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HomeMy WebLinkAboutApplication and WC TOWN OF YARMOUTH BOARD OF HEALTH E APPLICATION FOR LICENSE/PERMIT-2020 *Please complete form and attach all necessary documentspppppacket. by Decceember 13.2019. Failure to do so will result in the return of dy NOTE:ALL BUSINESSES WITH LIOUOR LICENSES MUST RETURN FORMS BY NOVEMBER 13"0. ESTABLISHMENT NAME: /< G TAX ID: . LOCATION ADDRESS: �� .7 P TEL.#: 5`of-3 SdJcFs MAILING ADDRESS: a-,- /di k I- E-MAIL ADDRESS: --710,,t//`iC.C 4102/ G 6� OWNER NAME: -'1 /V it. E.4e/ CORPORATION NAME(IF APPLICABLE): %a Al,V /', te //y /".4.-4/..95,5 �2:dc_ s�5 . MANAGER'S NAME: '76 0^7 4./l t lCur/'k ' TEL.#:f ei 5-7 y,P sG MAILING ADDRESS: 7,-."--. ;Z, (Pe-- POOL CERTIFICATIONS: Z z 71 The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated D o 1 a I Pool Operator(s)and attach a copy of the certification to this form. r ;i 1. 2. T Q ,:.. Q � Pool operators must list a minimum of two employees currently certified in standard First Aid and Community -a Cardiopulmonary Resuscitation(CPR),having one certified employee on premises at all times. Please list the H coLI 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. 2. it `, 3. 4. Fz, /7 FOOD PROTECTION MANAGERS-CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food t 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. 0 , Yon must provide new copies and maintain ..—Zfile at your establishment. ..—Z1. 4 /3411 V . G 2. PERSON IN CHARGE: Each food establishment mug have at least one Person In Charge(PIC)on site during hoursotion. b� i Al:c G1. 014 Nit-llf Gi() 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. You must provide new copies and maintain file at o/ establishment. OA// 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 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 �c/o�ies and mi sin a file at your place of business. ,, / 1. �/'� / ' lZt//7 2. /011i"\ A/tc-4 /4 3. �j/61.t�./ C A 4. RESTAURANT SEATING: TOTAL# S' I LODGING: OFFICE USE ONLY 1300-e-49-0880-0( LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 5 _CABIN $55 MOTEL $110 CAMP 55 =LODGE $55 TRAILER PARK $105 —SWIMMING POOL SI 10ea. _WHIRLPOOL $110ea FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# J_0-I00 SEATS $125 &"Q1�3CONTINENTAL $35 NON-PROFIT $30 >I00 SEATS $200 _CONTINENTAL VIC. $60 02O d3a WHOLESALE $80 RETAIL SERVICE: —REBID.KITCHEN $80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 ,.ft. $50 >25,000ft. $285 VENDING-FOOD $25 =<25,i t I sq.R $150 =FROZEN sq. $40 TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE = S 185.Qp 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 newal 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.MG 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 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 COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 13,2019. 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.T. RENOVATIONS MAY REQUIRF,EA SITE PL S / DATE: /i" S-/7 SIGNATURE: �%v L� � PRINT NAME& 111LE: /(' /f/t4.16Afe///, COu''�� Rev.10/15/19 The Commonwealth of Massachusetts ' nr: =*= Department of Industrial Accidents 4'1 ? Office of Investigations =0_ 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 6 49' X/ C nu . Address: City/State/Zip$cv 1 )4f -"/ Phone#: 5.0S- 3 J S I Are you an employer?Check the appropriate box: Business Type(required): 1.JI am a employer with 1,1 employees(full and/ 5. ❑Retail or part-time).* 6. ❑Restaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7. 0 Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers'comp.insurance required] 0. ❑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. **lf 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 workelle,compensation inss ra/nce for employees. Below is the policy information. Insurance Company Name: /' / 4 G. / cc�r✓�T tile Insurer's Address: 0 6( c .$ 9.9.2 _ / 2 .2 City/State/Zip: / .�� ati,.trG. /ea d?ref Policy#or Self-ins.Lic.# /7 d® SO3 4' 7 t Expiration Date: /. 0-' e..) 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,under the pai and ena of 'aril that the information provided above is true and correct. Signature: Date: ' �� s //. -S''/ Phone#: _re,S. s V 3 SAO 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 ` ESTIMATED BILLING y MA Retail Merchants WC Group Inc. PO Box 859229-9222 CoveRisk Braintree, MA 02185 Policy Reference: 014005034637119 For Period: January 01,2019 to January 01,2020 - Division: 00000 Print Date: November 28,2018 Rating State: MA TNT Family Enterprises,Inc. 928 Route 28 South Yarmouth,MA 02664 Class Ext Class Description Rabe Payroll Manual Code Premium i 9079 Restaurant Noc 1.03 138,000.00 1,421 ( 1/01/2019 - 1/01/2020) Premium Breakdown Merit Rating: Manual Premium 1,421.00 Mod ARAP Eff Dates Rate Deviation 20.00% 284.00- .9500 04/06/2018 Inc Limits: 500/500/500 1.000X 50.00+ Subject Premium 1,187.00 Merit Rating 0.9508 1,128.00 Standard Premium 1,128.00 Normal Premium 1,128.00 Expense Constant Balance Domestic Terrorism 41.00+ Premium 1,169.00 Estimated Premium 1,169.00 DIA Assessment 1.470000% 20.00 Expense Constant Premium Paid Balance 1,189.00 InstaNtaenhu Due January 1, 2019 604.00 Due April 1, 2019 585.00 IAmount Due January 1, 2019 $604.00- Serviced by: Cove Risk Services, LLC Agent: HUB International New England PO Box 859222-9222 02360 HUB International New England - N Chatha Braintree, MA 02185 265 Orleans Rd. (800) 790-8877 N. Chatham, MA 02650 (508) 945-0446 Page 1 of 1 TNTFAMI-01 ASANZO ,4coRv CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DWYYYY) 10/16✓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(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 war nee,certificates@hubinternational.com HUB International New England PHONE FAX 265 Orleans Road (A/C No, (508)945-0446 (A/C,No):(508)945-9136 North Chatham,MA 02650 : INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Arbella Protection Insurance Company 41360 INSURED INSURER B: TNT Family Enterprises,Inc.DBA Ropes End INSURER C Family Restaurant 908 Route 28 INSURER D: South Yarmouth,MA 02664 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 ADDL SUBR POUCY NUMBER POUCY EFF POUCY EXP LTR INSD W VD (MINDIYYYYYI (MIVDD/YYYYL LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE _ $ 1,000,000 CLAIMS-MADE X OCCUR 7520075520 8/1/2019 8/1/2020 DAMMGO EoNccTuErD 100,000 MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY_ $ 1,000,000 GEM_AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE J 2,000,000 X POLICY JET LOC PRODUCTS-COMP/OP AGG_ $ 2,000,000 OTHER: AUTOMOBILE UABIIJTY (EOMBINEnDLSINGLE LIMIT) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS E BODILY INJURY(Per accident) $ HIRED ONLY _ AUTOS ONLY ((PReOPERTYtDAAAAGE accaaddeenn $ UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'UABIUTY V/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OQF�FICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $ A Liquor Liability 7520075520 8/1/2019 8/1/2020 Liquor Liability 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town Of Yarmouth THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 146 1 ow o. a m ACCORDANCE WITH THE POLICY PROVISIONS. 28 South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE rtiv ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD