Loading...
HomeMy WebLinkAboutApplication and WC tl Souiin yacr„, ill,m / a17 gat ' 19 7 OWN OF YARMOUTHI; 1 • 'I I I HEAL ' '' t018 11 1 ��,' ' APPLICATI I 1 R LICENSE/PERl I i 2 I 9�'. s`` -'(Il _ * Please complete form and attach all necessary documen - ; :", 1,, ; 1 NOTE:ALL BUSINESSES WITH LIOUORLICENSES MUST REM' r it NOVEMBER Ir. Failure to do so will result in the return of your a plication packet. ESTABLISHMENT NAME: ./A of 0-PXle a\ aO(f, 1:1-1(D1 TAX ID: LOCATION ADDRESS: LH 1 �t t-t� t. TEL.#:`o�3_ ii iv - WO(( MAILING ADDRESS:(00 J Ss(on -1 . , 1xicct(-eti vi We, IN 37(7- E-MAIL ADDRESS:-(ax beerar w, \ celiiie 0 dopa.4--9 ileca I, c twi OWNER NAME: 7C>P-\e- ..LG CORPORATION NAME (IF APPLICABLE): 1)(7 Plot , I ,1 i_i— , MANAGER'S NAME: TEL.#: Co (GT C y(X MAILING ADDRESS: WO AltiQuV1 Qid,t j l (70061 I JAA\ei ; -pv -?o?2- POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated —___-_-Pool flperator(s)-and_att-ach a copy of the certification to this form. 1. N/k 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 yearsrecords. You must provide new copies and maintain a file at your place of business. 1.1N 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. 1\11Pt - NO Ma 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. 1. 1\1(k - No iv,C.E'r 2. ALLERGEN CERTIFICATIONS: All food service establishments are required to have at least one full-t —-ation, as defined in the State Sanitary Code for Food Service Esta,lishmen Vendor#352773 / attach copies of certification to this application. The Health Department Invoice#20191776704BL9 / must provide new copies and maintain a file at your establishment. Batch#16643 $ 150.00V r 1\li1. k - 1\a �€tJiCei 2. HEIMLICH CERTIFICATIONS: Vendor#352773 `/ All food service establishments with 25 seats or more must have Invoice#201917767TOBCITYI0 7 eimlich Maneuver on the premises at all times. Please list your employee Batch#166430w and attach copies of employee certifications to this form. The Health $ 110.00 V ecords. You must provide new copies and maintain a file at your plact 1. MI - NiO ‘N/A1 ith 2. 3. 4. RESTAURANT SEATING: TOTAL# 00 -1?-41 SS_DZ 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 SWIMMING POOL$110ea. _LODGE $55 _TRAILER PARK $105 _WHIRLPOOL $110ea. 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 sq.ft. $ I >25,000 sq.ft. $285 VENDING-FOOD 2 1 <25,000 sq.ft. 50 1Q-01D =FROZEN DESSERT $40 1 TOBACCO ,' ',110 ,M,Soria. NAME CHANGE: $15 NOV✓RECEIVED 13 2018 AMOUNT DUE = $ 260.00 *****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.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 REQU RE A SITE PLAN. DATE: \ j `U SIGNATURE: PRINT NAME&TITLE: Sia s±. Rev.10/23/18 The Commonwealth of Massachusetts Department of Industrial Accidents vii Office of Investigations 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/Organization Name: e, L l7 - t1-Q r. • ! a f'e (-17C9-7) Address: City/State/Zip: ( od Qift c ����d� 31012 Phone #: (Q l S (1000 Are you an employer?Check the appropriate box: Buss Type(required): 1. I am a employer with g (0 employees(full and/ 5. Retail or part-time).* 6. 0 Restaurant/Bar/Eating Establishment 2.-0 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] S• ❑ Nor-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.❑ 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 *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 my employees. Below is the policy information. Insurance Company Name: AOI , lv i Can Vl a ra v1Ce (0 W1 p 3 irl Insurer's Address: G/, L( G e trh ill B AV C ? City/State/Zip: N \li'l\\ T(\Y 1 - Policy#or Self-ins.Lic.# \1\11,A O V`1 l!/LJ'Q Expiration Date: 2- ( 0 ` 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 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 certify,u 'er the pains and penalties of perjury that the information provided above is true and correct Signature: L1 \cla0T Date: ( J (q3 Phone#: 15 ` J '64000 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 1 AR a CERTIFICATE OF LIABILITY INSURANCE Page 1 of 1 02/`09/20 8 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 CONTACT Willis of Tennessee, Inc. PHOS c/o 26 Century Blvd. (ANO NO 877-945-7378 HONE FAX NO) 888-467-2378 P.O. Box 305191 E-MAIL Nashville, TN 37230-5191 AnnRFSS certificates@willis.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: ACE American Insurance Company 22667-001 INSURED Dollar General Corporation INSURER B: Berkshire Hathaway Specialty Insurance Co 22276-001 & Its Subsidiaries & Affiliates INSURER C:ACE Fire Underwriters Insurance Company 20702-001 100 Mission Ridge Goodlettsville, TN 37072 INSURER D: INSURER E: I INSURER F: COVERAGES CERTIFICATE NUMBER:26085707 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 1MTH 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 ITR TYPE OF INSURANCE INSD wvn POLICY NUMBER (MM/DD/YYYYI IMMlDDIYYVVI LIMITS A X COMMERCIAL GENERAL LIABILITY XSL G27874678 2/10/2018 2/10/2019 IEAACCHHGGOEFCTCURRENCE $ 500,000 CLAIMS-MADE X OCCUR PFZEMISESQEaoccurence) $ 500,000 X SIR $750,000 MEDEXP(Anyoneperson) $ PERSONAL&ADV INJURY $ 500,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 20,000,000 PRO- X POLICY JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED — AUTOS ONLY .. AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE — AUTOS ONLY AUTOS ONLY (Per accident) $ $ B X UMBRELLA LIAB X OCCUR 47-UMO-303309-02 2/10/2018 2/10/2019 EACH OCCURRENCE $ 5,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $ 5,000,000 DED RETENTION$ $ A WORKERS COMPENSATION WLR C64625809 2/10/2018 2/10/2019 X PER OTH- AND EMPLOYERS'LIABILITY Y/N STATl1TE FR C ANY PROPRIETOR/PARTNER/EXECUTIVEI IN/A SCF C64625810 2/10/2018 2/10/2019 E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? A Mandatory in NH) WCU C64625834 2/10/2018 2/10/2019 E.L.DISEASE-EA EMPLOYEE $ 1,000,000 if yes,describe under _ --..- - -DESCRIPTION OF OPERATIONSbelow--_ __ _ El nISFASF'POLICY.LIMff ,$ _.._1,0_0D,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) DOLGENCORP of TX, Inc. is a non-subscriber to the Workers' Compensation System in the State of Texas and as such is not afforded benefits by the Workers' Compensation policies referenced herein in Texas only. Covers all cities/counties within the following states: AZ, CO, IL, KS, MA, MN, NH, UT, VT, ME, ND and OR CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE DG Retail LLC 100 Mission Ridge '� Goodlettsville, TN 37072 i / Coll:5178921 Tp1:2199947 Cert:2:085 07 ©1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD