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HomeMy WebLinkAboutApplication and WC TOWN OF YARMOUTH BOARD OF HEALTH .- 636 APPLICATION FOR LICENSE/PERMIT-2020 *Please complete form and attach all necessary documents by December 13,2019. Failure to do so will result in the return of your application packet. NOTE:ALL BUSINESSES WITH LIOUOR LICENSES MUST RETURN FORMS BY NOVEMBER 15'". ESTABLISHMENT NAME: L 0/_A'rj PJ LIQUORS, //VO. TAX ID•_ LOCATION ADDRESS: ,fl I (14 i it Sr.. jI. f A-itin0U TEL.#: „TO 1' :7-75:5T,JO MAILING ADDRESS: ad Sp#rNG0 /.U. /gf' A/i'Yldv�-t E-MAIL ADDRESS: y tvr4 o 4C-, V ILL kei t Cyd .LD/y) OWNER NAME: A-,PT7/44/IQ Al L.-14.--k CORPORATION NAME(IF APPLICABLE): t-i K es L i162.01ICS /NC MANAGER'S NAME: (,/¢I (r t<t a*c N t TEL.#:' Ti'i-513D 0 MAILING ADDRESS: in I 41 i r-t Si— IAA k pfber i vv-,/1 mpg 0,, L,7 3 POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s)and attach a copy of the certification to this form. 1 2. Pool operators must list a minimum of two emplo et tly certified in standard First Aid and Community Cardiopulmonary Resuscitation(CPR),having on c i is , aployee on premises at all times. Please list the m Z , employees below and attach copies of their certifi s o ' form.The Health Department will not use past m c �ii years'records. You must provide new copies a d m i tans a file at your place of business. r < l5 l --I .� 1. 2. = c o Gil 3. 4. 0 N (`; rn c Ignl --I CD "� 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. 2. i: PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. 1. 2. ALLERGEN CERTIFICATIONS: .:f, ' \. All food service establishments are required to t 1 one full-time employee who has Allergen certification,' as defined in the State Sanitary Code for Food Se i e blishments,105 CMR 590.009(G)(3)(a). Please attach n. copies of certification to this application. The H aith partment will not use past years'records. You must provide new copies and maintain a file at your establishment. 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 copies and maintain a file,at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# 130>s4F- 00328-44, OFFICE USE ONLY 804`tp,-14-OS'rP-OIo LODGING: LICENSE REQUIRED FEE PERMIT it LICENSE REQUIRED FEE PERMIT Sl LICENSE REQUIRED FEE PERMIT S B&B $55 CABIN $55 MOTEL $110 INN $55 —CAMP $55SWIMMING POOL$110ea.. _LODGE $55 =TRAILER PARK $105 _WHIRLPOOL $110ea FOOD SERVICE: LICENSE REQUIRED FEE PERMIT it LICENSE REQUIRED FEE PERMITS LICENSE REQUIRED FEE PERMIT S 0-100 SEATS $125 _CONTINENTAL $35 NON-PROFIT $30 >100 SEATS $200 _COMMON VIC. $60 WHOLESALE $80 RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEEERMIT S LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# L<50 sq.ft. $50 +-d03 >25,000ft. $285 PENDING-FOOD $25 <25,000 sq.ft. $150 _FROZEN DESSERT $40 TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE = $ U O.Oini *****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 J 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 V 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 640,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 ESTABLISHM , MOTEL OR POOL ' •AINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND OVED BY THE BO '41400 HEALTH PRIOR TO COMMENCE ENT. RENOVATIONS MAY RE PI DATE: 1 1 SIGNATURE: PRINT NAME&TITLE: Ag"u.o k .l res/den 14--- Rev Rev.10/15/19 The Commonwealth of Massachusetts Department of Industrial Accidents mik;R von" Office of Investigations 1 Congress Street, Suite 100 =SO= ' Boston, MA 02114-2017 41' www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Address: 5 1 ( t h 5T• City/State/Zip: -\`tV2m U(P7 4IArm Galo73Phone #: :0i -T7 5 0() Are you an employer?Check the appropriate box: Business Type(required): 1.)0 I am a employer with pl U employees (full and/ 5. 141 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] 8. ED 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]** 11.0 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'compensation insurance for my employees. Below is the policy information. Insurance Company Name:L'Ne its(c.cfyore S /iii, -. ekti1 cC.ka n - 10 C G i d t) Insurer's Address: P41a ^ e papa City/State/Zip: Ya t✓11 Y t' m1R 6, a 1 c 5 Policy#or Self-ins. Lic. # (d i 1J OD 106-1 b o I Expiration Date: /3/31 p Attach a copy of the workers' compensation policy declaration page(showing the policy number and xpiration 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, u er the pains and peilitir, of perjury that the information provided above is true and correct. Signature: Date: /1 //c2-- Phone#: SO —7 5 - / 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 I ���� LUKELIQ-01 COMMERCIAL Ate.. O® CERTIFICATE OF LIABILITY INSURANCE DATE(MMlDD/YYYY) 11/8/2019 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 rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: WM.F.Borhek Insurance Agency PHONE FAX 311 Plymouth St (A/c,No,Ext):(781)293-6331 I 7 Halifax,MA 02338 E-MAIL (ac,Na►:( 81)293-2171 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Continental Western Insurance 10804 INSURED INSURER B:Massachusetts Retail Merchants 34355 Luke Brothers,Inc.Etal INSURER C: 511 Main St 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. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LTR INSD WVD POLICY NUMBER IMM!DD/YYYY) IMM/DD/YYYY) UMITS A X COMMERCIAL GENERAL UABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR CPA5297982 7/15/2019 7/15/2020 DAMAGE TO RENTED 300,000 PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY 1,000, • 000 GENL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: Liquor 1,000,000 AUTOMOBILE LIABILITY Ea ac $ cN eD SINGLE LIMIT $ • ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTEO�S ONLY _ AUTOS WN D BODILY INJURY(Per accident) $ AUTOS ONLY _ AUTOS ONLY (Per accident)AMAGE $ $ UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ _ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ B WORKERS COMPENSATION X STATUTE ETH $ AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N 0140010598001 1/1/2019 1/1/2020 500,000 OFFICER/MEMBER EXCLUDED? N/A E.L.EACH ACCIDENT $ (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES `ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Location:511 Main St West Yarmouth MA 02673 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 1146 Route 28 ACCORDANCE WITH THE POLICY PROVISIONS. South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD