PROPERTY DAMAGE AUTOS ONLY * AUTOS ONLY (Per accident) $ $ B X UMBRELLA LIAB X OCCUR X00G28122779 003 06/01/2018 06/01/2019 EACH OCCURRENCE $ 5,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $ 5,000,000 DED RETENTION$ $ C WORKERS COMPENSATION SEE ADDITIONAL PAGE 06/01/2018 06/01/2019 X PER ER EMPLOYERS'LIABILITY Y/N STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBEREXCLUDED? N N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below - E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) EVIDENCE OF COVERAGE CERTIFICATE HOLDER CANCELLATION Advance Auto Parts,Inc. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 5008 Airport Road THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Roanoke,VA 24012 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh USA Inc. I Manashi Mukherjee McLf4..tocsn.i 44 ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD