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HomeMy WebLinkAboutApplication and WC t 6)116i4 I TOWN OF YARMOUTH BOARD OF H . 4 e, IA% APPLICATION FOR LICEN /PERMIT`=2 DEC 1 ' LU 1�J * Please complete form and attach all necessary documents by / - em!. Failure to do so will result in the return of your application a: - - . NOTE:ALL BUSINESSES WITH LIOUOR LICENSES MUST RETURN FORMS BY NOVEMBER 15m. ESTABLISHMENT NAME: 0ii toetV,`o-0(4 /71. ,e14-S TAX ID: LOCATION ADDRESS: T 4 7' /Yafiv J'4� .,�rvSI Wring✓ IN4 TEL.#:;S?)J.�?Y 3.57V MAILING ADDRESS: See Z6‘ E-MAIL ADDRESS: C ro//€r S , a r OWNER NAME: /city fr'-✓7Cc✓ ex f, Cl/2EclC,v�7c - `7NC CORPORATION NAME(IF APPLICABLE): ''e,r-/e.a.,;(.. JT c MANAGER'S NAME: S`7t', -f '1EL.#: J MAILING ADDRESS: f� POOL CERTIFICA ONS: The pool supervisor ust be certified as a Pool Operator,as require y State law. Please list the designated Pooi Operator(sj and a . ha copy of the certification to-this form 1. 2. Pool operators must list a mi urn of two employees currently certified in s dard First Aid and Community Cardiopulmonary Resuscitation CPR), having one certified employee on pre .ses at all times. Please list the employees below and attach copi- of their certifications to this form.The Healt Department will not use past yearsrecords. You must provi• new copies and maintain a file at your pla 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. ///- o 1v✓3'(0 7-11j-eu -i4P(-1ef 2. PERSON IN CHARGE: Each food establishment must have at le t one Person In Charge (PIC)on site during hours of operation. -4- 1. fr)SNR- dj2lAr 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 provHO de new copies and maintain a file/at your establishment. 1. •A/a/tID '"l O-PirJ 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. �d h►,.r 1m,Ma,,,f 2. �/uo, 72-Z i 3. No-64 s /4&-( _ 4. /k,,tip► /Y1, A) ,e/ / RESTAURANT SEATING: TOTAL# 10-4- (o )/V-OFFICE USE ONLY G0 _61GS_4U LODGING: LICENSE REQUIRED FEE PERMIT# 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 $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 _CONTINENTAL $35 I_NON-PROFIT $30 ?b >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# <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 = $ OO *****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 V7 OR / WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED t/ Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES t7 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 ,irlpools which have b closed for the season must be inspected by the Health Department prior to opening. Contact the -alth Departme o schedule the inspection three (3) days prior to opening.PLEASE NOTE: People are NOT allowed to .it in the I:. area until the pool has been inspected and opened. POOL WATER TESTING: The water must be tested fo• .seudomonas,total coliform and standard plate count by a State certified lab,and submitted to the Health Department e( days prior to opening,and quarterly thereafter. POOL CLOSING:Every outdoor in ground sw. ming pool mube 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 RESPON ILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY ECEMBER 13, 201 . 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: I/_`3 /9 SIGNATURE: PRINT NAME& TITLE: C%.,/,t //6- - � N��C� �/✓e c/p.r Rev.10/15/19 The Commonwealth of Massachusetts Department of Industrial Accidents =;� t Office of Investigations ==.11=:.. y� 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please JPrint Le gi bly Business/Organization Name: 4-0,',61/./e- SyJ ,71 Address: & J /0/71A Wee//J 02_6 y City/State/Zip: SO% Yd?i,420 l Phone#: SOS—?9 Y-35/Y Are you an employer?Check the appropriate box: Business Type(required): 1.igI am a employer with employees(full and/ 5. ❑ Retail orpart-time).* - - 6. 9 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. ❑ Entertainment their right of exemption per c. 152, §1(4), and we have 10.❑ Manufacturing no employees. [No workers' comp.insurance required]** 11.Z 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 orkers'c mpensatio1n insurance fora my employees. Below is the policy information. Insurance Company Name: / ' f ' i6 /" , , _ _ _ Insurer's Address: 3 Z cf a ,es,?-c kire., £q a1 /1/6.— 17 as-0 1 f i City/State/Zip: //�7 //7��/j _ / / p — Policy#or Self-ins.Lic.# /2 to ('S F 7 Expiration Date: 713//Os, 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 certtiify,,under the pains and penalties of perjury that the information provided above is true and correct. Signature: ( �it,�c /e& Date: /Z —d p' Phone#: T / - Z6 9 ZS Y 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 � ��� CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YY1fY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFI 7/E1/2020 I 7/19/2019 HOLDER.THI CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFF ORDEDCBY THE POLICIESS-- BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN`THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,LND,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 lieu of such endorsement(s). PRODUCER Lockton Companies �• ACT 3280 Peachtree Road NE,Suite#250 r14 Atlanta GA 30305 f Ext): ice,Nor (404)460-3600 aDEss: INSURERISI AFF9RWING COVERAGEI NAIC C • INSURED FC INSURER A: Columbia Casualty Company 31 127 Compassus,LLC INSURER B: Liberty Mutual Fire Insurance Company 1390032 and its subsidiaries 23035 See attached for additional insured names INSURER C: Ironshore Specialty Insurance Co 25445 10 Cadillac Drive,Suite 400 INSURER 0: Liberty Insurance Corporation 42404 Brentwood TN 37027 'ERE: COVERAGES CERTIFICATE NUMBER 12615844 REVISION NUMBER: XXXXXXX THIS IS TO CERTIFY THAT THE.POLICIES OF INSURANCE LIST•• BELOW HAV ' EN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR . - : • ANY CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT O ALLCT OR OTHER DOCUMENT WITH RESPECTOT EWHICH TH TERMS'S EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTR TYPE OF INSURANCE AD L SLIER OWN POLICY EXP - POLICY NUMBER LIMITS A © COMMERCIAL GENERAL LIABILITY N N HMA 60496NI50189 7/31/2019 7/31/2020 EACH OCCURRENCE CLAIMS-MADE®OCCUR DAMAGE TO RENTED $ 1,000,000 PREMISES(Ea occurrence) $ 1,000,000 III Deductible 10 000 MED EXP(My one person) $ 5,000 GEN'L AGGREGATE LIMIT APPLIES PER: PERSONAL&ADV INJURY $ 1,000,000 1111 POLICY❑JECT LOC • GENERAL AGGREGATE $ 3,000,000 OTHER: PRODUCTS-COMP/OP AGG $ 3 OOO OOO B AUTOMOBILE LIABILITY N N AS2-651-289329-069 7/31/2019 7/31/2020 COMBINED SINGLE LIMIT $ ■ ANY AUTO fEa a id nt) $ 1,000,000 ■ OV ED SCHEDULED BODILY INJURY(Per person) $ XXXXXXX MIAUT S ONLY AUTOS BODILY INJURY HIRED NON-OWNED (Per accident $ XXXXXXX AUTOS ONLY X AUTOS ONLY PROPERTY DAMAGE (Per rachiao $ XXXXXXX CIII UMBRELLA LIAR X OCCUR N N 003238802 $ XXXXXXX 7/31/2019 7/31/2020 EACH OCCURRENCE $ 10,000,000 ■ EXCESS LIAB X CLAIMS-MADE DED RETENTION$ AGGREGATE $ 10,000,000 D WORKERS EMPLOYERS'COMPENSATION LIABILITY Y/N N WC7-651-289329-049(WI) 7/31/2019 7/31/2020 XH $ XXXXXXX D ANY PROPRIETOR/PARTNER/EXECUTIVE WA7-65D-289329-039(Ads) 7/31/2019 7/31/2020 'STATUTE �OER (Mandatory N OFFICER/MEMBER EXCLUDED? N/A EL EACH ACCIDENT $ 1,000,000 HHyeessIn NH) eOPERATIONS below E.L.DISEASE.EA EMPLOYEE $ 1,000,000 A Professional Liability HMA 6049650189EL DISEASE-POLICY LIMIT 5 1,000,000 A N N Claims Made-Form 7/31/2019 7/31/2020 $1,000,000 Each Claim S3,000,000 Aggregate A Retro Dater Per Policy Ded Each Claim $10,000 Undeminity Only) DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION See Attachment SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 12615844 AUTHORIZED REPRESENTATIVE Windsor SNF 265NMainSt S.Yarmouth MA 02664 ACORD 25(2016/03) --.?. Of w�- ,. 01 88�Z0 AC•RD CORPO The ACORD name and logo are registered marks of ACORD TION.All rights reserved • 4 1 (:) at c,i g - ..... V) 4 :....t. 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