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HomeMy WebLinkAboutApplication and WC 4. . 'Litt- TOWN OF YARMOUTH BOARD OF HEALTH _ �� CAPPLICATION FOR LICENSE/PEI lT:=3e /1 '„ : ((]] * Please complete form and attach all necessary dtt cum ` ': December 13,V2(11 .Failure to do so will result in the return of your alication 2019 NOTE:ALL BUSINESSES WITH LIOUOR LICENSES MUST RETURN FORMS packet.Y NOVEMBER l5•..T ESTABLISHMENT NAME: C1 J A-CXL t--1-- f- e a GGA TAX ID: LOCATION ADDRESS: ) �jCQ p► S h0 t-cCr; S d . O.rano LithTEL.#: re $•35 E--/ S y/ MAILING ADDRESS: a.6 IO d �J`'�c trt S , S 0 .y a I' m �m C a u th d s- ,L.y E-MAIL ADDRESS: YY1 u r i e Ir ( 4� l tie n OWNER NAME: (le r< \a.c(&.-- !Sea rih C r�"'C D ►�D 4.)CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: ..10111•2_ )414 vrz IA aH TEL.#: L"?)Sr-3S k•t,51.e MAILING ADDRESS: a.0 dt-',S1► S!)► y a r yr D u-1 ii 141 ice. O4-6(i y 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. W 1 t` %proV t d-`E pr or % op LoyINJ 2. . Pool operators must list a minimum of two employees currently cert i ed 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. i. W t ` '( *WO v i clt_. Pr►d r -6 O pew 1 r 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. Oo%t✓—t(4-0063-46 RESTAURANT SEATING: TOTAL# �,)5��(�_�� �c, 130 c71- °C40 OFFICE USE ONLY (we BA F 6ob�—ob LODGING: 10*-44-0o Iola'6(0 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 1.MOTEL $110 , • •• INN $55 CAMP $55 j.SWIMMING POOL$110ea. _.y. ; ,3 LODGE $55 TRAILER PARK $105 i WHIRLPOOL $110ea. _ .•, FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 CONTINENTAL $35 NON-PROFIT $30 T>100 SEATS $200 (Wt.'', I I COMMON VIC. $60 cp.6-0 L* —WHOLESALE $80 —RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 <25,000 sq.ft. $150 _FROZEN DESSERT $40 TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE = $ 700.00 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** ` 7 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 prio o 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 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. RENOVATIONS MAY REQUIRE A SITE LAN. DATE: / 1 a'3—/ 5 SIGNATU� PRINT NAME&TITLE: M Gt.r 7 .1,1'' Rev. 10/15/19 The Commonwealth of Massachusetts Pk l Department of Industrial Accidents • E=;� Office of Investigations . —_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: •E' et J a i o Address: O /10 d . I t tLNA J�, City/State/Zip:SO , ytt r VYt UW ft-� Phone#: �Z FS ` 3 5S'-- Are you an employer? Check the appropriate box: Business Type(required): 1. I am a employer with employees(full and/ 5. 0 Retail or part-time).* 6. 0 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] 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 Heal are 4.❑ We are a non-profit organization,staffed by volunteers, r>:� with no employees. [No workers' comp. insurance req.] 12. they 5>e4 Soya r'eScr- *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: Z tAr 1 Ce-\,, Artr t ctL V-' Insurer's Address: 44-i-tithe et City/State/Zip: Policy#or Self-ins.Lie.# / 9 £ 0 6 N 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 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 ' ,under the pai and penalties of perjury that the information provided above is true and correct. Signature: Date: `//2-5/I Phone#: 5� cyZ0-13 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 • • ,��....,1 DAVEREA-01 NCANUSO .4CORO CERTIFICATE OF LIABILITY INSURANCE DATE 02/11/2019 Y) �� 02/11/2019 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 Ileu of such endorsement(s). PRODUCER CONTACT NAME: Valley Forge Captive Advisors t PHONE FAx 630 Freedom Business Center Drive I(NC,No,Ext):(610)458-3659 (Arc,No):(484)965-9627 I E-MAIL Suite 203 I ADDRESS: King Of Prussia,PA 19406 INSURER(S)AFFORDING COVERAGE NAIC/1 INSURER A:Zurich American Insurance Company 16535 INSURED INSURER B: Red Jacket Beach,LP INSURER C: i c/o Davenport Realty Trust 20 North Main Street INSURER D: South Yarmouth,MA 02664 INSURER E: 1 I 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 OF INSURANCE ADDL SUBR POLICY NUMBER /YPOLICY EFF POLICY EXP LIMITS LTR INSD WVD IMMIDDYYY) IMM/DD/YYYYI A X COMMERCIAL GENERAL LIABILITY j I EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR `I1GL08196255 03/01/2019 03101/2020 DAMAGE TO RENTED 1,000,000 PREMISES(Ea occurrence) $ ' MED EXP(Any one person) $ 1,000 I PERSONAL&ADV INJURY 5 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 2,000,000 PRO- JECT ! X POLICYLOC I I PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ A AUTOMOBILE LIABILITY I (EaOaccident) SINGLE LIMIT $ 1,000,000 X ANY AUTO BAP8196256 03/01/2019 03/01/2020 BODILY INJURY(Per person) $ OWNED r---1 SCHEDULED AUTOS ONLY 1 AUTOS I BODILY INJURY(Per accident) $ _ HIRED NON-AWNED 1 (Perraocident)AMAGE $ AUTOS ONLY AUTOS ONLY - S UMBRELLA LIAB III OCCUR I I EACH OCCURRENCE 5 _ EXCESS LIAB I CLAIMS-MADE AGGREGATE $ DED I IRETENTION 5 Illi $ A WORKERS COMPENSATION i I 1 X STATUTE PER ERH AND EMPLOYERS'LIABILITY Y/ry �WC8196035 03/01/2019 03/01/2020 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICERJM�MB EXCLUDED? ( N/A 1,000,000 (If yes,atory b NH) j E.L.DISEASE-EA EMPLOYEE $ ' If yes,describe under DESCRIPTION OF OPERATIONS below ' E.L.DISEASE-POLICY LIMIT $ 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 ACCORDANCE WITH THE POLICY PROVISIONS. Route 28 South Yarmouth,MA 02664 - ..- AUTHORIZED REPRESENTATIVE '42i/a ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD