Loading...
HomeMy WebLinkAboutApplication and WC • EGEIVP•a 02-( itiittio TOWN OF YARMOUTH BOARD OF HEALTH 3 �, ` APPLICATION FOR LICENSE/PERMIT 2020 U k k 0 2019....*, ( /480's * Please complete form and attach all necessary documentsDe� ] dt tt 2019. Failure to do so will result in the return of your application packet. . NOTE:ALL BUSINESSES WITHLIOUOR LICENSES MUST RETURN FORMS BY NOVEMBER 155. • ESTABLISHMENT NAME: h(iplaW OM 6$ P ion.-cc pikeq TAX ID: LOCATION ADDRESS: S 7 t Rrx T.. n K lurid yeti yGwn 1/4�473TEL.#: 5 '? WOO MAILING ADDRESS: S79 I3tck 1c ebid f i iA JP R•1— iHi6 (Q(07 3 • E-MAIL ADDRESS: • maw('mei zcA 6 mac*vjorrksl _call OWNER NAME: Si-e2 6 10...1 CORPORATION NAME(IF APPLICABLE): tkatio,IAJoccl 1'kcX acv rev Ptct_CQ A L,Rt"(..,C_ MANAGER'S NAME: `'Rcis tn-el (eteve.e ie i a TEL.#: tj 7rit) --6„)60,) MAILING ADDRESS: S7'( eigic- .StavvM 'Pnr..wk Wes+ eiw\c -ii" (Q113 POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated --.--Pool O erator s -and attach a copy p(y�of the certification to this form. 1. ¶ c..ih o rd . Y lZ›..._ci--() 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. T1s+, 4°n,z 2. RihoV a PP22O 0 3. ` S S S 4. Lima. A f-1zsov--1,tir • 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. <r 4- Pa,4ihe_I CS t 2. het--h S(r,,OC PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. 1. . 62,2 W ?-(l/‘e I 2. Kr'_&"v1 JVIv c ( 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 file at your establishment. 1. oaf ?o,i-cine,I 2. l'A.0.1 Ck i 1 ke r l , 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. - - c)car_V-QJ 2. Tb 3. K,,ri\Sfo 14i-1-r0 koS1--5,S 4. 2 (-)1,,e.44 Son RESTAURANT SEATING: TOTAL# 1304ne-tS—•t 303-0 _ _ __ LODGING: OFFICE USE ONLY 104-1-C— IS—1805—Q5 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 5 • CABIN MOTEL• $110 =LODGE $55 'TRAILER PARK $105 I SWIMMING POOL$110ea. + • P. WHIRLPOOL $110ea. .. .ZP; 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 ZO—OSCo _CONTINENTAL, VIC. $60 20—(d7 —WHOLESALE $80 RETAIL SERVICE: RESID.KITCHEN $80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sqq.ft. • 0 >25,000 sq.ft. $285 VENDING-FOOD $25 =<25,000 sq.ft. $1$50 FROZEN DESSERT $40 TOBACCO . $110 NAME CHANGE: $15 • AMOUNT DUE _ $ 4SQ. 00 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 tiie limitations of Motel or Hotel use,Transient'occupancy Mill' a 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. 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 APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY ' . _'r A SITE LAN. DATE: 07/34 SIGNATURE: efivt.,0 PRINT NAME&TITLE: i • :I (Df J .P kcst , cec.o.ix\r e b reclt)f Rev.10/15/19 • RECEIVED The Commonwealth of Massachusetts DEC 3 1 2019 Department.of Industrial Accidents c.= = Office of Investigations HEALTH DEPT. ,,_ 600 Washington Street 'Ei"= , Boston,MA 02111 , — , '''IN;.1,14 , www mass.gov/dia Workers'Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Maplewood at Mayflower Place Address: 579 Buck Island Road City/State/Zip: W Yarmouth, MA 02673 Phone#: 508-790-0200 Are you an employer?Check the appropriate box: Business Type(required): 1./.1 I am a employer with employees(full and/ 5. 0 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] o. ❑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 . 10.0 Manufacturing no employees.(No workers'comp.insurance required]•' 1 l.®Health Care 4.❑ We are a non-profit organization,staffed by volunteers, with no employees.[No workers'comp.insurance req.] 12.❑Other *Any applicant that checks box Cl 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 MI. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: The Memic Group insurer's Address: 180 Glastonbury Blvd#304 City/state/Zip: Glastonbury. CT 06033 Policy#or'Self-ins.Lic.# 3102804908 Expiration Date: 6/1/2020 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as re.. ed un Section 25A of MOL C. 152 can lead to the imposition of criminal penalties of a fine up to 51,500.00 and/or one r imp' ment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day agai iolat' . Be advised that a copy of this statement may be forwarded to the Office of Investi:ations of the DIA >r El,a -coverage verification. I do hereby certify,under -r A Ind penalties of peijury that the information provided above is true and correct i: :ture: . ' A A Datta: h. #' vi .. 