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HomeMy WebLinkAboutApplication and WC TOWN OF YARMOUTH BOARD OF HEALTH (-AarYti4- 03 i....nsicH 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 application packet. NOTE:ALL BUSINESSES WITH LIOUOR LICENSES MUST RETURN FORMS BY NOVEMBER I5`". ESTABLISHMENT NAME: 1110 .,.,I 1t'_' 4_•!►. ' 4,� _F - LOCATION ADDRESS: t a t Wall •4. ii r MAILING ADDRESS: & C) LX)I t. '01..12.K.IX * C' '"t' s 1•0 ' ( 3t, j E-MAIL ADDRESS: rtgant.6 di C .t_aiOrn OWNER NAME: CXR L'%W' Tre..- 9 g) A1C,,,• CORPORATION NAME(IF Apm.TrATILEI: 001, 9trAze.5 t • MANAGER'S NAME: Eli__,..1' et ti U.4,1 ' ' — ',..'t &4t&1$;" - TEL.#:,,til. 05 MAILING ADDRESS: dr 'e 1 .� L 1X91 �Lrl�4f�. Cyp:t ��,i 0. � c��Q POOL CERTIFICATIONS: N3 The pool supervisor must be celled 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. . —‘ROWED Pool operators must list a minimum of two employees currently certified in standard First Aid and Community Nov 2 n 2019 Cardiopulmonary Resuscitation(CPR),having one certified employee on premises at all times. Please list the G 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. HEALTH DEPT: 1. 2. 3. 4, FOOD PROTECTION MANAGERS-CERTIFICATIONS:1,3 trA Pie:-93..C. 0 1,C„�'-- All food service establishments are required to have at least one full-time employee who is ed 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 wilt not use past years'records. You must provide new copies and maintain a file at your establishment. V' 1. 2. N . PERSON IN CHARGE: : t Each food establishment must have at least one Person In Charge IC on site ��^ ��•y,� g (PIC) during hours of operation. i. el(ZGl.r�iC+'[► 1 1' )( ) 2. 5C6 -366 •440 I co 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 590.0.09(G)(3)(a). Please attach copies of certificationto 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: N ir 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 hoing 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# N I 6 v 0-F-(5-4 339-OS— OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMITS LICENSE REQUIRED FEE PERMIT if I.[Cl NSE REQUIRED FEE PERMIT S B&B $55 CABIN $55 ^_ MOTEL $110 INN $55 —CAMP $55 _--, ,.__— SWIMMING POOL$1 10ea. LODGE $55 TRAILER PARK $105 _WHIRLPOOL $110ea FOOD SERVICE: LICENSE REQUIRED FEE PERMIT S I..ICENSE REQUIRED FEE PERMIT S LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 _ _CONTINENTAL $35 NON-PROFIT $30 —>100 SEATS $200 COMMON VIC. $60 __—_-- -WHOLESALE $80 —RESIT).KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT S LICENSE REQUIRED FEE PERMIT I/ LICENSE REQUIRED FEE PERMIT S <50ft . $50 >25.000 sq.ft. $285 VENDING-FOOD $25 i<5,000 $150 =FROZEN DESSERT$40 TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE = S it57).00 *****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?<4 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 ic 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.640 or 830 CMR.640,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 in the suspension or revocation of your Frozen Dessert Pennit 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 COMMENCE FN '. RENOVATIONS MAY REQUI A SITE PL DATE: 1 SIGNATURE: PRINT NAME&TITLE: 1}epif1K3 Store Lic. Coordinator Rev.10/15119 The Commonwealth of Massachusetts l Department of Industrial Accidents Office of Investigations 1 Congress Street,Suite 100 4..m -° Boston,MA 02114-2017 www.massgov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name:VOL\pit, t(2 --* Q-i-' ► - Address: 3J LL Y R 1C olive, ` but!. 5O( lecerrakm City/State/Zip: P. 0,362a 4- Phone#: 3C1 " n-o& Are you an employer?Check the appropriate box: Bus' ess Type(required): 1.p I am a employer with i i employees(full and/ 5./N 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. ❑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, 11.0 Health Care with no employees. [No workers'comp.insurance req.] 12.❑ Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. *nf 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 workers'compensation ins ance for my employees. Below is the poli information. Insurance Company Name: 6 . '1 Insurer's Address: 44 G `�Chuirz- Ra City/State/Zip: NLjU\-D I Co3't4( Policy#or Self-ins.Lic.# L1V3' 405 Cli V."—i" Expiration Date: q= k`tL 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 cerrrtify,under,the pains and penalties of perjury that the information provided above is true and correct Signature 1�� , ,`tore Lic. Coordinatorate: I la 19 Phone#: W-5 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 ® DAT (MM/D AC d �) CERTIFICATE OF LIABILITY INSURANCE 09/05/2019 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 0 BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED w REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. o IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed.If m 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). c PRODUCER CONTACT y Aon Risk Services Central, Inc. NAME: Grand Rapids MI Office (NC.No.Ext): (866) 283-7122 (AIC No.): 800-363-0105 a 50 Louis Street NW E-MAIL p suite 200 ADDRESS: _ Grand Rapids MI 49503 USA INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A: Safety National Casualty Corp 15105 Dollar-Tree, Inc., INSURER B: Dollar Tree Stores, Inc. 500 Volvo Parkway INSURER C: Chesapeake vA 23320 USA INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:570078153261 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. Limits shown are as requested INSR ADD).SUER POLICY EFF POLICY k.XP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MMIDD/YYYY) IMMIDD/VYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY GL4059209 09/01/2019 09/01/2020 EACH OCCURRENCE $1,000,000 CLAIMS-MADE El OCCUR SIR applies per policy terms & conditions DAMAGE 10 REM ED $1,000,000 PREMISES(Ea occurrence) MED EXP(Any one person) Excluded PERSONAL&ADV INJURY $1,000,000 G GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $15,000,000 N X POLICY ❑JECT RO. I ILOC PRODUCTS-COMP/OPAGG $2,000,000 n 0 OTHER: I- A cAS4059210 09/01/2019 09/01/2020 COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY $3,000,000 (Ea accident) X ANY AUTO BODILY INJURY(Per person) o z OWNED —SCHEDULED - BODILY INJURY(Per accident) at AUTOS ONLY _AUTOS03 HIRED AUTOS NON-OWNED PROPERTY DAMAGE U v ONLY _AUTOS ONLY (Per accident) t= r 0 A UMBRELLA LIAB X OCCUR XEL4061307 09/01/2019 09/01/2020 EACH OCCURRENCE $3,000,000 V — — Excess General Liability AGGREGATE $11,000,000 X EXCESS UAB CLAIMS-MADE X DED RETENTION A WORKERS COMPENSATION AND LDS4059207 09/01/2019 09/01/2020 x PER STATUTE OTH- EMPLOYERS'LIABILMfER YIN A05 EXcI TX ANY PROPRIETOR/PARTNERI EXECUTIVE EACH ACCIDENT $1,000,000 A OFFICER/MEMBER EXCLUDED? N/A PS4059208 09/01/2019 09/01/2020 •EL (Mandatory in NH) WI E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000— A Excess WC SP4061289 09/01/2019 09/01/2020 EL Each Accident $1,000,000 Excess WC - OH EL Disease - Policy $1,000,000 1 SIR applies per policy terms & conditions EL Disease - Ea Emp' $1,000,000 a DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Evidence of Coverage. M CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE _. POLICY PROVISIONS. 2q Dollar Tree Stores, Inc. AUTHORIZED REPRESENTATIVE 500 Volvo Parkway Chesapeake VA 23320 USA t `Pe l M, .�jlC_i�lcpc�J,�/ �_ Eli ©1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD