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HomeMy WebLinkAboutApplication and WC .. 2 tier N In�� i P7� TOWN OF YARMOUTH BOARD OE. IE . `H NOV 1 4 L019SJ,1 5 EC" APPLICATION FOR LICEN '� TAtm. 5 p * Please complete form and attach all necessa . 144}�''I 'tilts December 13,2019. -_._.i P by 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: FE.b JIO}eI ?impale,Aiawe+on.Inn 4 Sc..-1cTAX ID: LOCATION ADDRESS:// Atm n i `I Z1' Lt)e yarmo,.4 MA TEL.#: ?8g VO- 384(.1 MAILING ADDRESS: 1105 Fall'A;vet Ave See.'�M M/ 07;7/1 E-MAIL ADDRESS: ►, '.., A .. 1' .,.1I, • earn . ,• . A V ' nos'. CI ,‘,.... OWNER NAME:\air i n9 D v,. o wyn ['n -t na c key c e_ lS Jv,c CORPORATION NAME(r1 APPLICABLE): n FF }{ a I (Prove.Arc L-1.- 1 MANAGER'S NAME:Pc enna 5'At`i\Java Af-4aylaSty TEL.#: gg.R 541,2- 35mq MAILING ADDRESS: Main S+ 7-le 28 V •-i- y,51,010 G., M POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated --Po— Operator(s) and attach a copy of the certification tcithictOrm. /� 1. SYenifla to 1 ll VOIh(M a).1a ) 2. tARY4 bel-orj . I Pool operators must list a minimum of two employees currently certified in standard First Aid and Community Cardiopulmonary Resuscitation (CPR), having one certified employee on premises at all times. Please list the 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.'Rocce,r4. 2. t$ n SA\Y1Scm 3. 8 nn a �'►A i iiv(1l (M4auna; ' 4.D\Vita Crimes 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. bi air omeS 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. { 1. gcenvms SAt ti V0. Uti--tairer4o) 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(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. 1. e'y'e T1Ybt �u.�liloun (040400o) 2. Diane, &We HEIMLICH CERTIFICATIONS: /l/ 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. i 1. mo._Su1tt 1 ut 0-1-60-s 2. 3. 4. Datit.,44-ovQ2-o6 (we)66u SP-N-048-oar RESTAURANT SEATING: TOTAL# W9-N-°`44-0'6 ®o4,0 c t — - -- - — - --E616"5e-et ofe -v, OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# INN $55 CAMP $55 j_MOTEL $110 Vs-O04 SWIMMING POOL$110ea. 2o-O66O04, I LODGE $55 _TRAILER PARK $105 LWHIRLPOOL $110ea. Zn-en-i FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 4-0-100 SEATS $125 ZO-ODZ.- CONTINENTAL $35 _NON-PROFIT $30 >100 SEATS $200 I COMMON VIC. $60 Z..0,0(8 —WHOLESALE $80 —RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 1 <50 sq.ft. $50 Z0--005- >25,000 sq.ft. $285 VENDING-FOOD $25 <25,000 sq.ft. $150 _FROZEN DESSERT $40 _TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE = $ G75-10 0 *****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. 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. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: IF 0 (qSIGNATURE: •✓" � PRINT NAME&TITLE: • • • Rev. 10/15/19 The Commonwealth of Massachusetts I. .7.7......=: l. Department of Industrial Accidents �'r Office of Investigations .. 0 1 Congress Street, Suite 100 ---�.-- Boston, MA 02114-2017 "-1.0100.. www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: g 1• • -P'CO*•r .0 _ . i. u1 •1• -r . 4 ..nC Address: ((05 F0.\1 4 ex Atst. (' 9 *A A 2 e 2-8 City/State/Zip: ,- -_s OtSy n autAk Phone #: 5o ZS` 3%-800(7.5g-i l a Sgt Are you an employer? Check the .ppropriate box: Business Type(required): 1.[i I am a employer with 2\8, employees(full and/ 5. 0 Retail or part-time).* 6. (—(_Restaurant/Bar/EatinLEstablishment 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] 8. ❑ 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.LIOther -{ *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 provAtM 'ng worker f'compensation insurance for my employees. Below is the policy information. Insurance Company Name: � h 5,A(aOCv -n61'Yi • i;013 Insurer's Address: 51/ 1-vi 1-virei AIR_ '?o a)( L/O 7Q City/State/Zip: 13 or I i (1 -voy, i MA 0) 603- d G o Policy#or Self-ins.Lic.# t/l)M Z$00 goo cjaLlq 26 y Expiration Date: 3f31 2020 Attach a copy of the workers' compensation policydeclaration page(showingthe policynumbean expiration tion 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 fme 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 pains and penalties of perjury that the information provided above is true and correct. Signatures k)4-1111" Date: i IH/1 Phone#: 50?- 33L— 3300 . 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 ''�.....N DARLDEV-01 LBROWN AC-ORD" DATE(MN/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 4/10/2019 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. II 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 endorsements). PRODUCER T Loretta Brown FBinsure,LLC FAX — _ 128 Dean Street INC, Ext):(508)824-86661240 INC,Not Taunton,MA 02780 AAS,LBrown@fbinsure.com INSURERS)AFFORDING COVERAGE NAIL X INSURERA:Arbella Protection Ins Co 41360 INSURED INSURER- Mapfre Insurance Company ,23876 FED Hotels Properties LLC ,INSURER c:AIM_Mutual_insurance Company ,33758 1105 Fall River Ave ,INSURER D:Ohio Casualty_Ins_Company— 24074 Seekonk,MA 02771 — – ---- -. 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 1I 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 LTR TYPE OF INSURANCE ,ADDL;SUBN POLICY EFF POLICY EXP INSD,MMD POLICY NUMBER IMMIDOYYYYI IMMIDOYYYY) WAIS A )( COMMERCIAL GENERAL uABILITY EACH OCCURRENCEE 1,000,000 CLAIMS-MADE X OCCUR ' DAMAGE TO RENTED 8500068374 3/31/2019 3/31/2020 ru�SEstEa ) ;$ 250+000 000 MED EXP_jAny oneperson) s 10+ PERSONAL&ADV INJURY $ 1,000,000 GENL AGGREGATE UNIT APPUES PER: GENERAL AGGREGATE - $ _ 2.000 000 POLICY X LOC Included PRODUCTS-COMP/OPAGG i_ OTHER Liquor Liab y 1,000.000 B AUTOMOBILE LIAeIUTY .--1 DSINGLE UNIT li_.__. 1,000,000 ANY AUTO BHVZZT 3/31/2019 3/31/2020 °_Bodo,INJURY(Per pe,sqn) sOVINE __ AUTOS ONLY ,,X SCHEDULED AUTOS MI p�.p�EEDp :BODILY INJURY(Per accident)_$ X;AUTCSS ONLY ';.-X AIS la 01h1LY ( PEERTY MAGE dent $ $ A X UMBRELLA LIAR X OCCUR 10.000,000 EACH OCCURRENCE !f —-- EXCESSLIAB CLAIMS MADE 4600068388 3/31/2019 3/31/2020 AGGREGATE $ 10,000,001 DED X RETENTIONS 10,000' $ CAt4D EMPLOYERS'UABIUTY NSATKIN X STI ER ATILTE ERlb YIN WMZ8008007249 3/31/2019 3/31/2020 ANF P�ROOPMREIEMTOR EXCLUDED? CUTNE -N N!A ELL.EACH ACCIDENT S 1,000,000 in ni yes ,_E_L.DISEASE-EA EMPLOYEE,t__- 1,000,000 IfDESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT+$ 1.000,000 D Excess Liability EC057913907 3/31/2019 3/31/2020 Per Occurrence 10,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached It more apace Is requhed) Umbrella Liability and Excess Liability policieslimits extend over the General Liability,Liquor Liability,Automobile Liability,and Workers Compensation policies. Regarding:Hampton Inn&Suites,99 Main St(Route 28),West Yarmouth MA 02673. ij CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Yarmouth RoYaACCORDANCE WITH THE POLICY PROVISIONS. 1146South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE , X. t8 , ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD