Loading...
HomeMy WebLinkAboutApplication and WC TOWN OF YARMOUTH ' \ Board of Health ' 1146 ROUTE 28, SOUTH YARMOUTH,MASSACHUSETTS 02664-24451 Health � "'-,�,� Telephone(508)398-2231, ext. 1241 Division Fax(508) 760-3472 1 (i-00 / STATE LICENSE NO. I27 7/4 PERMIT NO. e. O 4f 1 "O1I7 VEHICLE REG. NO. £79 91a 7 FEE: Food $55.00 Ice Cream $40.00 APPLICATION FOR LICENSES/PERMITS -2019 MOBILE FOOD SERVICE VENDOR SEASONAL ;YEAR ROUND V TAX ID EIN OR SSN) ' (� � NAME OF BUSINESS /7// /NG CGb Z BUS SS TEL.NO g#lek 7303 BUSINESS ADDRESS 3a /zte.v TOWN W ac ym ow /l /'I 7 OWNER'S NAMEfl2 Q/Q.✓�i�/1 Sw&ei.c.j �H�SOME TEL. NO.0411 s�a3 HOME/LEGAL ADDRESS 1 i 3�p '- ( sr N. %A/eve0-26?3 E-MAIL Cre-C° f -6N9/.L. e€94.11 IF MORE THAN ONE DRIVER, LIST ADDITIONAL NAMES, ADDRESSES, ETC. BELOW: (Name) (State License No.) (Exp. Date) (Tel.No.) (No. Street) (Town) (State) (Zip Code) PL ASE CHECK TYPE OF PR PUCT(S) TO BE VENDED NDWICHE ��Rpt v POTATO CHIPS V CANDY GUM SODA HOT DO v lc.r+�1 GS, POPCORN _ICE CREAM �/OTHER C-l, PLEASE LIST YOUR LICENSED FOOD PREPARATION COMMISSARY ESTABLISHMENT, AND PROVIDEAN OWNER-SIGNED LETTER CERTIFYING YOUR USE OF THIS FACILIT 5 3 (now /7 A/4//5 $/ v�dl UNDER CHAPTER 152, SEC. 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 WORKEROS COMPENSATION INSURANCE. THE ATTACHED WORKERS COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED. TOWN OF YARMOUTH TAXES AND LIENS MUST BE PAID PRIOR TO RENEWAL OR ISSUANCE OF YOUR PERMITS. PLEASE CHECK APPROPRIATE IF PAID:YES NO TURN OVER TURN OVER TURN OVER TURN OVER 11/07/18 PAGE 1 OF 2 PLEASE READ FOLLOWING RULES/REGULATIONS 1. ALL MOBILE VENDOR VEHICLES MUST BE INSPECTED AND LICENSED BY THE BOARD OF HEALTH, AND EACH DRIVER MUST BE IN POSSESSION OF A VALID STATE HAWKERS AND PEDDLERS LICENSE PRIOR TO OPERATING WITHIN THE TOWN OF YARMOUTH. 2. NO MOBILE FOOD VENDORS ARE ALLOWED AT BASS RIVER BEACH (A/K/A SMUGGLERS BEACH), SEAGULL BEACH, PARKERS RIVER BEACH, OR ON SEAGULL ROAD, WITHOUT PARKS &RECREATION DEPARTMENT APPROVAL. 3. NO VENDORS SHALL DISPENSE DRINKS IN CANS OR BOTTLES AT ANY TOWN BEACH OR PARKING LOT. 4. NO TWO VENDORS WILL BE ALLOWED INTO ANY BEACH OR PARKING LOT AT THE SAME TIME WITHOUT PARKS & RECREATION DEPARTMENT APPROVAL. 5. VENDORS ARE ALLOWED A TWENTY MINUTE STAY IN AN AREA. HOWEVER, TIME MAY BE EXTENDED IF THERE ARE PEOPLE WAITING TO BE SERVED. 6. A FEE (PLEASE CONTACT THE SELECTMEN'S PERMITS OFFICE FOR CURRENT AMOUNT)MUST BE PAID TO THE PARKS &RECREATION DEPARTMENT PRIOR TO OPERATING WITHIN THE TOWN OF YARMOUTH. SUCH FEE TO BE PAID AT THE SELECTMEN'S PERMITS OFFICE. 7. ANY VENDOR FOUND TO BE IN VIOLATION OF THE ABOVE CITED RULES/REGULATIONS WILL HAVE HIS/HER LICENSE REVOKED, AND ALL PRIVILEGES OF OPERATING WITHIN THE TOWN OF YARMOUTH SUSPENDED. 8. THESE RULES/REGULATIONS WILL BE ENFORCED BY THE BOARD OF HEALTH, PARKS &RECREATION DEPARTMENT,AND THE POLICE DEPARTMENT. f/2 PI . : •. (Date) 11/07/18 PAGE 2 OF 2 AWCERTIFICATE OF LIABILITY INSURANCE DATE(MMID°"'YY) 06/28/19 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 CONlACr NAME: Schlegel&Schlegel Ins Brokers,Inc. (NC.No.Ext): 5084714381 FAX No): 508-7714663 34 Main Street ADDRESS: schiegelinsurance@gmaii.com West Yarmouth,MA 02673 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: US LIABILITY INSURED INSURER B: PROGRESSIVE SAID INC. INSURER C: 160 HIGGINS CROWELL RD INSURER D WEST YARMOUTH,MA 02673 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 POLICY EFF POLICY EXP TYPE OF INSURANCE NW SD VD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ 50,000 MED EXP(Any one person) $ 5,000 A MGL19UD297 06/28/19 06/28/20 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY n PRO- JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ 50,000 B OWNED SCHEDULED AUTOS ONLY AUTOS 00853535 06/28/19 - 06/28/20 BODILY INJURY(Per accident) $ 100,000 HIRED NON-OWNED PROPERTY DAMAGE 100,000 AUTOS ONLY AUTOS ONLY $ (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? N!A E.L.EACH ACCIDENT $ (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ • DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) LISTED AS ADDITIONAL INSURED ON GENERAL LIABILITY AS ADDITIONAL INSURED AND WAIVER OF SUBROGATION: YARMOUTH CHAMBER OF COMMERCE CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN YARMOUTH CHAMBER OF COMMERCE ACCORDANCE WITH THE POLICY PROVISIONS. 424 ROUTE 28 WEST YARMOUTH,MA 02673 AUTHORIZED REP ©198: 20 ACORD CORPORATION. All rights reserved.