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HomeMy WebLinkAboutApplication and WC i,.,. TOWN OF YARMOUTH BOARD OF HEALTH, , i ULU 1 3 "la t APPLICATION FOR LICENSE/PE ' r 19 i HEALTH DEPT. * Please complete form and attach all necessary does e is • Uel LL.,,r / :. NOTE:'ALL BUSINESSES WITH LIOUORLICENSES MUSfRETti' ' O ' SBYNOVEMBER IP. Failure to do so will result� in the return of your application packet. ESTABLISHMENT NAME: ' fLV�'h Lt I I l:Ci _, TAX ID: ' " LOCATION ADDRESS: 1%r/et ROUTE a g S( LC11-I ')C.XP lalM V TEL.#: 15C 3C g igiR MAILING ADDRESS: 5t1/4rYl£ E-MAIL ADDRESS: M.(iQS VY1 1.1)-0)k%1-4-0Tm Olt- : COM OWNER NAME: 'V 1�;.�/1, \ ►M. CORPORATION NAME(IF�APPLICABL.p: MCV14 U. (',0m—f_lent, MANAGER'S NAME: ��t Y1�C Y TEL.#: 5o S 2—Z l 30/ 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 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 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 I 1. y\atA N.teSt 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC)on site during hours of operation. 1. MORI CA._O&Y\o1Q 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. T `Ct.' ‘)t.` beStrAcra,- 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# v 6 —Ki— R�� a 1 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: LSE REQUIRED FEE P T# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _0-100 SEATS $125 ir- --09 _CONTINENTAL $35 NON-PROFIT $30 >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# _<50 sq.ft. $50 > 5,000 sq.ft. $285 _VENDING-FOOD $25 <25,000 sq.ft. $150 FROZEN DESSERT $40 ligJ'60- TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE = $ *****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.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: PRINT NAME&TITLE: Rev. 10/23/18 The Cononeoreovealtik of la. c'h x ` Department oflndostrial Aoc . *:-__2,-7:--:4 Y` Office of lnvestig�onS — :n= 1 Congress Strut Suite 1010 . j -:"..Z..t."".".=-: -' Boston,.11L4 02114-2017 www.niassgovid a ' Workers'Compensation Insurance Affidavit General Businesses Anolicant Information Please Print Lgaibly Business/OrganizationName: . . i1ll f A i 11. 11 Address: i 'MC 0\`6 Li ✓1 C�,v G1/uri) pAck. 026 6 City/State/Zip: Phone#: q a, 7 ai1.5ri Are an employer?Check the appropriate bow Type(required): 1-JI am a employer with Ca employees(full and/ 5. 0 ' - or part-time).* 6. IP ' . .0 : , ,, .. Establishment 2.0 I am a sole proprietor or panne ship and have no 7. 0 Office and/or Sales cm&real estate;,auto,etc.) employees working for me in any capacity. S. ❑ [No workers'comp. required] 3.❑ We are acorpolution and its officers have exercised 9. 0 Entertainment their sight of exemption per c.152,§1(4),and we have 10.0 Manufacturing no employees.[No workas'comp.insurance required)" 11Health Care 4.0 We are anon-profit organization,staffed by volunteers, q--....; with no employees.[No workers'cep.- req.] 12. Other *Any applicant thatrhedcs box 11 must amo fill ontthe section below shaving then.makers'cc. ansadion policy informal= **lithe caw*officers have exempted themselves,but the=monition has other employees,a webers'cow policy is requhed sod sot*an agonized=shonldchedcbox R. I am an mar that is providing workers'compensation insurance for my employees. Below it;tlrepolky information. Insurance Company Name: )Ohl .1 NI G 0 O. n. bra ores Address:- "i q l a Y\V.Opt q k ' �� to 0240 ) Polity#or Self-ins.Lic.# LI(P) t i V " D 7 O 1 L1 1 I Attacha copy sof die workers'compensationpolicy declarationpage{ the policy number aid !ems ). Failure to secure coverage as required under Section 25A of MOL c,152 can lead to the imposition of cl penalties of a fine up to$1,500.00 and/or one-year has well as civil penalties in the form ofa 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 eerie,under the , , ,,, ,,, _. ofperjury that the ink provided above is , and eorrect , ,, L_. Ili dA / t (2 ' g Phone#; 601 ,/)o<11L Official use only. Do not write in this area,to be completed by city or tow officiaL City or Town: Permit/Laco ere# lamting Authority(drcle one): 1.Board of Health 2.Building Department 3.City!rowa Clerk 4.Limning Board S.Selet 's Office 6.Other Contact Peron Phone#: wwwmass gcivelia Alit©® DATE 06-201 rrYYY► CERTIFICATE OF LlAB1LITY INSURANCE I o4-os-tots TIURS CERTIFICATE IS IMBED AS A MATTER OF*FORMATION ONLY AND COWERS NO RIGHTS UPON TIE CERTFICATE HOLDER. THIS CERTFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMOID, EXTEND OR ALTER TIE COVERAGE AFFORDED BY TIN:POLICE'S BELOW.THIS CERTFICATE OF DANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN TIE_ISSUWG ),minim=REPRESENTATIVE OR PRODLICEFI,AND THE fERTFICATE HOLDER. WWORTANT:B the cerWlcatle!wider Is an ADDITIONAL RIMED,the pollcyQes)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and oomMions of the ply,certain policies may require an A statement on this ods does not corder res to the certificate holder is Neu of such ems}. PRODUCER _ CO DOWLING&ONEIL INS AGENCY PRONE Imo.NoI 973 IYANNOUGH RD Nue.No.ask HYANNIS,MA 02601 U emunEnnAFPORDINOCOM MGE NADP DOU ERA:HARTFORD UA :WRWWERS INS CO INSURED INSURER B: MARYS LIL CABOOSE INC INSURER c 1279 ROUTE 28 SOUTH YARMOUTH,MA 02664 INSURER D: INSURER E: MEURER COVERAGES CERTWICATE R: REVISION lam: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTW1THSTANDAIG ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAINI,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LUMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. EAR ADM SUER POUCIF EFF POUC'Y EDP LIR P1PEOFINSURANCE MED WEDPOLICY NUMMI DIENDOMMO ansvoirnm MOS COURERCNI.6BERALLMBLIVY EACH O +ICE $ ^°E n ° =I iIEDEXP(Any am pereaW $ PERSONAL ADV INJURY $ -_GEHLAt TELA TAPPLESPE : GE ALAG ATE $n nL -COSOP,GG $OTHEFt AUTOMOBILE UNMET =WEIGLE L41T $ ANY Atli0 BODILY INJURY(Par parson) $ _ AUTOS ONLY AUTOS BODILY INJURY(Peraoddent} HIREDMIMS NONOINNED ONLY — AUTOS ONLY gIVIZZOMMACE i $ UMTRB.LA LMB OCCUR EACH OCCURRENCE $ EXCESS UAB CLAYI3-INIDE ABORIEGATE $ CEO O IRETENTION s $ — VAXIKERS CORMIBA7 ON P@T on AND EMPLOYERS*MOM YIN STATUTE I ER APR ARTNERU EXECUTIVE OFFICERAIEMBER IN CIA _ UEI 0331-2018 03-3119 E.LEACH ACCIDENT s5500.000 EXCLUDED? EL DISEASE-EA BINNIMmye N IE 11(280701 EMPLOYEE =5500,000 yes.