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HomeMy WebLinkAboutApplication and WC ,f al TOWN OF YARMOUTH BOARD OF HEALTH _ ' APPLICATION FOR LICENSE1PERMIT-2019 *Pleaseform and attach all_ documents by NOTE:ma t BUSINESSES'completew*7TH resat in return appSg.f MUSTRcatURRN El 13 packet ESTABLISHMENT NAME:(r"-/ .--6.1.- T/4 C&OG,t-Y, -Tl�rgrlrAX ID- ' ' LOCATION ADDRESS: 3R3 `f,/1t uTT <3b'/G,.+est yAlvsktur-REL.#: 4774-40/ MAILING ADDRESS: E-MAIL ADDRESS: OWNER NAME: 1,/ Sf" yt#lvn't7 i' edWCeltGi(b&✓r,t c/OA Act, CORPORATION NAME(IF APPLICABLE): 4f MANAGER'S NAME: J=_ ^ !'.- --------7- . �.-, -Nu , TEL.#: A 0T 7751-' MAILING ADDRESS: 3t3 /27 L. — est A' (-occ7li &IA (l-6 7-4 POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated = s Pool Operators)and h a copy of the certification to this form. m ' • �� D ()„ = G7 Pool operators must list a minimum of two employees cluvently certified in standard First Aid and Community O ` res Cardiopulmonary Resuscitation(CPR),having one certified employee on at all times. Please list the v L employees below and attach copies of their certifications to this form.The He Department will not use past -1 CEJ years records. You m provide new copies and maintain a the at your place of business. 1. 4I2. 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. C Please attach copies of certification to this application. The Health Department will not use past years'records. Yon must provide new copies and maintain a file at your establishment. w,`j 1 re- c�-j- ) j/9 V 1. -7: 5)1'9-v' VP rG Crrh;-* 2. '-'1,'-f.--' 07-s) )cc,,--,ok` / s. 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(GX3Xa). Please attach copies of certification to this application. The Health Department will not use past years'records. Yon 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 yourees trained in anti-choking procedures below and attach copies of employee certifications to this form. TheemHealth will not use past years'records. file You must provide new copies and maintain a at your phare of busiesess. 1. �ar�l�G., - �0 1 ` b)/,cc.- ' 2. l<ren ---All, 3. .P,-- S 1,.-, a 0 ti 4. RESTAURANT SEATING: TOTAL# <�, BO 14-Ets-4500—b Li OFFICE USE ONLY LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# BGE $55 CABIN $55 MOTEL alio $55 CAMP $55 =SWIMMING POOL silos $55 =TRAILER PARK $105 WHIRLPOOL $110ea FOOD SERVICE: FEE LICENSE REQUIRED $ F 25 PERMIT# Ll „AWED L $3 PERMIT# LICENSE ROFIT Ep FEE TAM? ®>100 SEATS $200 COMMONVIIC. $60 `4-WHOLESALE� 1530 $80 RETAIL SERVICE: —REBID.KITCHEN SE LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <S0"O. $50 >25 000 q,1t $285 VENDING-FOOD$25 -25,000 sq.ft. $150 FRb7EN DESSERT$40 TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE = S 3O.QQ 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) prior to opening.PLEAS: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 p mons,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. 1 CATERING POLICY: Temporaryeoe who Food caters Sewithin Application the Town fofYarmouth m 72 hours must notify the Yarmouth Health Department film the ired Departmt,or from the Town's website at www,yarmouttma.us under Health Department,Dow prior to the catered event These fonts cann Departat ment FROZEN DESSERTS: Frozen desserts must be tested by a State certified lab prior to opening and monthly thereafter,with sametresults submitted to the Health Department Failure to do so will result in the suspension or revocation of your Frozen a 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 COMPLE i Ell 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.IOnYIE The Commonwealth of Massachusetts �_–•_ Department oflndustrial Accidents -..7 141) ._= ../ Office oflnvestigations '�_ I Congress Stree4 Salle 100 -_=,,=_- Boston,MA 02114-2017 ' www.mass.gov/die ' Workers' Compensation Insurance Affidavit: General Businesses Mnncant Information Please Print Legibly Business/Organization Name: � �%�r�a�X24 -c) `6,/,.-,, el/,/,/: I) Address: g,k? i . C City/State/Zip: �;ci /°4/A:„/-A, AO- 'Phone#: �-/,�'-?21 P �'�/ Are nus an employer?Check appropriate box: Business Type(required): 1. I am a employer with employees(full and/ 5. 0 Retail or parttime).* 6. 0 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• iffNon"prom 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.❑Health Cane 4.❑ We are a non-profit organization,staffed by volunteers, with no employees.[No workers'comp.insurance req.] 12.❑Other *Any applicant that checks box#1 must also fill out the secdoo below showing than workers'compensation policy informed= "If the corporate offices have exempted themselves,but the=potation hes other employees,a workers'compensation policy is tequmed and such an organization should check box#l. Ian an employer that is providing wo 'ern inmraatee for my employees. Below is the policy information. 1 Insurance Company Name: t't v' 1'0 IA4"`V`"l— Inatuers Address: k', 11 p/,� 5 t City/State/Zip: 5 P A e U�PvA A MI d i e s " / -` v Policy#or Self-ins.Lic.# 40"�5 k ' Expiration Date: Attach a copy of the workers'compensation policy decoration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MOL 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 cert((y,under the pabus and penalties of perjury that the information provided above is true and corcorrect.ee Sigthature: J L, /4. i „ Date: /JA 3 J/ Phltit#: 9& 27 C cscjI Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Inning 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.mea.pw/dia _--""", WESTY-1 OP ID:DT ACORU' DATE(MNYDD/YYYY) Ar....•--- CERTIFICATE OF LIABILITY INSURANCE 11/19/2018 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 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 508-620-6200 COTACT George Hulme Fitts Insurance Agency,Inc. PHONE508-620-6200 FAX 508-481-0227 2 Willow Street,Suite 102 (AIC,No,Ext): I(AIC,No): Southborough,MA 01745-1020 titan:GHuIme@Fittslnsurance.com George Hulme INSURERS)AFFORDING COVERAGE NAIC# INSURER A:Twin City Fire Insurance Co. Z29459 INSURED West Yarmouth UCC Church INSURER B: 383 Route 28 West Yarmouth,MA 02673 INSURER C INSURER D: 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. ILTR TYPE OF INSURANCE IIMS0 POLICY NUMBER (MW CYryyyyl I POUNpUDONYYh LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR DAMAGE TO RENTED $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GE AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PET LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE UABIUTY ( Mc ED Ea i en)INGLE LIMIT $ ANY AUTO BODILY INJURY(Per person) -$ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(PeraccidenQ$ _ HIRED NON WNED PROPERTY DAMAGE _-_ AUTOS ONLY AUTO ONLY (Per ) -_— $ - ^,a-- -------- $ 3 `� UMBRELLA UAB OCCU' EACH OCCURRENCE _- $ `-' 1 EXCESS LIAR CLAIMS MADE ��^ - -- _-_-- - ......_._ AGGREGATE $ v DED RETENTION$ ' �. _.. $ +A ''WORKERS COMPENSATION *: ' PER OERH AND EMPLOYERS'LIABILITY ,/N dr 08WECNN5968 y 10/01/2018 10/01/2019 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE ,a E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A i - -- -- ---- - - - (Mandatory in NH) ( E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under '' `.^. __--_--- �..� DESCRIPTION OF OPERATIONS below �' .' '., E.L.DISEASE-POLICY LIMIT $ 1,0��,�00 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION TOWNYAR SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS. Route 28 S.Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE I .94. r`7: Cts ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD