HomeMy WebLinkAboutApplication and WC R1i5
TOWN OF YARMOUTH BOARD OF HEALTH
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 LJOUOR LICENSES MUST RETURN FORMS BY NOVEMBER 15`h•
ESTABLISHMENT NAME: A►ttoWn Yarmou441 TAX ID:
LOCATION ADDRESS: 511 -t-et-tion Ave•, *out,* MA TEL.#: 502•- 3614- 2$'2.1
MAILING ADDRESS: $00 S0I4hl S•hrf.ef, SUtiC 500,. JU Mi n1 MA 02.53
E-MAIL ADDRESS: QQ,rrni}S @ lloloalP.Com
OWNER NAME: Gi0 at tAnfl-k110 Group CorP
CORPORATION NAME(IF APPLICABLE): C310toal t-tO(1+U10 ((roup corp
MANAGER'S NAME: KUTICrf t_oVe TEL.#: 5ng>-3q4-2jz1
MAILING ADDRESS:$p() SOUL WQe+,Suit 500 Litt-Hnam MA 02(453 fa�nri o �I
D c In,i1
, p POOL CERTIFICATIONS: (S;
The pool supervisor must'be certified as a Pool Operator,as required by State law. Please list the designated = N H n
Pool Operator(s)and attach a copy of the certification to this form. u ND
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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
years'records. You must provide new copies and maintain a file at your place of business.
1. 2. t" 114PI
3. 4. '
FOOD PROTECTION MANAGERS-CERTIFICATIONS; 1"
All food service establishments are required to have at least one full-time employee who is certified as a Food . F
Protection Manager,as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. .C7
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. LP
1. 2. y
PERSON IN CHARGE:
Each food establishment must have at least one Person hi Charge(PIC)on site during hours of operation.
1. ka-NhIetn LNf, 2.
ALLERGEN CER IIFICATIONS:
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.
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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# (gyp lw-t S- (073-65'
OFFICE USE ONLY DDWr9—t5 —to-75-05-
LODGING:
LICENSE REQUIRED FEE PERMIT it LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
B&B $55 _______ CABIN $55 MOTEL $110
INN $55 —CAMP $55 — SWIMMING POOL$110ea.
_LODGE $55 =TRAILER PARK $105 =WHIRLPOOL $I10ea.
FOOD SERVICE:
LICENSE SEA REQUIRED FEE PERMIX t) LICCONTII_CONTINENTAL
$35 PERMIT S LICENSE NON-PRREOFIT FEE PERMll`P#
____>100 SEATS $200 COMMON VIC. $60 —WHOLESALE $80
—RESID.KITCHEN $80
RETAIL SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT S
<50 s•ft. $50 >25.000 sql. $285 VENDING-FOOD $25
1<25,1.1 NI. $150 2p-Oi 3 =FROZEN DESSERT$40 4 TOBACCO $110
NAME CHANGE: $15 AMOUNT DUE = $3$5.00
*****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 X
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.640 or 830 CMI.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 inspectedbby 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, MO FEL 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 SITEPLAN,
DATE: II 'I� ( I 1 SIGNATURE:
PRINT NAME&TITLE:_2 r1N—�'1 P
Rev 10/15/19
The Commonwealth of Massachusetts
I Department of IndustrialAccidents
5—4_ Office of Investigations
ION . Lafayette City Center
t Isi p 1 as :
fil
2 Avenue de Lafayette,Boston,MA 02111-1750
Nt-
WWMmass.gov/dia
Workers'Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name:Global Montello Group Corp.
Address:800 South Street, Suite 500
City/State/Zip:Waltham, MA 02453 Phone#:(781)894-8800
Are you an employer?Check the appropriate box: Business Type(required):
I.11 I am a employer with employees(full and/ 5. 011 Retail
or part-time).* 6. 0 Restaurant/Bar/Eating Establishment
2.E] I am a sole proprietor or partnership and have no 7. D Office and/or Sales(incl,real estate,auto,etc.)
employees working for me in any capacity.
El
[No workers' comp,insurance required] 8. Non-profit
3.0 We are a corporation and its officers have exercised 9. 0 Entertainment
their right of exemption per c. 152,§1(4),and we have 10.0 Manufacturing
no employees. [No workers' comp. insurance required]** ,
11.0 Health Care
4.0 We are a non-profit organization,staffed by volunteers, .
with no employees. [No workers' comp. insurance req.] 12.11 Other Cony Store/Gas Stations
*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:Liberty Mutual Insurance Corp
Insurer's Address:173 Berkeley Street
City/State/Zip: Boston, MA 02116
Policy#or Self-ins. Lie, #WA7-69D-460066-019 Expiration Date:10/1/20
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under§25A of MOL 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 clift,wide the pains and penalties of perjury that the information provided above is true and correct.
Signature: tittk ti 1161
ela
Date: 10-7-19
Phone#: 781-398-4032
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(check one):
I°Board of Health 2.0 Building Department 3.0 City/Town Clerk 4.1:Licensing Board
50 Selectmen's Office 6.DOther
Contact Person: Phone#:
www.mass.gov/dia
1
®
ACCORDCERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY)
10/1/2020 10/1/2019
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 pollcy(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 Insurance Brokers,LLC CONTACT
CA License#0F15767 (P(HUC No.Eat): FAX
(A/C,Not.
Three Embarcadero Center,Suite 600 EMAIL
San Francisco CA 94111 ADDRESS;
(415)568-4000 _,-_ INSURER(S)AFFORDING COVERAGE NAIC S
INSURER A:Liberty Insurance Corporation 42404
INSURED Global Companies,LLC INSURERS:
1369067 Global OF,LLC
INSURER C:
Alliance Energy,LLC INSURER D
800 South Street
P.O.Box 9161 INSURER E
Waltham MA 03151 INSURER F:
COVERAGES GLOPAOI CERTIFICATE NUMBER: 15643044 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.
INS TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP
LTR INSD WVD POLICY NUMBER IMM/DD/YYYY) (MOD/MY) LIMITS
COMMERCIAL GENERAL LIABILITY NOT APPLICABLE EACH OCCURRENCE $ XXXXXXX
DAMAGE TO RENTED
CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ XXXXXXX
MED EXP(Any one person) $ XXXXXXX
PERSONAL&ADV INJURY $ XXXXXXX
GE 1.AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ XXXXXXX
—
POLICY JECT LOC PRODUCTS-COMP/OP AGG $ XXXXXXX»'
OTHER: $
AUTOMOBILE LIABILITY NOT APPLICABLE CEOMBa aBII aED1SINGLE LIMIT $ XXXXXXX
ANY AUTO BODILY INJURY(Per person) S XXXXXXX
OWNED SCHEDULED '_$.XXXXXXX.—
AUTOS ONLY AUTOS BODILY INJURY(Per accident) $
HIRED NON-OWNED PROPERTY DAMAGE
AUTOS ONLY _ AUTOS ONLY _(Per accident) $ XXXXXXX
S XXXXXXX
UMBRELLA LIAR —OCCUR NOT APPLICABLE EACH OCCURRENCE $ XXXXXXX _
EXCESS UAB CLAIMS-MADE AGGREGATE $ XXXXXXX
DED RETENTION$ $ XXXXXXX
A AND EMPLOYERS'UA I WORKERS COMPENSATION
Y YIN N WA7-69D-460066.019 10/1/2019 10/1/2020 X,L.5TATSLTE PER ER-
ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000
OFFICER/MEMBER EXCLUDED? n N/A
(Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000
it yes,describe under .
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more apace is required)
CERTIFICATE HOLDER CANCELLATION See Attachment
15643044
Evidence of Insurance SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPR E AT1VE
N.ItS 1 414111 .41441 .4.14.
CO 1988-2015 ACORD CORPORATI . All rights reserved.
ACORD 25(2018/03) The ACORD name and logo are registered marks of ACORD
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