&scam DESCRIPTION OAF OPERATIONS below EL D 'POLw'Y =5500,000 LBAIr DESCRIPTION OF OPERATIONS/LOP.MIS/VENOUS( 101.4ddYiaMRNmsiS dd*mabe alEmbedIHmieapsostsman* CERTIFICATE HOLDER CANCELLATION TOWN OF YARMOUTH SHOULD ANY OF MEADOW DEDPOUCESBECANCEI.LED 1146 ROUTE 28 INEFORE TIM EXnoATIO11 DATE 'THEREOF, NOTICE WILL BE SOUTH YARMOUTH.MA 02644 nE.w DI ACCORDANCE wI11IIRE POLICY PROVISO* AURIONEEDI A7NE 1 B 10MR,IIIIS Arman insio stir IM AM Ant**ereerwrl tit 7(fej * tr...;) r Ifilatb LA _ _Pc_AA-Ft-bi teiciLl_1(151Thodtat, gfulhag THN CERTEICATE IS ISSUED AS A MATTER OF INFORMATION OILY AND COFFERS NO • UPON THE CERTEICATE HOLDER.THIS CERTWICATE DOES NOT AFFNIMATNELY OR NEGATIVELY-AMEND,EXTEND-OR ALTER THE COVERAGE AFFORDED BY TIE POLKAS BELOW MS CERiFICATE OF BEURANCE DOES NOT CONSTITUTE A CONTRACT BE1WE31 TIE 1SSUMIG B (S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND TIE CEitTEICATE HOLDER. IIWORTANT:If the certificate holder is an ADDITIONAL INSIRWD,the policypes)must be endorsed.If SUBROGATION IS WAIVED,suDJect to the terms and candidata at the policy,math poNcies nary morphs an endorsement A statement on this center:Me does not corder lights to the certificate holder h Neu of such endorsement(s). PRODUCER Dowling&O'NelI insurmwe Agy Ern,508 775-1620 ,o 5087781218 973 lyannough Road moms P.O.Box 1990 Hyannis,NA02601 ISSaR (M ERAFFORDINGCOVERAGE p+ue. youriER A:weememebieweerebewerey 32859 INURED INSURER Mary's LN Caboose Inc R 1279 Route 28 nsllaele: INSURER o: SWANYmmwlth,MA 02664INSURER E: INSURER F: COVERAGES CERTEICATE SER: REVISION MAH ER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LIMED BELOW HAVE BER4ISS TOTHE Nom)MIMED ABOVE FOR THE POLICY PERIOD RATED. NOTWITHSTANDING ANY R U ENT,TERM OR CON ITIONOF ANY connuerOR OTHER DOCUMENT WITH REST TO WHICH TENS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE MANCE A BY THE POUCHES DESCRIBED HEREIN!IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AM)CONDITIONS OF SUCH POLICIES. UNITS SHOWN MAY HAVE BEEN REDUCED BYppPAAll)pC�.AIMS. EgtTYPE OF NUANCE MUM NUMBER aMMIQr1fYY�Yi,INiMaMYYYX}, MIS A rE/ER*1LIlal= PAV0161318 03!30/2018 03/31 2019 EACH OCCUs1,000,000 _ X COmmEnclALGEILERALuAsurr RESSMILTIRencel $100,000 MAW-BADE 1 !OCCUR MED EXP(My one person) s5,000 _ PeTSONAL a ADV*WRY $1,000,000 GEAERALAGREGATE. s2,000,000 GEN_AGGREGATE LAST APPLES PER: PRODUCTS-COAR'JOP AGG s2,000,000 POUCY n rl LOC $ AUTOMOBILE TAMMY CONS SAIGLE mar tEa accident/ t _ _ ANY AUTO BOOLY INJURY(Per preen) $ — AAUUTOS _ AUTOS OWIED ® BODILY"WRY(Per at*** S NDEOW ED PROPERTY DAMAGE _ HIRED AUTOS AUTOS We,acciderel $ WITS Ettil trAB _ OCCUR EACH OCCURRENCEEXCESS UM CLAMS-MADE _S I AGGREGATE S DED ( RETENTION; $ wommCnisCOMPENSATION - WCSTATU- I W- AND EMPLOYERS'LIA IiTY YIN WIRY mita sa E>QCLUDES N/A ELEACIiACCDeII ilwamPARnS Y Menttattry f EL DISEASE-EA BELOYIE$ D RFrION OF OPERATIONS below EL DISEASE-POLICY LINT $ oincenIDNOFOPERATIONS/LOCATIONS/VOICES WWI*CODE%AGNE WReamesSobeMbsl1merememlarequired) insurance coverage is Ondled to the terms,conditions,accksions,other Imitations Std endorsemerds. Nothing contained in the certificate of kuswance shall be deemed to have altered,waived,or extended the coverage Provided by the policy provisions. CERTIRCATE HOLDER CANCELLATION Town of Yarmouth SHOULD ANY OF TIE ABOVE DESCRIBED POLICES BE CAINISLED BEFORE TIE EXPwATION DATE TIIl3EOF, NOTICE INU. BE DEJVERED Nt 1146 Route 28 ACCORDANCE VIM THE PODGY PROMS. South Yarmouth,MA 02864 AUTHOR ED REPRESENIRTME I Ibweri Pr '',f - 6011/1-02- 1 Vittte2. .11 - PO/N215(--„,L' 1 21L- (8 . TIES BSER IS A TEMPORARY INSURANCE CONTRACT summer TO TIE CONDITIONS SHOWN ON TIE FEVERSE SIDE TLI1FORK PRODUCER Matta emz 508-7754620 COMPANY s Mt mok 9087781218 HINNordUmlerrrraerstlslranceCom 884DER449271 Dowling&O'Neil hisuratice Agy DATE EffECTLVE TWEE DA laP ' " n 973 iyannough Road 03,31/18 12:01 X AM 051111/18 X 12:01AM P.O.Box 1990 PM NOON Hyannis,MA 02601 TICS BENDER IS ISSUED TO ExTEND COVERAGE N THE ABOVE NAMED COMPANY CODE: SIB CODE: PER EXPIRING POLICY# ruselposen I 765703 , DESCRIPTION OFOPENA wssoLondon) INTI Mary's iii Caboose Mc Loch :1279 Rouse 28,South Yarmouth, 1279 Route 28 MA 02664 South Yarmouth,MA 02664 COVERAGES WARS TYPE OFNISURANCE COAD DEDUCTIBLE CONS 11. AMOUNT PapPEMY CAUSES OF LOSS BASIC ri SAD f f SPEC GENERAL LIABILITY EACH OCCURRENCE $ - DAMAGETO COMMERCIAL GENERAL UA EJrY RENTED PPEINSES $ CLAIMS MADE f f OCCUR MED EW(Anyone person) $ PERSONAL&ADV*WRY _$ GE EIRALAGGRE GATE $ RETRO DATE FOR CLANS MADE PRODUCTS-WIMP AGG $ AUTOMOBILE LIABLJTY GOWNED SINGLE UTMT $ ANY AUTO BOXY INJURY(Per person) $ ALL OWED AU OS BODILY INJURY"area:IMOS AUTOS PROPERTY DAMAGE .$ __ HIRED AUTOS MEDICAL PAYMENTS -$ NOIFOWPED AUTOS PERSONAL KURT PROT s UNINSURED MOTORIST $ S AUTO PHYSICAL DAMAGE DIMUCTIBLE _j AU.VEHCLES I I SCHEDULED D VEH ICLES A C RMLCASH VALUE COWSRON: STATED AMOUNT $ OTHER THAN COL: OTHER OARAGELIABILJIY AUTO ONLY-EAAomen- S ANY AUTO OTHER THAN AUTO ONLY: EACH ACCIDENT $ _ AGATE $ EDS mourn EACH OCCURHTETICE _$ LAMELLA FORM AGWEGARE $ OTHER THAN UMBRELLA FORM RETRO DATE FOR CLAIMS MADE: SELF-INSURED RETEQTRON S X I WC STATUTORYLEAETS ISOMERS COMPENSATION EL EACH ACCE ENT S 500,000 AND EMPLOYERS LIABEJTY EL DISEASE-EA EMPLOYE s 500,000 See Spec. E.L.DISEASE-POLTCY LaYT $500,000 Mary's LII Caboose Inc FEES $ 1 TAXES $ attached COVERAGES -aSpec Coifs page.) .ESTIMATED TOTAL PREMIUM $ NAiE A ADDRESS Town of Yanno lt11 _ MORTGAGEE _ADDITIONAL ISURED LOSS PAYEE X tilde 1146 Route tom/ South Yarmouth,MA 02664 • AIIIHO ® ATTVE