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HomeMy WebLinkAboutApplication and WC TOWN OF YARMOUTH BOARD OF HEALTH APPLICATION FOR LICENSEJPERMIT-2019 *Please complete form and attach all necessary documents by December l5 2018. S NOTE:ALL BUSINESSES WITH LIQUOR LICENS MUST RETURNFFORLMSBYNOVEMBER 151* Failure to do so will result m the return of ESTABLISHMENT NAME: ulna Dy N YNnp' 4- Tqx 1D LOCATION ADDRESS: Q 5 o,h tYN t°n1/-CMVLe..-- TEL.#: MAILING ADDRESS: '1) 13 . I �� SV. P i4in i,S 611`7 6 Z(v 6� E-MAIL ADDRESS: Fye ['('/ham i t 1 ,U Oyy1 v}1 ny OWNER NAME: VD�'�'ln 41 l Cil rl d l /�.6tiv‘ Y J leo v (4/150-nb i,le 1i CORPORATION NAME(IF APPLICABLE): P Ia 6 MANAGER'S NAME: WA i Li rapt-k TEL.#: 79 g /f 4 `�3 C/ MAILING ADDRESS: 1 of dy /61,/s- SO= �c',�'I n 1 i 419-O7647) I 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 form. 1. 2. Pool operators must list a minimum of two employees currently certified in standard First Aid and Community Fri; Cardiopulmonary Resuscitation(CPR),having one certified employee on premises at all times. Please list the > C) 111 employees below and attach copies of their certifications to this form.The Health Department will not use past E„ � lS?) years'records. You must provide new copies and maintain a file at your place of business. _, O 1. 2. m a nnl 3. 4 03 0 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. pp 1. 2. PERSON IN CHARGE: fiP .•" Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. 1. 2. .• , 4.1, 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(GX3)(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 CER1'WICATIONS: 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# ,66 k —A,M(03 —03 OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMITS LICENSE REQUIRED FEE PERMIT* B&B $55 CABIN $55 MOTEL $110 INN $55 CAMP $55 =SWIMMING POOL$110ea _LODGE $55 TRAILER PARK $105 WHIRLPOOL $110es. 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 RETAIL SERVICE: —RESID.KITCHEN$80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT<50 25 =45,000 sq.R $1500 ih 443 >25,000 N DESSERTS285$40 TOBACCO $VENDING-FOOD110 NAME CHANGE: $15 AMOUNT DUE = $ 150.00 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.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.P EASE 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 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 RE 4 !' S,r�` PLAN. f � DATE: 1Z.171(8.- SIGNATURE: .f-RePRINT NAME&TITLE: AL- er- a•t ?rps;ds 1771- Rev. v.10/23/18 The Commonwealth of Massachusetts _ Department of Industrial Accidents ► 1 c�= ► Office of Investigations � 'c 1 Congress Street, Suite 100 Boston,MA 02114-2017 �� www mass.gov/dia Workers'Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organisation Name: Pa' O+S rl `W. Ct bit, ul UV t N ntl0( Address: PO Bo>< l 64S - City/State/Zip: SO. t e r iSi 016.60 Phone#: Ll LI tP 11311 Are yo an employer? Check the appropriate box:- Busin�es Type(required): 1. am a employer with 2I 1 employees (full and/ 5. UR-et-ail 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. ❑Non-profit • 3.❑ Weare 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]** 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 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 Amy employees. Below is the policy information. Insurance Company Name: �P" .thQ\\ 'MPXG wee_ (Up l y\c • • Insurer's Address: Po \& b5121-2._ - 612-1-2— City/State/Zip: 13ra iln t 1' -1 MA rit t 7 Policy#or Self-ins. Lic.# 01 LI 0050321-14Y)1 IExpiration Date: \)6r) i)2O['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 $250.00 a day against.the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby certify,- z der.tlr a pains and penalties of perjury that the information provided above is true and correct. .tea Signature: ' P// e . de n T Date: LII z.6/ r Phone#: - .q tl q 7l`► -1 J'1_l Official.use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: WWW mace am;hiia /""11 1 LIQUNMO-01 JPOWERS AC :WO" CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY) `-""`-- 10/23/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the pollcy(Ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsements). PRODUCER License ti 1780862 NAL Acr John Powers H265 OrleansUB tRoad ional New England PHONE FAX