Loading...
HomeMy WebLinkAboutApplication and WC 5iliij C 440-LL TOWN OF YARMOUTH BOARD OF HEALTH ULC 2019 'Li ' APPLICATION FOR LICENSE/P .4,_202 >;. HEALTH DEPT. * Please complete form and attach all necessa. ,.i ocu enfs yb4', ., ber 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 15`h. ESTABLISHMENT NAME: Col sect.gvt l&f l f 1 ,1-1-4 • TAX ID: ® - LOCATION ADDRESS: titi(D S 10V�NV1 UL) Saab. ` ar Q .#: L U1-'1Lf3-0t MAILING ADDRESS: acco PI,. h-eld 1 (1 V vV jto l�1, o �[,1.� E-MAIL ADDRESS: E `1'10 WO' P S1 dC Q`L(ert • !O WI 1 OWNER NAME: (40 170 e't ' t(LSU) L-LG. CORPORATION NAME(IF APpLIC' :LE): 0l� 014errider i L u. MANAGER'S NAME: reit 1 (QMQ I TEL.#: 4ol-(ell-3i1 a'-' MAILING ADDRESS: act-v P 1 ai v jea a' )0 raktilv 1 �(l vi ' O ae a) POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated ----- - Pool Operator(s)md zittaeh a copy of the-certification to thisforim- --- — 1. h114' 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 yearsrecords. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 14I A' 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. 4 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC)on site during hours of operation. 1. fre 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 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�f/ni�le at your establishment. 1. WO 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. 141 iPr 2• 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY -19 331-a! LODGING: 004.1-,—(4--3934,-0 t 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 $110ea. 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.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 r<25,000 sq.ft. $150 LO—M.A.( _FROZEN DESSERT $40 TTOBACCO $110 ?o-6\(e NAME CHANGE: $15 AMOUNT DUE = $ 2.60!0C) *****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 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,Transientoccupancy shall be limitettto 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 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. 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 A ' : OVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY RE• i ' A SIT AN. DATE: la) 11 I L 1 SIGNATURE: PRINT NAME&TITLE: A , q0 J2.0 O (VP Ofef&Oitr Rev.10/15/19 The Commonwealth of Massachusetts Department of Industrial Accidents I.r=: t Office of Investigations 7.F__- =' i= 1 Congress Street, Suite 100 .� Boston, MA 02114-2017 `'-t �, www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information /yC'-S Please Print Legibly Business/Organization Name: ti A'_/ OA i /6 , - . 1 I Al A Ja`eC e.) • Address: ao pia:Inf ,�ld Ma City/State/Zip: eittAN k/ a Dacia) Phone #: WI—ql/3-Ca Are ou an employer? Check the ppropriate box: Business Type(required): 1. I am a employer with employees(full and/ 5.' etail or part-time).* 6. Restaurant/Bar/Eating Establishment 2.U 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. 0 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.❑ 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#1. I am an employer that is providing workers'co enation insurance for my employees. Below is the policy information. Insurance Company Name: reale M &i tth _tits'urcwr e efiYlit kj . Insurer's Address: Po. ecyg City/State/Zip: 0 wia.l O(7 via, j M xiqcocoo Policy#or Self-ins.Lic. # tp O7(41-L1 Expiration Date: 1 i i / O' fJ 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 'ertify under pains and penalties of perjury that the information provided above is true and correct. Signature Date: I a )11 I 11 Phone#: t/pf� "l 113--DVOS 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 • ACCORD DATE(MM/DD/YYYY) ®Sh L1 CERTIFICATE OF LIABILITY INSURANCE 06/28/2019 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 CONTANAME:CT CLIENT CONTACT CENTER FEDERATED MUTUAL INSURANCE COMPANY HOME OFFICE:P.O.BOX 328 (s/C,No ,Extl:888-333-4949 FAX No):507-446-4664 OWATONNA,MN 55060 ADDRESS:CLIENTCONTACTCENTER(cr�,FEDINS.COM INSURER(S)AFFORDING COVERAGE HAIL# INSURER A:FEDERATED MUTUAL INSURANCE COMPANY 13935 INSURED 176-600-5 INSURER B: EAST SIDE SERVICE CENTER INC,EAST SIDE MANAGEMENT INC INSURER C: EAST SIDE COLLISION CENTER INC,MVC ENTERPRISES INC 2050 PLAINFIELD PIKE INSURER D: CRANSTON,RI 02921-2062 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:4 REVISION NUMBER:1 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. ILNSR TR TYPE OF INSURANCE ADD sWVD PODGY NUMBER IMPaDID' I IbiagrA) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $1,000,000 CLAIMS-MADE X OCCUR DAMAGE TO RENTED $100,000 PREMISES(Ea occurrence) MED EXP(Any one person) A N N 6074190 07/01/2019 07/01/2020 PERSONAL may INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 X POUCY PRO LOC X I I JECT I I PRODUCTS•COMP/OP AGO $2,000,000 OTHER: AUTOMOBILE LIABILITY (Ea accident) Dfl51NGLE DMR $1,000,000 X ANY AUTO BODILY INJURY(Per person) —OWNED AUTOS ONLY A N N 6074190 07/01/2019 07/01/2020 BODILY INJURY(Per accdonE —SCHEDULED HIRED AUTOS ONLY NON-OWNED PROPERTY DAMAGE AUTOS ONLY {per accidenfl A JX UMBRELLA LIAB X OCCUR EACH OCCURRENCE $5,000,000 EXCESS LIAB CLAIMS-MADE N N 6074192 07/01/2019 07/01/2020 AGGREGATE $5,000,000 DED U RETENTION WORKERS COMPENSATIONX PER STATUTE ER AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETORIPARTNERIEXECUTIVEE.L.EACH ACCIDENT $1,000,000 A OFFICER/MEMBER OCCLUDED'? I I NIA N 6074191 07/01/2019 07/01/2020 (Mandatory in NH) EL DISEASE-EA EMPLOYEE $1,000,000 yes,describe under DESCRIPTION OF OPERATIONS below EL DISEASE-POUCY LIMIT $1,000,000 D DESCRIPTION OF OPERATIONS!LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) GARAGEKEEPERS COVERAGE PROVIDED ON A LEGAL LIABILITY BASIS WITH A LIMIT OF $600,000. COMPREHENSIVE AND COLLISION DEDUCTIBLES: $2,500 EACH VEHICLE. CERTIFICATE HOLDER CANCELLATION 41 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POUCY PROVISIONS. AUTHORIZED REPRESENTATIVE `�//�1.i �- © 1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016(03) The ACORD name and logo are registered marks of ACORD 00 Commonwealth of Massachusetts Letter ID:L1927326592 I a, Deparbment of Revenue Notice Date:May 24,2019 i Christopher C.Harding,Commissioner Account ID:SLS-11710146-032 NZwreit mass.gov/dor SALES AND USE TAX REGISTRATION CERTIFICATE iIIiiiIIIIiIH hifiliIiI'uIiiIIiiiihnliiniiIIIIiiIIIIliliuI COLBEA ENTERPRISES LLC §= COLBEA ENTERPRISES,LLC W 2050 PLAINFIELD PIKE WA CRANSTON RI 02921-2062 Attached below is your Sales and Use Tax Registration Certificate(Form ST-1). Cut along the dotted line and display at your place of business.You must report any change of name or address to us so that a revised ST-1 can be issued. At any time,you can log into your MassTaxConnect account at mass.gov/masstaxconnect to view and re-print a copy of this certificate. DETACH HERE ss s4, MASSACHUSETTS DEPARTMENT OF REVENUE Form ST-1 n Sales and Use Tax Registration Certificate �c = °�) This registration must be posted and visible at all Ny� times. COLBEA ENTERPRISES LLC Account ID: SLS-11710146-032 COLBEA ENTERPRISES,LLC Location ID: 11710146-0102 446 STATION AVE Certificate Number:70588416 SOUTH YARMOUTH MA 02664-1208 This certifies that the taxpayer named above is registered under Chapters 62C, 64H and 64I of the Massachusetts General Laws to sell tangible personal property at retail or for resale at the address shown above. This registration is non-transferable and may be suspended or revoked for failure to comply with state laws and regulations. Effective Date:December 5,2008 o,Eo ,,,g0"CP4tx Commonwealth of Massachusetts Letter ID:L0853584768 �•� Department of Revenue Notice Date:May 24,2019 Christopher C.Harding,Commissioner Account ID:MLS-11710146-083 LR - mass.gov/dor SALES TAX ON MEALS AND BEVERAGES REGISTRATION CERTIFICATE IIiiiILi1iiiIhi11liiIiiiiiiiIIi�iI�Ii�hIllI III11IjII'I111111' COLBEA ENTERPRISES LLC o EAST SIDE ENTERPRISE W C 2050 PLAINFIELD PIKE CRANSTON RI 02921-2062 Attached below is your Sales Tax on Meals and Beverages Registration Certificate(Form MT-1). Cut along the dotted line and display at your place of business.You must report any change of name or address to us so that a correct MT-1 can be issued. At any time,you can log into your MassTaxConnect account at mass.gov/masstaxconnect to view and re-print a copy of this certificate. DETACH HERE 4ecaus,tsMASSACHUSETTS DEPARTMENT OF REVENUE Form MT-1 Sales Tax on Meals and Beverages Registration Certificate Vd This registration must be posted and visible at all times. COLBEA ENTERPRISES LLC Account ID: MLS-11710146-083 446 STATION AVE Certificate Number: 2016745472 SOUTH YARMOUTH MA 02664-1208 This certifies that the taxpayer named above is registered under Chapters 62C and 64H of the Massachusetts General Laws to sell meals and beverages at the address shown above. This registration is non-transferable and may be suspended or revoked for failure to comply with state laws and regulations. Effective Date:June 1,2019 .Sstt=httasp Commonwealth of Massachusetts Letter ID:L1734744960 ` ' Department of Revenue Notice Date:May 28,2019 u� i,,-. . Account ID:CGL-11710146-060 MCI 4 Christopher C.Harding,Commissioner mass.gov/dor . RETAILER LICENSE FOR SALE OF CIGARETTES II'Illiiiipii,IIT,iII ,I,Il,I,,,lL,I„1(i111iIIli11"I 'I'I" COLBEA ENTERPRISES LLC EAST SIDE ENTERPRISE 2050 PLAINFIELD PIKE _- CRANSTON RI 02921-2062 • Attached below is your Retailer License for Sale of Cigarettes (Form CT-3T). Cut along the dotted line and display at your business location. At any time,you can log into your MassTaxConnect account at mass.gov/masstaxconnect to view and re-print a copy of this license. If you have any questions about your license, callus at(617) 887-6367 or toll-free in Massachusetts at (800)392-6089,Monday through Friday, 8:30 a.m.to 4:30 p.m. • DETACH HERE 4_,sp cxr�,c4,_ MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T yi P �y�/ Rg. Retailer License for Sale of Cigarettes a �e ay •. �.r ��.I,civ.'-`' This license must be posted and visible at all times.The sale of tobacco • products to anyone under 18 years of age is prohibited. COLBEA ENTERPRISES LLC Account ID: CGL-11710146-060 COLBEA ENTERPRISES,LLC Location ID: 11710146-0103 446 STATION AVE License Number: 359630848 SOUTH YARMOUTH MA 02664-1208 This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws to sell at retail at the address shown above. This license is non-transferable and may be suspended or revoked for failure to comply with state laws and regulations. Effective Date: May 28,2019 Expiration Date: September 30,2020 -o Commonwealth of Massachusetts Letter ID:L0182496128 p `p " Department of Revenue Notice Date:May 24,2019 Christopher C.Harding,Commissioner Account ID:CRL-11710146-066 pt mass.gov/dor RETAILER LICENSE FOR SALE OF CIGARS AND SMOKING TOBACCO iIIIllnIIIlllIklIIIIIlIlhIIImIIIIIIIIIIrttIrIIIItlnIIItll COLBEA ENTERPRISES LLC o COLBEA ENTERPRISES,LLC N 2050 PLAINFIELD PIKE CRANSTON RI 02921-2062 Attached below is your Retailer License for Sale of Cigars and Smoking Tobacco(Form CT-3T). Cut along the dotted line and display at your business location.At any time,you can log into your MassTaxConnect account at mass.gov/masstaxconnect to view and re-print a copy of this license. If you have any questions about your license,call us at(617) 887-6367 or toll-free in Massachusetts at (800) 392-6089,Monday through Friday, 8:30 a.m.to 4:30 p.m. DETACH HERE t.ea MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T Retailer License for Sale of Cigars and Smoking Tobacco §t o This license must be posted and visible at all times.The sale of tobacco products to anyone under 18 years of age is prohibited. COLBEA ENTERPRISES LLC Account ID: CRL-11710146-066 COLBEA ENTERPRISES,LLC Location ID: 11710146-0104 446 STATION AVE License Number: 1681201152 SOUTH YARMOUTH MA 02664-1208 This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws to sell at retail at the address shown above.This license is non-transferable and may be suspended or revoked for failure to comply with state laws and regulations. Effective Date:May 24,2019 Expiration Date:September 30,2020