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HomeMy WebLinkAboutApplication and WC } L �t TOWN OF YARMOUTH BOARD OF HEALTH #11* APPLICATION FOR LICENSE/PERMIT-2019 *Please complete form and attach all necessary documents by December 15 2018. NOTE:ALL BUSINESSES WITH LI UORLICENSES MUST RETURN FORMS BYNOVEMBER IS`h. Failure to do so will resu tin t e return o your application packet. ESTABLISHMENT NAME:VircbO cSC.X•+zrs‘C� L,SP►/"1.eNE- TX ID - LOCATION ADDRESS:''' .1. 4\.r.xm�:'t'� or-. �; ' V'¢,., ; .la "'P�'L ' 'JMA .mt-- 1l-0 `i1 MAILING ADDRESS: \c.)U Vim -+x�..CN ptl-.C�^'-ZPo'c�`NR.y 8'\.c`-: Nom--(206- Cr-y E-MAIL ADDRESS: \ iC2NCN, e,„*" e✓%C.N. \ \CX)-C1=+c°C"`. — OWNER NAME: CORPORATION NAME(IF APPLICAP.LE):Q^voM `nGY+C>%AAi 3"c-. MANAGER'S NAME:_\apt Q:>crC,.:ate TEL.#: 6-°`''!d'.- (taro 1 i{ MAILING ADDRESS: ( oC ‘74.-vs. d�-`r POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Ope,'tor,.,s required by State law- Please list the desigi-cited Pool Operator(s)and attach a copy of the certification to ttn;s form. 1. / ./LA 2. . I . z Pool operators must list a minimum of two employees currently certified in standard First Aid and Community D O •y Cardiopulmonary Resuscitation(CPR),having one,:ertified employee on premises at all times. Please list the r- 0 employees below and attach copies of their certificatiocs to th:a form.The Health Department will not use past -4 years' records. You must provide new copies and maintain a file at your place of business. 0: :. �n L.:, k.:* 1. 2. 3. An/1' 4. H co ,j 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. VVk 2._. PERSON IN CHARGE: Q' Each food establishment must have at least one Persor;In Charge(PIE)on site during hours of operation. • 1. Ant4 2. ,.. _F 4 t,...) -„ ALLERGEN CERTIFICATIONS: All food service establishments are required to have at least one fall-time employee who has Allergen certification, as defined in the State Sanitary Code for Food Service stab"shments,105 CMR 590.009(G)(3)(a). Please attach copies of certification to this application. The Health Dc1;artment will not use past years'records. You must provide new copies and maintain a file at your establishment. I. IV /A 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 er:ployees 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. 2• 3. �1 A 4. RESTAURANT SEATING: TOTAL# N I A OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQ:.'IRED FEE PERMIT# LICENSE REQUIRED FEE PERI.:IT;# B&B $55 CABIN $55 MOTEL $110 _INN $55 CAMP $55 _SWIMMING POOL$110ea. LODGE $55 TRAILER Pi,21( $105 _WHIRLPOOL $110ea. FOOD SERVICE: G� �O LICENSE REQUIRED FEE PERMIT# LICENSE REQi1i'. D FEE PER.IiT# \Y,ICENSE REQUIRED FEE PERMIT# O� 0-100 SEATS $125 __C:.uNTINENTAL $35 rk NON-PROFIT $30 —_>100 SEATS $200 _COMMON Vit.'. $60 17 '1,1WHOLESALE $80 laaC F-lrj--t'et7S- _RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQU'RED FEE ;F'' LICENSE REQUIRED FEE PERMIT# <50 sq ft. $50 >25,000 sq ft. i VENDING-FOOD $25 =<25,000sq.ft. $150 _FROZEN DESSr;'B4h _TOBACCO $110 __,__ NAME CHANGE: $15 ' AMOUNT DUE _ $ .ap. *****PLEASE TURN OVER AND COMPL i. HER 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 X_ 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 )(i NO MOTELS AND OTHER LODGING ES'T'ABLISHMENTS 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 rot more than thirty(30)days•rad an aggregate of not more than ninety(90)days within any six(6) month period. Use of a guest unit as a reside.n a or dwelling unit shall not be considered transient. Occupancy that is subject to the collection of Room Occupancy Exci e,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.yarmouah.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 wiser/wait-ess service),must have prior approval from the Board of Health. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a: tail 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 REQUI ' TE PLAN. DATE: /0~ I 17 SIGNATU • PRINT NAME TLE: S 1 1fe r'>✓l Rev.10/23/18 The Commonwealth of Massachusetts Department of Industrial Accidents • eft Office ofI vestigations wa _if 1 Congress Street, Suite 100 4r 141Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly • Business/Organization Name: e c-� S Address: '--6-9" A\e- City/State/Zip: S• Lac-'Crv- �.-��►-iN Phone #: js% Are you an employer? Check the appropriate box: Business Type(required): 1.❑ I am a employer with 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. ❑ Office and/or Sales(incl. real estate,auto, etc.) employees working for me in any capacity. [No workers' comp. insurance required] I ❑ Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4), and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]** 11.EJ Care 4.El We are a non-profit organization,staffed by volunteers, a F with no employees. [No workers' comp. insurance req.] 12.WA ther Who , c oil a (tib *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: Insurer's Address: A41-- City/State/Zip: Policy#or Self-ins. Lic. # Expiration Date: 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 per.hies 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 cut,; of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify, under ins and penalties of perjuty that the information provided above is true and correct. Signature: — Date: l U-1)s--�`� P e#: c�Fl - et. 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.rvass.gov/dia ® DATE(MM/DD/YYYY) AR LF CERTIFICATE OF LIABILITY INSURANCE 1/31/2020 1/21/2019 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 LOCKTON COMPANIES CNAO NTACT 2100 ROSS AVENUE,SUITE 1400 A/C Nt o FAX(A/C,No): DALLAS TX 75201 E-MAIL 214-969-6700 ADDRESS INSURER(S)AFFORDING COVERAGE NAM# INSURER AACE American Insurance Company 22667 INSURED BBU,Inc.on behalf of itself and INSURER s:Indemnity Insurance Co of North America 43575 1359436 U.S.subsidiaries including INSURER C:ACE Fire Underwriters Insurance Company '0702 (see attached addendum) ' INSURER D: _ 255 Business Center Dr. Horsham PA 19044 INSURER E: INSURER F: COVERAGES * CERTIFICATE NUMBER: - 13797149 REVISION NUMBER XXXXXXX 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 INSD SUER LTR POLICY NUMBER MMIDDIYYYY) (MMD/YEXPYYY) LIMITS INSD WVD I(, A X COMMERCIAL GENERAL LIABILITY Y Y HDO G71212117 1/31/2019 1/31/2020 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED I CLAIMS-MADE X I OCCUR PREMISES Ea occurrence) $ 1,000,000 MED EXP(My one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GE 'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 10,000,000 POLICY 'SCOT- X LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ A AUTOMOBILE LIABILITY N N ISA H25277272 1/31/2019 1/31/2020COMBINED SINGLE LIMIT (E $ a accident) 5,000,000 X ANY AUTO BODILY INJURY(Per person) $ XXXXXXX OWNED SCHEDULED BODILY INJURY(Per acddent) $ XXXXXXX HIRED ONLY N $ XXXXXXX HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY , AUTOS ONLY (Per accident) $ XXXXXXX UMBRELLA LIAB OCCUR NOT APPLICABLE EACH OCCURRENCE $ XXXXXXX EXCESS LIAB CLAIMS-MADE AGGREGATE $ XXXXXXX DED RETENTION$ _ $ XXXXXXX WORKERS COMPENSATION N , ) 1/31/2019 1/31/2020 X STATUTE C R__ A AND EMPLOYERS' WLF C65434040 CAaMA LIABILITY ( B ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N WLR C65434003(_AOS) 1/31/2019 1/31/2020 E.L.EACH ACCIDENT $ 1,000 000 C OFFICER/MEMBER EXCLUDED? n N/A SCF C65434088( I) 1/31/2019 1/31/2020 — - - (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If es,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 1 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space is required) Certificate holder includes:Maines Paper&Food Service,Inc.its subsidiaries,affiliates,directors,officers,agents,customers,and employees. CERTIFICATE HOLDER CANCELLATION See Attachments 13797149 Maines Paper and Food Service,Inc. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 101 Broome Corporate Parkway THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELJERED IN y ACCORDANCE WITH THE POLICY PROVISIONS. P.O.Box 555 Conklin NY 13748 AUTHORIZr_a REPRESENTATIVE rs. ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logs,are registered marks of ACORD Attachment Code:D559175 Master ID: 1359436,Certificate ID: 1379 i149 INSURED: BBU, Inc.on behalf of itself and U.S.subsidiaries including(see attached addendum) 255 Business Center Drive Horsham, PA 19044 USA The following are Named Insureds under the GL and Auto policies: Acelerada,LLC Advantafirst Capital Financial Services,LLC Arnold Sales Company LLC Bays Bakery Inc. Bimbo Bakeries USA,Inc. Bimbo Bakeries Distribution Company,LLC Bimbo Foods Bakeries Distribution,LLC Earthgrains Baking Companies,LLC Earthgrains Distribution,LLC(fka Sara Lee Distribution) Stroehmann Line-Haul,L.P. Tia Rosa Bakery of Ohio,Inc. Wholesome Harvest Baking,LLC Bimbo QSR US,LLC Bimbo QSR Ohio, LLC Bimbo QSR Chicago,LLC Olympic Freightways,LLC The New Bakery Transportation Company,LLC Bimbo QSR Chicago Logistics,LLC The following are Named Insureds under the WC policies: Bays Bakery Inc. Bimbo Bakeries USA,Inc. Wholesome Harvest Baking, LLC Bimbo QSR US,LLC Bimbo QSR Ohio,LLC Bimbo QSR Chicago,LLC Olympic Freightways,LLC The New Bakery Transportation Company,LLC Bimbo QSR Chicago Logistics,LLC