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HomeMy WebLinkAboutApplication and WC 4 s _ TOWN OF YARMOUTH BOARD OF HEALTH APPLICATION FOR LICENSE/PERMIT-2019 •Plan e� complete form and QQam�ch all doaumeata Failure to dodo wilNM:ALL ltesuTt in n application packet. lam• ESTABLISHMENT NAME: 4 .A , -' y ' c�I TAX ID: LOCATION ADDRESS: 6 l tic,o d 1d kr TEL#: MAILING ADDRESS: b(.t.w►'Fr E-MAIL ADDRE S fl GO Z °i oat. OWNER NAME:Kan4 A 4 hrrot•_ 6h tip a,F /--4_11 lac u•er CORPORATION NAME(p1f APPLI MANAGER'S NAME: f•th/i°L C J! )I engrix.,c. / '1EL.#: , MAILING ADDRESS: ;611 ( Lt)QQrl 4 r/YLGt/�h 1 Al K? o hePOOL CERTIFICATIONS: The pool supervisor mad be certified as a Peel 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. D (11 (S') Pool operators must list a minimum of two employees currently certified in standard First Aid and Community z [L Cardiopulmonary Resnschat on(CPR), one certified on at all times. Please list the0 _ emplo+ees below and attach copies of their ce tlf catiooa to this form. � will cot use past years records. Yea mast provide new copies and maintain a file at your pine m o G n H ca J;: 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 Establis mieots,105 CMR 590.000. tk. .1,741 Please attach copies ofcrtification to this application.The Health Department w®not use past years'records. You mRi11°° Jth provide newand ma at year estabisebsaat. 1. ©/� aim& JA PERSON IN CHARGE establishment must have at least are Person In Charge(PIC)on site during hours of operation. Pfmi I440C vGn l tl!6! 2. `ALLERGEN CERTIFICATIONS: . All food service establislmients arerequired 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 390.009((0 f 3Xa). Please attach copies of certification to this application. The Health Department will not use past years'records. Yea most 7taand Main a file at your establishment. .74.:76(1/11“ �., f . 2. HEIMLICH CERTIFICATIONS: All food service establidonents with 25 seats or mine must have at last one employee trained in the Heimlich Maneuver on the premises at all times. Please list yewimplores trained in procedures below and attach copies ofemployee certifications to this form. The fl.akh Department will not use pest years'records. You must provide new copies andel maintain a file at year place of business. 1. Aid I 14@o is 1`�, I Y 2. 3. U 4. RESTAURANT SEATING: TOTAL# / v oo kke-A4--Qq(0.1-c OFFICE USE ONLY LICENSE REQUIRED Prig PERMIT a LICENSE REQUIRED LT PERMITS REQUI RBD P� PERMIT 3 CAH1N S53 SWIMMING POOL 6110 SSS5 PARK $1Moe 1005 SiIlOcs FOOD SERVICE: LICEIff ;8 SEATS 125 PERMIT/� II! RE srrA Bp$35 FEE PERMIT e =>I00 SEATS ( LCOMIIy0Al1 r1VIC. sus S$500 RETAIL OR —REBID.KITCHEN Sm LICENSEg��EQ JEWELED F PERMITS LICENSELppRREEQ.UIRED FEE PERMITS EN •REQUIRED FEB PERMIT Si =Q5,wu eq.& 5150 =-FROZEN DST 510 ="icsACCD S110 NAMEt:BMiGE: S15 AMOUNT DUE . 2.49.00 *****PLEASE TURN OVER AND COMMiTE 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 Waiter's Compensation Insuamoe. THE ATTACHE) 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 taxa and liens must be paid prior to renewal or issuance of your pew. PLEASE CHECK APPROPRIATELY IF PAID: / YES d NO MOTELS AND OTHER LODGING ES'TABLISHIWIINTS TRANSIENT OCCUPANCY:For purposes ofthe limitations of Motel or Hotel use,Tamieat 000vpao:y shall be limited to the temporary sod short term occupancy,ordinarily and customarily aaociated with need sod hotel use. Transient occupants must have sod be able to demonstrate the they maintain a principal place of re dance Orem.Transient occomma r shall gene*neer to 000tissoas000upiewy ofnot mare than thirty(30)days,and at wept. than obey(90)days within any six(6)month period Use of a guest unit as a residence or dwelling alit shall not be considered transient. Occupancy cy that is subject to the collection of Room Occupancy Excise,as defined in 14.03.c.640 or 130 CMR 640,as amended,shall generally be consideed Transient. POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the sands mat be impacted by the Healthprior to opening. Coated the Health ser'to the three(3)days D� People are NOT allowed to sit in the pool area until the pool inpemedd and end to POOLA The must be tested for total collfam sed at®deed piste count by a State certified admitted to the Health Deportment th ee )(s to opening,and quarterly*amber. POOL CLOSING:Every outdoor in ground swimming pool mat be drained or covered within levan(7)days of closing. FOOD SERVICE SEASONAL FOOD SERVICE OPENING: An food service esteblishments mist be inspected by the Health Depaenent pier to*psalm& Please coded the Health Deportment to schedule the impsotioa three(3)days prior to opening. CATERING POLICY: Anyone who osiers within the Town of Yarmouth must notify the Yarmouth Hlea&Department by Ming the Tampoaary Food Service Application form 72 hours prior to the catered evert These leis cera be Mend at the Deportment,or from the Town's website st yrww.ya noulh nen a under Health Dept Downloadable Forms. FROZEN DESSERTS: Frcmuda...itauastbctassedbyaSiate certified lab irncrlo opening aid muddythereafter,with somple resewsabedMadto the Health Deportment. Failure to do so will result in the sapesson or revond=atyaw Proem Dessert Permit off the above terms have beer met. omens CAFES: Outside can(i.e.,outdoor seating wide service),mat have prior approval from the Bond of Ham. OUTDOOR COOKING: Outdoor cooking.palmation.or display of any food product by a retail or food service elabiisinnanet 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 me expired license,and the tobacco license cap is reduced. NOTICE:Permits nm annually from January 1 to Decanber31.TT IS YOUR RESPONSIBILITY TO RETURN THIE COMPLETED RENEWAL APPLICATIONS)AND REQUIRED FEE(S)BY DECEMBER 15,2018. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i ., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO APPRO Y THE BOARD OF HEALTH PRIOR TO CO . RENOVATIONS '-u i' ITS . DATE: lig SIINA , PRINT NAME alt TITLE: -di/AL Dt l' l(��ipfLt a...hatttr$ The Commonwealth of Massachusetts Department of Industrial Accidents ' r'= � '= t Office of Investigations =.1.-t. 1 Congress Street, Suite 100 f y � Boston, MA 02114-2017 yWr, trt www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: 91- 2 '3 k U d Address: /5P I 1OOC e-d_ City/State/Zip:Si l(✓fI/f4 10c7P64hone #: 0 ' D C9 I i Are you an employer? Check the appropriate box: Business Type(required): 1. 2/I am a employer with 310 employees(full and/ 5. ❑ Retail or part-time).* F 6. D Restaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7. ❑ 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. ❑ 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. 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 work��mpensation insurance for emplo s. Below is the policy information. Insurance Company Name: /�4�,Uti b f K/7a*net ,' w nl d V Insurer's Address: Q g41 l 11 1<-e,') 61 V iJ City/State/Zip: au let r in t) ))L'i Policy#or Self-ins.Lie.4 Olt?'MO 6 k5c -OI- Expiration Date:--- /04- __ 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. I do hereby certi , under the p s and penalties of perjury that the information provided above is true and correct. Signature: C(jl/VI. (l l/ Date: � h Phone#: Df . 7Q 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 • ' ROMACAT-02 LSOUZAI ACC71121:7 CERTIFICATE OF LIABILITY INSURANCEoE(MMIDois� 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(les)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 License#1780862 finjecT Lucia Mendes HUB International New England l o, ,(508 235-2210 FAX 222 Milliken Boulevard (NC, ) IAS.No): Fall River,MA 02721 SS:Lucia.Mendes@hubintemational.com INSURER(S)AFFORDING COVERAGE NAIC 0 INSURER A:Associated industries of Massachusetts Mutual Insurance Compan 33758 INSURED INSURER B: Roman Catholic Bishop of Fall River, INSURER C Corp.Sole P.O.Box 2577 INSURER D: Fall River,MA 02722 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 ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE RAD WVD POLICY NUMBER (IMt/DD/YYYyt IMMIDD/YYYY) UNITS COMMERCIAL GENERAL LABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $ MED EXP(Any one person) $ ��- PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: t-` LIT�j�DD GENERAL AGGREGATE $ POLICY j1a LOC MAYWU �j n Q PRODUCTS-COMP/OP AGG $ $ AUT OTHER:OOMOBLE Am, �+ "� " Ea accident) LIMB $ ANY AUTO BODILY INJURY(Per person) $ AUTOS ONLY AAUUTµOSSyy�NE�Dp HEALTH DEPT, BODILY INJUpRpYt(Per accident) $ AUTOS ONLY AUTOS ONLY jteOr PERP) GE $ $ UMBRELLA LAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED RETENTIONS $ A WORKERS YE AND EMPLOYERS'UAPER BLITY STATUTE ER ANY PROPReTOR/PAr NER/VECUt)VE — 18A 07/0112018 07/01/2019 1,000,000 E.L.EACH ACCIDENT $ QFFZF�MBER EXCLUDED? N I A 1,000,000 1(�Myes NNHH)) E.L.DISEASE-EA EMPLOYEE $ If DESCRIPTION OF OPERATIONS below under 1,000,000 E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If mon space le required) RE:St.Pius X School,321 Wood Road,So.Yarmouth,MA 02664 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Yarmouth,Health Division THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED 8( 1146,Route 28 ACCORDANCE WITH THE POUCY PROVISIONS. South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) 01988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD