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HomeMy WebLinkAboutApplication and WC ;�1 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 yourapplication rocket. NOIR:ALL BUSINESSES W1THLIOUOR LICENSES MUST FORMS BYNOVEMBER 1,0. ESTABLISHMENT NAME:D(,1%MAif1 U11,Y1lA.-1-c, TAX ID: LOCATION ADDRESS: (9 Z'Qkt bY1 Pr\€Salo t tGi*h mrt(2W-i TEL.#:5I2o 3GL1-i►'-41 MAILINGADDRESS:P.0,% 3)( 4$5 5.Dt is.hlc. , ot& E-MAIL ADDRESS: C..OLkfWteat\c..fr ch( 0 o.11.C©1A OWNER NAME:kiVal Fra.1AIkAnt,- CORPORATION NAME. APPLICABLE):(t'�� oltireal.R!EtO��l!iu, u_ 4• (A 616 h i �s� � MANAGER'S NAME: f\[�. ,�Ye 2 S TEL.#: 6N. 731-g VI MAILING ADDRESS:V,0. 5b'L tt Sitt J k a AIMS Mli-0)total) POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operators)and attach a copy of the certification to this form. L 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 tunes. Please list the employees below and attach copies of their certifications to this form.The Health Department will not use past = rte*1 73 years'records. You must provide new copies and maintain a file at your place of business. m 1. 2. r n 3. 4. I m 0 r C mc:-.-, fn FOOD PROTECTION MANAGERS-CER l'WICATIONS: 13 Q 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. k,7 ' °i 1. l: r j 2. PERSON IN CHARGE: Farh food establishment must have at least one Person In Charge(PIC)on site during hours of operation. 1. 9CLI 6,1\.Q 2. Vr4,Z* ALLERGEN CERT IFICATIONS; .44 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)(3Xa). Please attach copies of certification to this application. The Health Department will not use past years'records. You mist pro e ne�wpcopies and maintain a file at your establishment. 1. (,/3 C.4o, i I6L� S 2. c9 HEIMLICH CERTIFICATIONS: t 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 Healthp t will not use past years'records. You must provide new copies and maintain a file at your place off business. 1. uale,vi l'5 — 2, 3- 4. RESTAURANT SEATING: TOTAL# 24) OFFICE USE ONLY LODGING: LICENSEE REQUIRED FFEE PERMIT# LICCNS�REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&BBODGE $55 CAMP $55 'S MOWIMMINGPOOL$110ea TRAILER PARK $105 _WHIRLPOOL $11Oea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT it LICENSE REQUIRED FEE PERMIT S LICENSE REQUIRED FEE PERMIT# 1_0-100 SEATS $125 CONTINENTAL $35 NON-PROFIT $30 >I00 SEATS $200 =COMMON VIC. $60 —WHOLESALE $80 RETAIL SERVICE: —RESID.KITCHEN $80 LICENSE REQUIRED FEE PERMITS LICENSE REQUIRED FEE PERMITS LICENSE REQUIRED FEE PERMIT it <50 sq EL $50 >25,000 sq ft. $285 VENDING-FOOD$25 <25,000 sq.R $150 FROZEN DESSERT$40 TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE = S 185.DA *****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 j CERT.OF INSURANCE ATTACHED OR WORKER'S COMP.AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior t renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND 0"HER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations ofMotel or Hotel use,Transient occupancy shall be limited to the temporary and short team 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 uired 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.maus 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 M REQUIRE A Sfl'1; .AN. DATE:1 U 11 \ SIGNATURE_ 1 1! k� ,,Q� y� PRINT NAME& 111 LE: l�0-1-titil t j LD ..,0.0q h L U t 1 C LQ&X Rev.10!15/19 AR D0 CERTIFICATE OF LIABILITY INSURANCE DATE(MkIDD/YYYY) 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(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 N11 Stephen Neto Neto Insurance Agency Inc P Em (508)678-9068 I .No$ (508)672-9265 1470 Pleasant Street EMAIL MA SS: stephen@netoinsurance.com INSURERS)AFFORDING COVERAGE NAIL S Fall River MA 02723 IiSURERA: Safety Insurance Co 39454 INSURED INSURER e: SafetY Station Ave Donuts INSURER C: Wesco Insurance 25011 436A Station Ave INSURER D: INSURHtE: South Yarmouth MA 02664 INSURER F: COVERAGES CERTIFICATE NUMBER- CLI911506115 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POUCY 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.UNITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. TYPE OF INSURANCE qry. POLICY NUMBER (MNIOCWYY�YY) (rte YY� LIR Y) LBWS X COMMERCIAL GENERAL I.ABRnY EACH OCCURRENCE $ PO RbliTtD CLAIMS-MADE )1:1 OCCUR PREMISESoccurrence)ocaence) $ 1/3°'°°° MED EXP(Anyone person) __ $ 10,000 A BMA0026475 03/24/2019 03/24/2020 PERSONAL BADV INJURY $ _ GEMLAGGREGATE UMITAPPIJES PER: GENERAL AGGREGATES 1'�'� — POLICY JECT n LOC PRODUCTS-COMP/OP AGG _ $ OTHER: Non-o med $ 1,000,000 AUTOMOBILE LIABLnY CO SINGLE UNIT $ ANY AUTO BODILY INJURY(Per person) $ — OWNED SCHEDULED BODILY INJURY(Per al) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE _ AUTOS ONLY _ AUTOS ONLY (Per accident) $ X UIERE r ALAB OCCUR EACH OCCURRENCES 1,�,� B EXCESS UAB CLAIMS-MADE CMU0005953 01/01/2019 01/01/2020 AGGREGATE $ DED I XI RETENTION$ 10,000 $ WORICERS LL I PER STATUTE I I ER C ANY PROPRI�CUTIVE ITY YI I Nrw WWC3391424 01/01/2019 01/01/2020 EL EACH ACCIDENT $ �•� OFFICER/MEMBER EXCLUDED? (Mandatory in NH) EL DISEASE-EA EMPLOYEE $ 5° • °0 L yes,desalts wader DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY UNIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Sdrednle,may be attached I more space is regrired) CERTIFICATE HOLDER , CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Town of South Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENIATiVE � South Yarmouth MA 34�y_��,F /r,..� i7. 27e 4 — I ®1956-2015 ACORD CORPORATION. Afi rights reserved. ACORD 25(2015103) The ACORD name and logo am registered marks of ACORD NP 111194630 NOTICE NOTICE TOTO EMPLOYES -R EMPLOYEES The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston, Massachusetts 02111 617-727-49W---.1ittp://www.mass.govidia As required by Massachusetts Genera Law,Chapter 152,Sections 21,22,30,this will give you notice that I(we)have provided for payment to our injured employees under the above-mentioned chapter by irwitning with: W Company NAME OF INSURANCE COMPANY t I Superior Avenue East,21st Floor,Cleveland,OH 44114 ADDRESS OF INSURANCE COMPANY WW03391424 111/2019 to 1/1/2020 POLICY NUMBER EFFECTIVE DATES 1468 Pleasant Street,Fall River,MA Neto Insurance Agency,Inc. 02723 (508)678-9068 NAME OF INSURANCE AGENT ADDRESS PHONE# Station Ave Donuts ILC 436A Station Ave,S Yarmouth,MA 02664 EMPLOYER ADDRESS EMPLOYER'S WORKERS'COMPENSATION OFFICER(IF ANY) DATE MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the services provided by the treating physician will be paid by the insurer,if the treatment is necessary and reasonably connected to the work Mated injury. In cases requiring hospital attention,employees are hereby notified that the insurer has arranged for such attention at the NAME OF HOSPITAL ADDRESS TO BE POSTED BY EMPLOYER.