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): . I.Board of Health 2.Building Department 3.City/Town Clerk 4.Licensing Board S.Selectmen's Office 6.Other Contact Person: Phone N: www.masa.govldia / , ® DATE(MM/DD/YYTY) A`.�o CERTIFICATE OF LIABILITY INSURANCE 5/31/2019 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 CONTACT NAME: Commercial Lines M&T Insurance Agency, Inc. PHONE FAX 285 Delaware Avenue, Ste 4000 WAC No.Ext):716-853-7960 (A/C,No):855-595-4605 E-PBuffalo NY 14202 ADDRESS: CLServicing@mtb.com INSURER(S)AFFORDING COVERAGE NAIL# INSURER A:MEMIC Indemnity Co 11030 INSURED MAPLE-5 INSURER B:Hallmark Specialty Ins Co 26808 Maplewood Mayflower Place, LLC C/o Maplewood Senior Living, LLC INSURER C: 1 Gorham Island INSURER D: Westport CT 06880 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:1405602514 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 TYPE OF INSURANCE ADDL SUER POLICY NUMBER (MM/DD/ YYYY) (MM/DLICY EFF D/W P INSD Y) LIMITS LTRWVD B X COMMERCIAL GENERAL UABILITY Y Y 75LTP000739 6/1/2019 6/1/2020 EACH OCCURRENCE $1,000,000 DAMAGE TO RENTED CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $50,000 MED EXP(My one person) $ PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $3,000,000 POLICY JEa X LOC PRODUCTS-COMP/OP AGG $1,000,000 X OTHER: Policy Aggregate Policy Aggregate $10,000,000 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 3102804908 6/1/2019 6/1/2020 X AND EMPLOYERS'LIABILITY Y/N STATUTE ERH ANYPROPRIETOR/PARTNER/EXECUTIVE N/A E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 B Professional Liability 75LTP000739 6/1/2019 6/1/2020 Each Prof!Indent 1,000,000 Occurrence Form Prof,Aggregate 3,000,000 Shared Policy Agg 10,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) RE Maplewood Real Estate Holdings,LLC for Location: Maplewood Mayflower Place ALF,LLC 579 Buck Island Road 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 ACCORDANCE WITH THE POLICY PROVISIONS. Town of Yarmouth Building Department 1146Route 28 South Yarmouth MA 02664 /AUTH•.;V D REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD r ® DATE(MM/DD/YYYY) A 9 o CERTIFICATE OF LIABILITY INSURANCE 5/31/2019 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). CONT PRODUCER NAMEACT Commercial Lines M&T Insurance Agency, Inc. PHONE FAX No):855-595 4605 285 Delaware Avenue, Ste 4000 (A/C.No.EMI:716-853-7960 Buffalo NY 14202 ADDRESS: CLServicing@mtb.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:MEMIC Indemnity Co 11030 INSURED MAPLE-5 INSURER B:Hallmark Specialty Ins Co 26808 Maplewood Mayflower Place ALF, LLC do Maplewood Senior Living LLC INSURER C: One Gorham Island INSURER D: Westport CT 06880 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:1400906037 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 TYPE OF INSURANCE LTR INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS B X COMMERCIAL GENERAL LIABILITY Y Y 75LTP000739 6/1/2019 6/1/2020 EACH OCCURRENCE $1,000,000 DAMAGE TO CLAIMS-MADE X OCCUR PREMISES(EaENTED occurrence) $50,000 MED EXP(Any one person) $ PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $3,000,000 POLICY JE X LOC PRODUCTS-COMP/OPAGG $1,000,000 X OTHER: Policy Aggregate Policy Aggregate $10,000,000 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 3102804908 6/1/2019 6/1/2020 X STA UTE ETH AND EMPLOYERS'LIABILITY N ANYPROPRIETOR/PARTNER/EXECUTIVE YNN NIA E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBEREXCLUDED9 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 B Professional Liability 75LTP000739 6/1/2019 6/1/2020 Each Prof! Incident 1,000,000 Profl Aggregate Occurrence Form Shared Policy Agg 10,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached N more space is required) 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. Town of Yarmouth Board of Health 1146 Route 28 South Yarmouth MA 02664 AUTH•-DREPRESENTATIVE I ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD NOTICE The undersigned, an employer within the meaning of the Workers' Compensation Law of the State of Massachusetts hereby gives notice to employees that the employer has secured the payment of Compensation to its employees and their dependents in accordance with the provisions of said law, by insuring with MEMIC Indemnity Company 1750 Elm Street, Suite 500 Manchester, NH 03104 Policy No: 3102804908 Effective: 06/01/2019 - 06/01/2020 Maplewood Senior Living, LLC Employer Dated: 05/29/2019 By: WC 7618a(6-91) Page 1 of 1