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HomeMy WebLinkAboutApplication and WC TOWN OF YARMOUTH BOARD OF HEALTH, RECEIVED ,� `'i1 APPLICATION FOR LICEN _. i - °° ' _4 T �EG U3 2018 �� Please complete form and attach all d#"umei `, NOM ALL BUSINESSES tWITH U TRE � '�.`ti`f.'i 1 l;` C�' "j ' Failure to do so will resultin thmtihi of your application packe . tag►-�., ESTABLISHMENT NAME: , ub r}FCscvkS 'er c IgA --C,6w,c,C14 TAX ID: LOCATION ADDRESS: 1 -1,13 1t.S PCx I 4-57 TEL.#:5Q�j���-/1C-00 MAILING ADDRESS: o r+rvt: Pr v c i E-MAIL ADDRESS: ` rn 4.5 L.11 Sk.towam cleiti,ei 04 rvt-e.v\.-E of ctnkp . co OWNER NAME: .I Q xvt,en -rori CORPORATION NAME(IF APPLICAB rLc ; L-L C MANAGER'S NAME: A SV-1I� 5-r TEL.#:PDCreB 4 q 11 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 attach a copy of the certification to this forth. 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 years' records. 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. )Q.Y1l1 '%-2 2. LollA r i—e V PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. 1. ‘.--01\11 Lx 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)(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. 1. �� t LJ L s> 2. 1 OW- —6e.^-.,. Fs o-coo HEIMLICH CERTIFICATIONS: eo -- L yt6.O`{ 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 t 'loyees trained in anti-choking procedures below and attach copies of employee certifications to this form. The :ealth Department will not use past years'records. You must provide new copies and maintain a file at your place of business. a.h - 1. 2. 3. 4. • OFFICE USE ONLY • LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# INN $55 CAMP 55$55 MOTEL $110 • _LODGE $55 TRAILER= PARK $105 SWIMMING POOL$i l0ea. WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-00 SEATS SEATS $225 --125 CONTINENTAL $35 NON-PROFIT $30 COMMON VIC. $60 WHOLESALE $80 RETAIL SERVICE: RESID.KITCHEN $80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq ft. $50 >25,000 sq.R. $285 VENDING FOOD $25 <25,000 sq.ft. $150 =FROZEN DESSERT $40 _TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE _ $ 125.00 *****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 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.MG 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 fornas,total coliform and standard plate count by a State certified lab,and submitted to the Health Department three( )�day 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 byfiling the required Temporary Food Service Application form 72 hours prior to the catered event These Downloadable btaineFd Health Department,or from the Town's website at www.yarmouth.ma.us under Health t, Departm 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. • xla O N o tz. o 4 H x A a W J0 +cg CA W '% ww H z -Oo o .„ � w w I ; �` i. ww o 7 '0 Z x Q 0' \„, rr� w Q, • 8 � g \' 0 Q Z 0 >4 O o H �›. :: 0 H til g �-< wWz 0 , g ~ OOH , a O < � a � aH i, W � W -0 0SIO zaoz z .. � o z H zz z � a P; 041-- O �. A 41 0U 6' o 0 •~ W < . x o a 0z '.--, ' 0 o i A ° H41 a o O o zH „la ¢ waO A The Commonwealth of Massachusetts 1. rf _ Department of Industrial Accidents -14"' Office oflnvestigations _ = " I Congress Street,Shite 100 .- Boston,MA 02114-2017. www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Annlicant Information Please Print Legibly Business/Organization Name: J 6.)i sill 0 L ' g „_ .lit)r Address: )a Wilvte.S PA it 4 S City/State/Zip:S(4 Vm m ,AA Ici Phone#: 5-0 $'— , tl-75o 0 Are you an employer?Check the appropriate box: Business Type(required): 1 akI am a employer with 1 0 employees(full and/ 5. VIAtall or parttime).* 6. F .RestaurantlBar/Eating Establishment 2.0 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 10.0 Manufacturing no employees.[No workers'comp.insurance required]" 11.0 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 chedcs box#1 must also fill out the section below showing their workers'compensation policy information. **H&c corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should cbedc box#1. I am an employer that Ls providing workers'compensation Insit7yefonry employes. Below Ls the policy information.Insurance Company Name: 1 ft 0),-/ 4 Insurer's Address: I 6-1'7. -' n{' City/State/Zip: a o rlu- - A)y 14(./U Policy#or Self-ins.Lic.# —1 Co vU g Cr f} C. I h/ PP Expiration Date: l i I 1 S t I I 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. Ido hereby c esdfy,under the pains and penalties of perjury that the information provided above is true and correct. Signature: < .__ a -'- • Ze' 18 Phone#: 'D I-14 bki 3 3. J Official use only. Do not write in this area,to be completed by city or town officiaL 1 1 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 1 6.Other Contact Person: Phone#: www.mass.gov/die DATE(MMIDD/YYYY) '' '"'� CERTIFICATE OF LIABILITY INSURANCE 11/20/2018 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 SUBROGATIONIS 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 PAYCHEX INSURANCE AGENCY INC/PHS NAME: 76210756 PHONE No,Ext): (877)287-1312 FAX 888)443-6112 (NC,No): 150 SAWGRASS DRIVE E-MAIL ROCHESTER NY14620 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: The Hartford Accident and Indemnity Insurance Company 22357 INSURED INSURER B: SUB ACQUISITION LLC DBA SUBWAY INSURER C: 45 PINEHILL DR INSURER D: EAST GREENWICH RI 02818-1905 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 INSR WVD (MMIDD/YYYY) (MM/DD/YYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE CLAIMS-MADE n OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) MED EXP(Any one person) PERSONAL&ADV INJURY GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE POLICY PRO n LOC PRODUCTS-COMP/OP AGG JECT OTHER: COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY (Ea accident) ANY AUTO BODILY INJURY(Per person) — ALL OWNED S• CHEDULED BODILY INJURY(Per accident) _ AUTOS AUTOS HIRED AUTOS — N• ON-OWNED PROPERTY DAMAGE AUTOS (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE EXCESS LIAR CLAIMS-MADE AGGREGATE DED RETENTION$ WORKERS COMPENSATION PER x OTH- AND EMPLOYERS'LIABILITY STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE YIN E.L.EACH ACCIDENT $1,000,000 A OFFICER/MEMBER EXCLUDED? NIA — 76 WEG ACIWPF 11/25/2018 11/25/2019 — — (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under E.L.DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) Those usual to the Insured's Operations.Re:Subway#12312 at 12 Whites Path STE 5,South Yarmouth,MA 02664. CERTIFICATE HOLDER CANCELLATION FRANCHISE WORLD HEADQUARTERS(FWH) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 325 SUB WAY THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. MILFORD CT 06461-3081 AUTHORIZED REPRESENTATIVE �f wean c;37 ©1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD