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HomeMy WebLinkAboutApplication and WC a 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 applicationacket. NOTE:ALL BUSINESSES WITHLIOUOR LICENSES MUST RETURN FORMS BY NOVEMBER 15`x. ESTABLISHMENT NAME: M)©K.— N- £o LL TAX ID: . LOCATION ADDRESS: 13 t' . Q,rl ..<-1-- ,3. Yarn-sou 1, , /174 TEL 8- 76-0--,..9,9(o MAILING ADDRESS: . ,??P AS •19601E • E-MAIL ADDRESS: V to LA-) c ) o I.CO rYt . OWNER NAME: 0 Yoe,nf,? .S . 40(..4.) CORPORATION NAME IF APPLICABLE : j3 1a'ld0 r3 .Zig G S'MANAGER'S NAME: akyi PhD TEL.#:57)g 76 0 1,19 1(0. MAILING ADDRESS:2.. x, ¢tz A-Bvy-- POOL CER IIFICATIONS: 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 b 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. L 1 3. 4• tr FOOD PROTECTION MANAGERS-CERTIFICATIONS: . �o, 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 newcopiesand maintain a file at your establishment. /► 1. '1 n L• j ) /'1 Ci/1 • 2. __.�.. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation N O V 1 2 2019 1. ni iii 3 , zit f. 2. DEPT 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. lrra/1 1, ZIQh 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# I 0 - OMf 1s—Coo(05-05— OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $110 —INN $55 CAMP' $55 ^SWIMMING POOL$I 10ea LODGE $55 =TRAILER PARK $105 _WHIRLPOOL $I IOea FOOD SERVICE: LICENSE REQUIRED FEE PERMIT LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# ,_0-100 SEATS $125 $ ( CONTINENTAL $35 NON-PROFIT $30 >100 SEATS $200 =COMMON VIC. $60 'Sc WHOLESALE $80 —REBID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50-..R $50 >25,000 sq ft. $285 VENDING-FOOD $25 =<25,1 M sq.ft. $150 =FROZEN DESSERT$40 TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE = $ i85 OD *****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 V 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 m 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 ' 'PROVED BY THE BOARD OF HEALTH PRIOR TO COMME CEMENT. RENOVATIONS MAY RES, i:' A SUE PLAN. DATE: 11 1.-fco/9 SIGNATURE: PRINT NAME&TITLE: r De/1 0 J . do / & , s'1i' /e Rev.10/15/19 0 J t V11EI The Commonwealth of Massachusetts 11111 1 Department of Industrial Accidents latk== Office of Investigations 4 mown e, 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: k)o K- LL. Address: /3/9 , YYJ a,t r -�1L S . yam o o m 7 ©a (•6 - . City/State/Zip: Phone#: Sb8 - 76 0 `'6 ' Are you an employer?Check the appropriate box: Business Type(required): 1.t I am a employer with if employees(full and/ 5. 0 Retail or part-time).* 6. ®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]** 11.0 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 ganization should check box#1. am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. isurance Company Name: /4-/ In ` �) a pJv 9t Ca#1C 12 Q . isurer's Address: 54 , TA 1l'd Ave , 1�LA.,ItItiDKi 1�4 (� g.Q3 (J r ity/State/Zip: /� olicy#or Self-ins.Lic.# to G /FO o 7o>S 372 — aD /7i4 Expiration Date: 4/3/a0,..)0 ` ,ttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ne 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 f up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of ivestigations of the DIA for insurance coverage verification. do hereby certify,under the pains and penalties of perjury that the information provided above is true and correct. ignature: Date: hone#: 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 DATE(MM/DD/YYYY) AC®Rd©' CERTIFICATE OF LIABILITY INSURANCE 11/05/2019 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 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 CONTACT NAME: Sharen Rabesa MURRAY&MACDONALD INSURANCE SERVICES INC PHONE Et. (508)289-4160 ( ,Nor. �RESS: sharen@riskadvice.com 550 MACARTHUR BLVD INSURER(S)AFFORDING COVERAGE NAIC# BOURNE MA 02532 INSURER A: AIM MUTUAL INS CO 33758 INSURED INSURER B: BRANDON INC INSURERC: INSURER D: 1319 ROUTE 28 INSURER E: SOUTH YARMOUTH MA 02664 INSURER F: COVERAGES CERTIFICATE NUMBER: 469264 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 ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WV!) POLICY NUMBER (MMR?D/YYYY) (MWDD/YYYY) LAWS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS MADE OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GE 'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ _ POLICY PRO- LOC PRODUCTS-COMP/OP AGG $ JECT _ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS _ AUTOS (Per accident) UMBRELLA UAB _ OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X PER STATUTE ETH - AND EMPLOYERS'LIABIUTY A OFFICER/MEMBER EXCLUDED?ECUTIVE E.L.EACH ACCIDENT $ 100,000 N/A WA N/A AWC40070253722019A 02/03/2019 02/03/202() (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/Iwd/workers-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Yarmouth Health Dept ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Rt 28 AUTHORIZED REPRESENTATIVE South Yarmouth MA 02664 Daniel M.Crgr ey,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD A`CPRIJ CERTIFICATE OF LIABILITY INSURANCE DATE(sA1DDPrYYY) 11/05/2019 THIS CERTIFICATE 1S 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 CONTACT Zachary Tonello NAME: Murray&MacDonald Insurance Services,Inc. INC. ). (508)540-2400 FAX No.. (508)289-4111 550 MacArthur Blvd. EMAIL zach©riskadvice.com ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# Bourne MA 02532 INSURER A: Phoenix Insurance Co. 25623 INSURED INSURER B: Brandon,Inc. INSURER C: 1319 Route 28 INSURER D: INSURER E: South Yarmouth MA 02664 INSURER F: COVERAGES CERTIFICATE NUMBER: 19-20 Master 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. ILTR ZPOUCY EFF POLICY EXP TYPE OF INSURANCE NSD WLI VD POLICY NUMBER LIMITS (MMIDDMMI lY`n (MDDIYYYY) X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO CLAIMS-MADE X OCCUR PREMISES(EaENTED occurrence) $ 300,000 _ MED EXP(Any one person) $ 5,000 A 6808745A509 09/03/2019 09/03/2020 PERSONAL&ADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 PO- POLICY n JECT n LOC PRODUCTS-COMP/OP AGG ,$ 2,000,000 - OTHER: Medical payments $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ _ AUTOS ONLY _ AUTOS ONLY (Per accident) _ UMBRELLA UAB _ OCCUR EACH OCCURRENCE EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/NSTATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE r---1N/A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS beloe E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I 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 THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Yarmouth Health Dept. ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Rt 28 AUTHORIZED REPRESENTATIVE South Yarmouth MA 026641+ y� rd1✓ J` ®1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD