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HomeMy WebLinkAboutApplication and WC .)-21- - - - ,Alorr''' TOWN OF YARMOUTH BOARD OF HEALTH 4 It 0 ,, -. APPLICATION FOR LICENSE/PEItIktt 1 ' tot1/41- ' 1 NOV 20 2019 * Please complete form and attach ail rteeessaryltloi. - .v,,, byJ)-` , b , 13 -1 tH DEPT NOTE:ALL BUSINEFSthISEurSeWitoTdilo LsolOwIt 1 itre/JsuictEliSthESe reAlUtimIST°RETurtiRN4PFliOcalitiftl°Sn BPaeY Nket(ivEMBER Ir. ... , _ ESTABLISHMENT NAME e e. c TAX is• ..,, ,,, : 10 04,c, v-(...4.-kit-, - TAX. , . .- LOCATION ADDRESS: $"-- 4-44...f C,"yiziKI -N2e,z-- yo,,,t4L--TEL.#: S-D ---3 -- v:ez() ./tAILrNG ADDRESS: 5-----1-C.4,04.- fi/64, - n..4-- tz, y14,44 4 itio__ a..1-kb y E-MAIL ADDRESS: / 0,-,-0....Ce-_e vi--.4-nes--- --- Ce, / f,..--- OWNER NAME: 1"9, 'Y--7"4- CORPORATION NAME(IF APPLICABt.E). MANAGER'S NAME: TEL.#: MAILING ADDRESS: POOL CERTIFICATIONS: 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. I. 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 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. 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. file 2 A't 04- frInica 49'1f' ---CulI -4.. ------- ' PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. 1, M(4-4 c--- (3--eq, /4, 7,,,. 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 CIVIlt 590,009(0)(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. no—tCs6 #'ZtY-oso 1. ,/14 evi- k9,,‘- --ovid/„..f / 2. ) C--\ 4t-zil_05-7 Pr) 42b-1006 IIEIMLIC14 CERTIFICATIONS: 6 owc-ts"---L 309-19(5-- 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. I. 2. 3. , 4. l/LC \..V,ftIft//6 rvGULHL U) A214a31411./6 LIVIta Department of Industrial Accidents Office of Investigations = r 1 Congress Street,Suite 100 .. Boston,MA 02114-2017 xs www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: _.41 Ag.e i u Address: ' L- C'���v►� � City/State/Zip: S• /j�.,,, Zvi ,,a obL/ Phone#: 5 ' 3 ?/%GU Are you an employer?Check the appropriate box: Business Type(required): 1. . I am a employer with /0 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]** 4.❑ We are a non-profit organization,staffed by volunteers, MD Health Care with no employees. [No workers' comp.insurance req.] 12.❑Other *Any applicant that checks box#1 must also fdl out the section below showing their workers'compensation policy information. **If the corporate officers have exempted themselves,but the corporation har 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: stil i o f 2 d n-e i Insurer's Address: ' (J. �i (, )c9'9 d City/State/Zip: /I y-14.-0, at eiG t' G Policy#or Self-ins.Lic.# lvc` -S2,0 >Z!I 1 r t,11,9- Expiration Date: G r/p/f e - 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 certify, nder the pains and penalties of perjury that the information provided above is true and correct+ Si. ature: Date: I77f j a 0/q Phone#: Cr -C9 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 Client#:45428 2CCCR1 ACORDTM CERTIFICATE OF LIABILITY INSURANCE DATE(MMYY) 11/13/20192019 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 any rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: The Hilb Group of N.E.dba PHHCNN,Ext):508 775-1620 FAX Ne): 5087781218 Dowling&O'Neil Insurance Agy E-MAIL P.O.Box 1990 ADDRESS: Hyannis,MA 02601 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Associated Employers Insurance Company 11104 INSURED INSURER B: Cape Cod Creamery, LLC 5 Theater Colony Road 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 ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER (MMlDD/YYYY) (MM/DD/YYYI) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS MADE OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE _$ POLICY JET LOC PRODUCTS-COMP/OP AGG_$ OTHER: 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 LIAB OCCUR EACH OCCURRENCE _$ EXCESS LIAB CLAIMS-MADE AGGREGATE _$ DED RETENTION$ $ A WORKERS COMPENSATION WCC50050119952019A 05/01/2019 05/01/2020 X PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? N N 1 A (Mandatory In NH) If yes,describe under E.L.DISEASE-EA EMPLOYEE $1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Insurance coverage is limited to the terms,conditions,exclusions,other limitations and endorsements. Nothing contained in the certificate of insurance shall be deemed to have altered,waived,or extended the coverage provided by the policy provisions. CERTIFICATE HOLDER CANCELLATION Town of Yarmouth SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 1146 Route 28 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) 1 of 1 The ACORD name and logo are registered marks of ACORD #S246905/M246902 RPCH1