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HomeMy WebLinkAboutApplication and WC Florio, Mary Alice From: Florio, Mary Alice Sent: Tuesday, November 19, 2019 2:23 PM To: 'vishal_72176@yahoo.com' Subject: 2020 License Application -YP Village Store Good afternoon. I was processing the application for the Yarmouthport Village Store which you submitted this morning,and I saw that I had left off the Food Service (0-100 seats) license charge. I only had charged for the Retail Food Service and the Tobacco Sales,totaling$260.00. The Food Service fee is an additional$125.00. I apologize for the inconvenience, but would you please submit the additional$125.00 fee owed at your earliest convenience,so that I may finish processing your application? Thank you. MaryAlice Florio Principle Office Assistant Yarmouth Health Division 1146 Route 28 South Yarmouth, MA 02664 508-398-2231,ext. 1241 NOV 19 2019 HEALTH DEPT. 1 '''`!2 _fLAtVaTOWN OF YARMOUTH BOARD-Or ' I ALT I v - 9 /019 APPLICATION FOR LICENSE/P `' 5 - 0 J h 0 * Please complete form and attach all necessaey 1 mnDe.em, •, ' i� 'A.T Failure to do so will result in the return of your application pac et. NOTE:ALL BUSINESSES WITH LIOUOR LICENSES MUST RETURN FORMS BY NOVEMBER is'''. ESTABLISHMENT NAME:ya r ou4 f l pexfi if,`11 cid e &)--o 7r - TAX ID: $/— LOCATION ADDRESS: 330 Rou/-e 614 ti atrinolitivoYf• mil o263c TEL.#: S° -A62-2,5tt, MAILING ADDRESSue Route. 6 A- '�1 anrma -l-ii()O t) rc14 1 2& c E-MAIL ADDRESS: "5)�0.4_, x-213-6 ca L(a:/,oa_ Ga rn OWNER NAME: (/i 6bed S))W4'I 4 CORPORATION NAME (IF APPLICABLE): Neu LIcarmau+Pn Go -P- MANAGER'S NAME: U t J- L. S h c.l k)4 TEL.#: MAILING ADDRESS: 3 Pai ndc, i ) &/ , PAISPS-Idc4-e7 }716} O26WV 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 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. 2. 3. 4. 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. 2. 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: 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. 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# 501AF—eco-1.3e5---a4 LODGING: OFFICE USE ONLY 60 "1'P-V.-17396-0-1 LICB&B $55 ENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# INl�1 $55 —CAABI $55 55 _MOTEL $110 _LODGE $55 =TRAILER PARK $$ 5 —SWIMMING POOL$110ea. WHIRLPOOL $110ea. FOOD SERVICE: — 1/CENSE REQUIRED FEE PERMI LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 2O-O _CONTINENTAL $35 LICENSE REQUIRED FEE PERMIT# _>I00 SEATS $200 —COMMON VIC. $60 _NON-PROFIT $30 WHOLESALE $80 RETAIL SERVICE: —RESID.KITCHEN $80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sqq.ft. $50 >25,000 sq.ft. LICENSE REQUIRED FEE PERMIT# Z<25,000 sq.ft. $150 _2�_� =FROZEN DESSERT$$40 VENDING-FOOD $25 LTOBACCO $110 NAME CHANGE: $15 AMOUNT DUE = $ 00 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** t y 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 ice' 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 REQ:DIRE ' •ITE PLAN. DATE: I H S"r I SIGNATURE: r_ u-- PRINT NAME&TITLE: Ui 9& P SGI i l4 C Pies!c 1(341.0 Rev.10/15/19 The Commonwealth of Massachusetts Department of Industrial Accidents 1.000. Office of Investigations �.V —v !_4 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: Neu) licerenoubs e yty2sinat-f j Address: 336 1;6* 60 City/State/Zip: Itifornixthipzeti Yom 021 Phone#: 50&• 2-2 960 Are you an employer? Check the appropriate box: Business Type(required): 1.5rI am a employer with employees(full and/ 5• TA1 Retail or part-time).* 6. 0 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. ❑ 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]** 4.❑ We are a non-profit organization,staffed by volunteers, 11.❑ Health Care 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: f f ir/LI . ,- riv,&t W C'Cmu C. & H IDl(cznrTL, Insurer's Address: ( .0.l3ox • O3O City/State/Zip: U22 co mi m 62r3 Policy#or Self-ins.Lic.# (D i 2-too 5 O I2.0L 19 Expiration Date: i—) 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 pains and penalties of perjury that the information provided above is true and correct. Signature: —"-"IF;41111.' Date: l/— , 4 Phone#: cOk-c 331-Ki 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 a�RD CERTIFICATE OF LIABILITY INSURANCE DATE(5/2°°g'' 11/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 wwmcr G.H. Dunn Insurance Agency Deborah Hathaway P.O.Box 330 PHONEO Exo: (508)322-3242 (508)322-3243 FAx (A/C No). NIIL Buzzards Bay,MA 02532 E,eDol SS: deborah@ghdunn.com INSURER(S)AFFORDING COVERAGE NAIL II INSURER A: MA Retail Merchants AC Group Inc A0514 INSURED New Yarmouth Corp New Yarmouth Realty LLC INsuRERs: Mount Vernon Fire Insurance Company 26522 330 Route 6A Yarmouth Port,MA 02675 INSURER C: INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: TINS 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 CR OTHER DOCUMENT WITH RESPECT TO WHICH TIPS 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 SI-OWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ADDL SUER POLICY EFF POLICY EXP LTR TVPEOFINSURANCE INSD VAID POLICY NUMBER (MM'Ddyriyl (MM'DdWYYI UMTS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ ■7_,I_! CLAIMS-MADE OCCUR I(ll::TT���� . ,•,. MED EXP M one•erson $ PERSONALS ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY n JECT n LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident) $ $ UMBRELLA LIM OCCUR EACH OCCURRENCE $ EXCESS LAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ A WORKERS COMPENSATION $ 014005034124119 01/01/2019 01/01/2020 STATUTE ERS AND EMPLOYERS'LIABILITY Y/N ANY OFF ICF PROPRIETORR EXXCTLUDEDD?ECM� n N/A E.L.EACH ACCIDENT $ 500,000 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 K s,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 B CL 2704946C 10/28/2019 10/28/2020 Liquor Liabiliy Occurrence 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEMCLES(ACORD 101,Addtbrml Remarks Schedule,may be attached If more space Is required) Store 252 Main Street Vlkst Yarmouth MA 02673 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCREED POLICIES BE CANCELLED BEFORE TIE EXPIRATION DATE THEREOF, NOTICE WILL BE DELNERED IN Town of Yarmouth Building Department ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Rt 28 South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD