Loading...
HomeMy WebLinkAboutApplication and WC .� TOWN OF YARMOUTH BOARD OF HEALTH APPLICATION FOR LICENSE/PERMIT-2018 JAN 31 2020 * Please complete form and attach all necessary documents by Dece rte, • • •T Failure to do so will result in the return of your application 1)74' j'"'T - �� P • •yio t9 ESTABLISHMENT NAME: I . V a TAXI I: �r , i`- LOCATION ADDRESS: 52e, &' J `A" - ' t<04 TEL.#: SJ) logq MAILING ADDRESS: 52,0at/g-prnii, k . MaiyAffinci74f 11413-. E-MAIL ADDRESS: GIC•Cv e) • 69I1.') OWNER NAME: CORPORATION NAME (IF APPLICABLE): &biL- If-Ve-• MANAGER'S NAME: � � TEL.#: CBMIYAa___523-7- - MAILING ADDRESS: c919 f old va- POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operat i as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certificatio is form. 1. 2. Pool operators must list a minimu . two employees currently certified in standt irst Aid and Community Cardiopulmonary Resuscitation ' 'R), having one certified employee on pry Res at all times. Please list the employees below and attac -spies of their certifications to this form. Thy Health Department will not use past years' records. You t 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 Co. - for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this applicatio he Health Department will not use past years'records. You must provide new copies and maintain a e at your establishment. 1. 2. PERSON IN CHARGE: Each food establishment must h. e at least one Person In Charge (PIC) on site during hours o .peration. 1. 2. ALLERGEN CERTIF ' ATIONS: All food service est. ishments are required to have at least one full-time e - Iyee.who has Allergen certification, as defined in the ,State Sanitary Code for Food Service Establishments, 10 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 w' 25 seats or more must have at least one employee trained • e Heimlich Maneuver on the premises at al Imes. Please list your employees trained in anti-choking . : edures below and attach copies of employee ce 'cations to this form. The Health Department will not e past years' records. You must provide new co:ies and maintain a file at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# X301 —�S-rio5-05- OFFICE USE ONLY 60141V-is t 50f0--0 5- 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 $I l0ea. 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 WHOLESALE $80 —RESID.KIT 1,:w RETAIL SERVICE: • '. I/c.,, 2 !/ LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENS .1 'ED FEE PERMIT# <50 sq.ft. $50 ����� >25 000 sq.ft. $285 V �'01 1 -FOOD $25 T<25,000 sq.ft. $150 =FROZEN DESSERT $40 •B•CCO $110 ? ZO�OIa— NAME CHANGE: $15 AMOUNT DUE _ *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** /(5?) ' 00 02383 04/0 4 P//o.Or) cit,-/HOT 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 O & PAVE, WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid p ' r to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO i 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. k 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 f 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 CAFÉS: 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. 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 15, 2017. ALL RENOVATIONS TO ANY FOOD ESTABLISHM , , MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND ' : 'OVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REt1� •�, ; : ' P '0. DATE: SIGNATURE: i /f/fl Z_____.------------' PRINT NAME &TITLE: 4 11 , ' / , _ s I / ; „ l. -1 � IMO Rev. 10/12/17 The Commonwealth of Massachusetts Department of Industrial Accidents val Office of Investigations _ =st= 1 Congress Street, Suite 100 ==yrf Boston, MA 02114-2017. �'-tt www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly L / Business/Organization Name: /, Address: l - `; , j a ViS City/State/Zip: ``_.�'r'�1%.'i:'v €�/l ►� 1 .,J /. Phone #: , % (i/l.. ' L/�i' Are you an employer?Check 1 e appropriate box Business Type(required): 1.❑ I am a employer with employees(full and/ 5. Retail or part-time).* 6. 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 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#l. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: . Insurer's Address: �� ------ ___5C:::A___><.e-j) fir 1 City/State/Zip: Policy#or Self-ins.Lic. # 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 .1.'nst the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of th- 0 'or insurance coverage verification. I do hereby certi Ili' s,%:r the pains n��penalt of perjury that the information provided abov is tru and correct. Signature: / /��� Date: / ) X Phone#: ) 5� q (o 1 Official use onl Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Autho ily(circle one): 1.Board of He:lth 2.Building Department 3. City/Town Clerk 4.Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone#: www.mass.gov/dia 1 AL/+�RCERTIFICATE OF LIABILITY INSURANCE DATE(MMID I °"'"''' 02/03/20 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 1 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 lieu of such endorsement(s). PRODUCER CONTACT NAME: Schlegel&Schlegel Ins Brokers,Inc. �PpH/�ONqE 508-771-8381 34 Main Street E-MAILo•Ext►: (FAIc,No): 508-771-0663 West Yarmouth,MA 02673 ADDRESS: schlegelinsurance@gmail.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: Nautilus Insurance INSURED INSURER B: Guard Insurance AKMU Inc 1047 Route 28 INSURER C South Yarmouth,MA 02664 INSURER D INSURER E: 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 ADDLBUbK LTR TYPE OF INSURANCE HARD_VMD POLICY NUMBER LMM YD E __FF I POLICY EXP X COMMERCIAL GENERAL LIABILITY � '11(MMroD/YYYYL LIMITS EACH OCCURRENCE $ 1,000,000 1 CLAIMS-MADE n OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $ 500,000 A MED EXP(Any one person) $ 10,000 NC828396 06/07/19 06/07/20 PERSONAL&ADV INJURY - $ 1,000,000_ GEN'L AGGREGATE LIMIT APPLIES PER: POLICY 1-1'mi. n LOC GENERAL AGGREGATE _ $ 2,000,000_ OTHER: PRODUCTS-COMP/OP AGG $ 1,000,000 AUTOMOBILE LIABILITY $ COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO OWNED SCHEDULED BODILY INJURY(Per person) $ AUTOS ONLY _ AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE $ - (Per accident) - UMBRELLA LIAR - - EXCESS UABOCCUR $ EACH OCCURRENCE _ $ CLAIMS-MADE AGGREGATE DED I I RETENTION$ $ — WORKERS COMPENSATION $ AND EMPLOYERS'LIABILITY Y/N I PER I I ETH_ ANY PROPRIETOR/PARTNER/EXECUTIVE STATUTE ER B OFFICER/MEMBER EXCLUDED? n N I A AKWC140544 02/03/20 02/03/21 E.L.EACH ACCIDENT $ 100,000 (Mandatory In NH) If describe under DESCRIPTIONE.L.DISEASE-EA EMPLOYEE $ 100,000 OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) Insurance Covers Both Locations Location#1.1047 Route 28 South Yarmouth,MA 02664 Location#2. 528 Buckisland RD West Yarmouth,MA 02673 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Town OF Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 South Yarmouth,MA 02664 AUTHORIZED REP' ©1988-2015 ( ) The ACORD name and logo are registered marks of ACORD CORPORATION. All rights reserved. ACORD 25 2016/03