No): (A1C,No,Eat):(508)945-7866 North Chatham,MA 02650 E-MAILDRSS:John.Powers@hubinternational.com INSURERS)AFFORDING COVERAGE NAIC$ INSURER A:Merchants Mutual Insurance Company 23329 INSURED INSURER El:Massachusetts Retail Merchants Workers'Compensation Group,In 34355 Liquor'N More Patriot Spirits Inc dba INSURER C PO Box 1645 INSURER D: South Dennis,MA 02660 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 OF INSURANCE ADDL SUER POLICY EFF POLICY EXP LTR INSD WVD POLICY NUMBER (MM/DD/YYYYI (MMIDDIYYYYI LIMITS A COMMERCIAL GENERAL LIABIUTY EACH OCCURRENCE $ 2,000,000 CLAIMS-MADE OCCUR BOP9101367 06/20/2018 06/20/2019 PREMISES(EsErrence) $ 500,000 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ Included GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE _1 4,000,000 POLICY IN& LOC PRODUCTS-COMP/OP AGGJ 4,000,000 OTHER: $ AUTOMOBILE LIABILITY 4EaMaccide Q INGLE LIMIT $ ANY AUTO BODILY INJURY(Per person) $ — OWNED — SCHEDULED AUTOSRE� ONLY _ AUTOS BODILY RRINJURY(Per accident) $ AUTOS ONLY _ AUTOS ONLY (Per agURAMAGE 3 _ _ $ UMBRELLA UAB _ OCCUR EACH OCCURRENCE J EXCESS UAB CLAIMS-MADE AGGREGATE DED RETENTION$ $ B WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER ANY PROPRIETOR/PARTNERIEXECUTIVE 14005032748118 01/01/2018 01/01/2019 500,000 FILER/MEM EXCLUDED? N N/A E.L EACH ACCIDENT $ andafory in 500,000 If yes describe under E.L.DISEASE-EA EMPLOYEE $ DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 500,000 A Liquor Liability BOP9101367 06/20/2018 06/20/2019 $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Located:461 Station Ave.South Yarmouth MA 02664 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE n Of Yarmouth THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Tow Tow Route m ACCORDANCE WITH THE POLICY PROVISIONS. 11468 South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE I ?;.99.4 .— _ ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and loco are reaistered marks of ACORD �1(AYotfiv\ COMMERCIAL LINES POLICY BUSINESSOWNERS POLICY DECLARATIONS Policy Number: BOP9101367 Named Insured: PATRIOTS SP IR ITS INC Policy Period: 06/20/18 to 06/20/19 BUSINESS LIABILITY Limit of Insurance Business Liability Limits General Aggregate Limit (Other than Products-Completed Operations) $ 4,000,000 Products-Completed Operations Aggregate $ 4,000,000 Personal and Advertising Injury Included Business Liability/Occurrence $ 2,000,000 Fire Legal Liability Limit (Damage to Premises Rented to You) $ 500,000 Medical Expense (Any One Person) $ 5,000 Optional Liability Coverage Hired Auto & Non-Owned Auto Liability Each Occurrence $ 1 ,000,000 Aggregate $ 2,000,000 Liquor Legal Liability Each Common Cause $ 1 ,000,000 Aggregate $ 2,000,000 Loc. No. 001 Bldg. No. 001 FORMS AND ENDORSEMENTS ATTACHED AT INCEPTION APPLYING TO THIS COVERAGE PART AND MADE PART OF THIS POLICY AT TIME OF ISSUE: BP0404 0110 HIRED AUTO AND NON-OWNED AUTO LIABILITY BP0415 0110 SPOILAGE COVERAGE BP0446 0106 ORDINANCE OR LAW COVERAGE BP0456 0110 UTILITY SERVICES-DIRECT DAMAGE BP0457 0110 UTILITY SERVICES-TIME ELEMENT BP0489 0110 LIQUOR LIABILITY COVERAGE BP0523 0115 CAP ON LOSSES FROM CERTIFIED ACTS OF TERRORISM BP0542 0115 EXCL-PUNITIVE DAMAGES RELATED TO CERTIFIED ACTS OF TERRORISM BP0547 0110 COMPUTER FRAUD AND FUNDS TRANSFER FRAUD BP0598 0106 AMENDMENT OF INSURED CONTRACT DEFINITION MU8237 0114 EMPLOYMENT PRACTICES LIABILITY MU8245 0114 MAP RETAIL PLUS * MU8271 1015 EMPLOYMENT PRACTICES LIABILITY INSURANCE SUPP DECLARATIONS MU8277 1111 ADDITIONAL INSURED BY CONTRACT AGREEMENT OR PERMIT MU8285 0114 FINE ARTS MU8369 0114 CONTRACTORS' INSTALLATION TOOLS AND EQUIPMENT * MU8947 0114 PROTECTIVE SAFEGUARDS MU9068 0117 ESTIMATED PREMIUM AUDIT BP0003 0110 BUSINESSOWNERS COVERAGE FORM BP0108 0311 MASSACHUSSETTS CHANGES BP0453 0110 WATER BACKUP AND SUMP PUMP BP0454 0106 NEWLY ACQUIRED ORGANIZATIONS BP0493 0106 TOTAL POLL EXCL W/BLDG HEAT EQUIP EXCEPT/HOSTILE FIRE EXCEPT BP0501 0702 CALCULATION OF PREMIUM BP0517 0106 EXCLUSION-SILICA OR SILICA RELATED DUST BP0577 0106 FUNGI OR BACTERIA EXCLUSION (LIABILITY) BP0698 0110 MASSACHUSETTS-FUNGI ,WET/DRY ROT, BACTERIA EXCL & LIMITATIONS BP1504 0514 EX ACC OR DISC OF CONF/PERS INFO & DATA RELATED LIAB W/O BI * MSIU05 1199 FRAUD TIP LINE * MU8186 0114 IDENTITY RECOVERY COVERAGE MU 8382(07/17)