Loading...
HomeMy WebLinkAboutApplication and WC C'4461 'YRECEIVED TOWN OF YARMOUTH BOARD OF HEALTH APPLICATION FOR LICENSE/PERMIT -2018 47:41V2 Y "�4 2019 * Please complete form and attach all necessary documents by Dece ber 15, 2017. Failure to do so will result in the return of your application p ckeHEALTH DEPT. ESTABLISHMENT NAME: Old <0h1s (olc€e TAX ID: LOCATION ADDRESS: LiRT ag t *vim ocAl TELA-7--)4 — p•- S 338 MAILING ADDRESS: 1 O!o Mc' Ficw.o ' 42ri(fe !j, �G4 O7&Lfk ( * E-MAIL ADDRESS: OWNER NAME: fr\a.v V COr l i55 CORPORATION NAME (IF PPLICABLE): de).de). &I y5 Cofr e LL( MANAGER'S NAME: .cf� Coe LS TEL.#:S'Og 5.-2 0058 MAILING ADDRESS: &yi S k j-kc ct, MA 0 4 S- POOL POOL CERTIFICATION : The pool supervisor must be c• 'fled as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) and attach a copy • he certification to this form. 1. 2. Pool operators must list a minimum of two empl• -es currently certified in standard First Aid and Community Cardiopulmonary Resuscitation (CPR), having one c- ified employee on premises at all times. Please list the employees below and attach copies of their certifications . his form. The Health Department will not use past yearsrecords. You must provide new copies and mainta : • 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. /-� (�or/FS S 2. /11/ y PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. /4.* (0 r/,SS 2. /Jelly Sfree 'e 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. I4'1 � �r1�sS 1. 2. Woi'ter Pep 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. k/aLOr 2. 3. 4. 'J RESTAURANT SEATING: TOTAL# �I a 60aci-3291 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: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 1 0-100 SEATS $125 ofq-6-43 CONTINENTAL $35 NON-PROFIT $30 _>100 SEATS $200 I COMMON VIC. $60 ig--OQq WHOLESALE $80 —RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 _<25,000 sq.ft. $150 _FROZEN DESSERT $40 TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE = $ /65.00 *****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. E 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, 2017. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, OTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND VED BY T BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY ' U ' _ 'LAN. DATE: 5^z-y-r, SIGNATURE: PRINT NAME &TITLE: tit/WK G x/(53 Rev. 10/12/17 The Commonwealth of Massachusetts ---- ---�- Department of Industrial Accidents t `=_.L' _!,I Office of Investigations 8 _ 1 Congress Street, Suite 100 Boston, MA 02114-2017 ik,k,,,,„--LF www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information �, Please Print Legibly Business/Organization Name: V ((/1 ` 1) S 6 e• C i. ,G- old_ etNet1 'S p co - •e, vuS�2 LIU Address: l �� We,5 yairm O ) City/State/Zip: W . 'a( (3 O J ' \ Phone #: SO8 %7 CS8 Aro,an employer?Check the appropriate box: Business Type(required): , 1. ''—I am a employer with l2 employees(full and/ 5. ❑ Retail or part-time).* 6. Restaurant7Bar/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. Li Non-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.] 12.0 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'co compensation insurance for my employees. Below is the policy information. Insurance Company Name: ]y y a1'c I A � y Insurer's Address: 190 y C r(q0 t City/State/Zip: [' O/4�(� ) V V I k— 6 X6 Policy#or Self-ins. Lic. # we.e s- Z(-7 S Expiration Date: 6— 1 a6 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 certify, 5 the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: 5 aa---- 19 Phone#: 568 "Q b 4/808 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 Client#:766820 2OLDKI ACORD.. CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 05/22/2019 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 any rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT ME: Joanne Sullivan NA The Hilb Group of N.E.dba PHONE 508 775-1620 I ac 508 778-1218 (AIC,No,Ext): 1 WC,N )r-_... Dowling&O'Neil Insurance Agy E-MAIL sullivan doins.com P.O.Box 1990 ADDRESS: jsullivan@doins.com MA 02601 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Continental Casualty Company 20443 INSURED INSURER B:CNA Insurance Companies 20478 Old Kings Coffee,LLC 540 Main Street,STE 18 INSURER C: Hyannis,MA 02601 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. INSR TYPE OF INSURANCE ADDLSUBR POLICY EFF I POLICY EXP LIMITS LTR---------_.-_--- INSR MDPOLICY NUMBER (MMlDD/YYYY) (MMIDD/YYYY A X COMMERCIAL GENERAL LIABILITY B6025207549 05/27/2019 i 05/27/2020 EACH OCCURRENCE I$1,000,000 Ep _ . CLAIMS-MADE XJ OCCUR PREMISES(EaEocccu rence) $300,000 MED EXP(Any one person) '$10 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: j GENERAL AGGREGATE $2,000,000 ____� POLICY i— JECOT X I LOC PRODUCTS-COMP/OP AGG $2,000,000 I OTHER: -_— - — $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) I$ I ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident)i$ AUTOS ONLY _ AUTOS I$ _. HIRED NON-OWNED PROPERTY DAMAGE T AUTOS ONLY _ AUTOS ONLY (Per accident) , $ B XI UMBRELLA LIAR1 X OCCUR 6025229406 06/01/2019106/01/2020 EACH OCCURRENCE $1,000,000 EXCESS UABCLAIMS-MADE AGGREGATE $1,000,000 I f DED I I RETENTION$ $ WORKERS COMPENSATIONj PER ERH- B YIN WC625207552 06/01/co-iv106/01/2020 X ;STATUTE I ER 1 AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE I E.L.EACH ACCIDENT $1,000,000 'OFFICER/MEMBER EXCLUDED? L N J N/A I (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under I DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMITI$1,000,000 I I DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Operations performed by the named insured subject to policy terms and conditions. CERTIFICATE HOLDER CANCELLATION Town Of Yarmouth Health SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Department ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 South Yarmouth,MA 02664 AUTHORIZED REPREESS�ENTATIIVyE�)1ar ©1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) 1 of 1 The ACORD name and logo are registered marks of ACORD #S236110/M236107 JRS