Loading...
HomeMy WebLinkAboutApplication and WC1 FOOD IA a. / TL,c.,„,a. V 553 7 7 TOWN OF YliriMOUTIE1 ' 1. '11 1 ' :I I` i.,.:AsW 1NLIV I 4 Zt)19 APPLICATION FORLI t . *Please complete form and attach all necaintry&an/tents •, 'I .,..' ., -.n-, r Failure to do so will result in the return of your aWiestum pac.et. NOTE:ALL BUSINESSES WI271 LIOVOR LicoNspf5 itiffST RETL1R N FORAIS BY NCWEMBER 1.r. ESTABLISHMENT NAME: lliTiPATN. WeIPAli'VIIIIIIIIMIIIIIIIIIIIMIEMrrilW- . • LOCATION ADDRESS: 1 0: f441110/11111,11111/Mu'VagMlifIti TELA: •i. " -• '9.5. rrmirreini+rwirma MAILING ADDRESS' II°0 CIP 0 ..ao • VS 0 lalidliManir4IRItilLiTalgri -- 0 gl(0 E-MAIL ADDRESS: 1,, '13 .1"-•, Mitt- v..)01/4. .C.ArYi . OWNER NAME: ' ii. IIIIMIntallir 0 ilLis ,,,e, di • CORPORATION NAME(IF AP'LICABLE): i... Mar ' .. a a MANAGER'S NAME: * ' /A. ,,,_ El .I*10.*: 'Iti:latijElle 5 MAILING ADDRESS: • :111111:411411,1X9111111&`11161ffrilii111111111111.14. _ 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. 1. 2. Pool operators must list a miniumm of two employees eurrentlY certified in standard-First Aid and Community Cardiopulmonary Resuscitation(CPR), baiting.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 certificatiori to this application. The Health Department will not use past years'records. You must provide new copies and maintain a file at your establishment A e)(0(11,CleTh 'rAiti 0 1. 2.. PERSON IN CHARGE: Each food establishment must have at least one Person In.Charge(PIC)cm site during hours of operation, 1 . AVeSauncte(-Pav‘to 2. ALLERGEN CERTIFICATIONS: All food service establishments are reauiredto have at least one full-time employ=who has Allergen certification, as defined in the State Sanitary Code for Food Service Estedllishmeins,105 CMR 590.009(0X3)(a). Please atmeh 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. -1-)\e)r-GlinaeC.PC (..k.k 0 2. HEIWILICII CERTIFICATIONS; All food service establishments with 25 seats or more must have 4 least one employ=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. •3 i A 1. 1 2. 3. 4. 13 ot-t- --18-2M(.3-02_ RESTAURANT SEATING: TOTAL# 00 vt-re-(8-7.-LIA0 OFFICE USE USE ONLY LODGING: LICENSE REQUIRED FEE pular s LICENSEN REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PEIIMIT# B&B $55 CABI $55 morn., Si10 ON $55 --Clk./4P $55 --SR/RAKING POOL$110ca, LODGE $55 TRAILER PARE $101 --""witumPool, slices. _ _ Poop senvice: LICENSE REgisJIRED FEE PERMIT* LICENSE REQUIRED FEE PERMIT ft L1CDISE REQUIRED FEE PERIGT 0-100 SEA $125 COliTINENTAL $35 NON.PROFIT $30 -->100 SEATS $200$200 COMMON VIC. $60 -- WHOLESGTCHEN $80ALE $80 ...-.--RESID.1 RETAIL SERVICE: LICENSE REQUIRED FEE eRtovirrs L NSE REQUIRED FEE PERNAIT li LICENSE REQUIRED TEE PERMIT* -n.ft. $285 A a0-021. VE14DING-FOOD $25 _ $150 — ROZEN DESSERT $40 -- TOBACCO $110 EL)-0 I 1.0 NAME CHANGE: $15 ---- AMOUNT DUE = S 3 .00 *****P1ZASE UJRJ4 OVER AND COMPLETE OTHER SIDE OF FORM***** ---- ' . ADMINISTRATION Under Chapter 152,Section 25C,Subsection 6,the Town ofYarmouth is nowrecintred to hold issuance or renewal of any license or permit to operate a bitsiness if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORI<ER'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 ESTAIIIASHNIINTS TRANSIENT OCCUPANCY: For purposes ofthe limitations ofIkeLMel or Hotel use,Transient occupancy shall be limited to the temporary and short tem occupancy,ordinarily and customarily associated with motel and hotel use. Transient occupants must have and he 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 titan 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 IVI.G.L. c. 64G or 830 CMR 640,as amended,shall generally be considered Transient. POOLS POOL OPENING: All swimming,waling and whirlpools whichhave been closed for the season must be ins.-.. ;-. by the Health Department prior to opening. Contact the Health D-.- ,,1.,, to schedule the inspection three (3) prior to opening.PLEASE NOTE:People are NOT allowed to sit in .,e pool area until the imoi has been inspected and .ed 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 ins/motion three(3)days prior to opening. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department ' filhtg the rmuired Temporary Food Service Application form 72 hours prior to the catered event These forms can be ... ,ed at the Health Department,or from the Town's website at www.yarmotitli.innes under Health Department,Downloadable Forms. FROZEN DESSERTS: Frozen desserts must be tested by a State certified lab prior to opening sidreanthly 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 CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Booth of Health. OUTDOOR COOKING: Outdoor cooking,preparation,or dk,,play 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*Zap is reduced. NOTICE:,Permits run annually from January I to Deceinber31. IT IS YOURRESPONSIBILtlYTORETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 13 2019. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (Le,.,, PAINTING, NEW EQUIPMENT,ETC.) MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY IJQ1JIRE A SITE PLAN.. 0 / 1 / /1 q SIGNATURE: i ity (./t4viite, DATEz / l PRINT NANIE&TITLE: Tiffany Corcoran Rev.10/1119 Supervisor Tax 1 The Commonwealth of Massachusetts Department of Industrial Accidents i. =.-0,,-=:. Office of Investigations 'ir= '` 1 Congress Street,Suite 100 Boston,MA 02114-2017 1/4411...., s- www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Shaw's#3692 Address:1108 State Road City/State/Zip:South Yarmouth, MA 02664 Phone#:508-394-0995 Are you an employer?Check the appropriate box: Business Type(required): 1.❑✓ I am a employer with 98 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#1. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name:ACE American Insurance Company Insurer's Address:5600 West 83rd St, 8200 Tower, Suite 1100 City/State/Zip: Minneapolis, MN 55437 Policy#or Self-ins.Lic.#WLRC6604287A Expiration Date:8/1/2020 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,under the ains and penalties of perjury that the information provided above is true and correct. Signature: l, ,t�,,t1-. Date: ///12-// Phone#:623-869-4326 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 1 1 , . AL CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 07/26/2019 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 —O REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. > cel 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 i certificate does not confer rights to the certificate holder In lieu of such endorsement(s). c PRODUCER CONTACT dl Aon Risk Services Central, Inc. NNW Minneapolis MN officePHOa. b,Exty (866) 283-7122 ra No.): (800) 363-0105 5600 west 83rd Street EMAIL -420 8200 Tower, Suite 1100 ADDRESS: _ Minneapolis MN 55437 USA INSURER(S)AFFORDING COVERAGE NAIC C INSURED *ISMER A: ACE American Insurance Company 22667 Albertsons Companies. Inc. INSURER B: ACE Property & Casualty Insurance Co. 20699 Including Safeway Inc., Albertson's LLC & Subsidiaries MISURERC: Steadfast Insurance Company 26387 250 East Parkcenter Blvd INSURER D: Boise ID 83706 USA INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:570077666367 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 DLTR ER TYPE OF INSURANCE /U)DL SA IR' POUCY EFF POUCY EXP INSD WVD POLICY NUMBERIt LBBTS A X COMMERCIAL GENERAL UABLITY XSLG71448721 18/01/201' 18/01 202' EACH OCCURRENCE $3,000,000 CLAIMS-MADE n OCCUR SIR applies per policy terms & condi-ions DAMAGE TO RENTED $3,000,000 PREMISES(Ea occurrence) _ X Druggist Llab Induded MED EXP(Arty are person) Excluded PERSONAL&ADV INJURY $3,000,000 GEM_AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE _ $18,000,000 X PRO- Ill POLICY n/ECT LOC PRODUCTS-COMP/OP AGG $6,000,000 OTHER Liquor Liability Um Included o A AUTOMOBILE LtAN LRY ISA 1125301274 08/01/2019 08/01/2020 COMBINED SINGLE LIMITio (Ea accident) $5,000,000 X ANYAUTO BODILY INJURY(Per person) 0 OWNED SCHEDULED BODILY INJURY(Per accident) Z —HiRREEDAU ONLY NON-OWNED PROPERTYDAMAGE3 —ONLY —AUTOS ONLY — E so a x UMBRELLA UAB X OCCUR X00G2794761A004 08/01/2019 08/01/2020 EACH OCCURRENCE $10,000,000 t) — — SIR applies per policy terms & conditions $10,000,000 EXCESS UAB CLAIMS-MADE AGGREGATE DED X RETENTION A WORKERSCOMPENSATION AND WLRC6604287A 08/01/2019 08/01/2020 x PER STATUTE OTH- EMPLOYERS'LIABILITY Y' ANY PROPRIETOR/PARTNER/EXECUTIVE �INN AOS ER C OFFICER/MEMBEREXCLUDED? I . I N/A EWT008362504 08/01/2019 08/01/2020 E.L.EACH ACCIDENT $2,000,000 (Mandatory In NH) TX E.L.DISEASE-EA EMPLOYEE $2,000,000 I yu,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $2,000,000— inli DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached*more apace Is required) Blanket Additional Insured for General Liability and Waiver of Subrogation for General Liability status extend to those parties to whom the Insured has contractually agreed to provide this status. Safeway Inc. is a qualified self-insurer for workers' * Compensation in the following states: AZ, CA, CO, HI, MT, OR, WA. Albertsons LLc is a qualified self-insurer for workers' Compensation in the following states: AZ, CA, HI, MT, OR. -a-.'a e*: z CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF HIR: ABOVE DESCRIBED POLICES BE CANCELLED BEFORE THE Z EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POUCY PROVISIONS. VI Albertsons Companies, Inc. Including Safeway Inc. AttrHOR�DREPRESENTATNE Albertson's LLc & Subsidiaries 250 East Parkcenter Blvd. "3 W Boise ID 83706 USApa 6'� G 1.1 ©1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: 570000070861 G[3RC� LOC#: ' ADDITIONAL REMARKS SCHEDULE Page _ of _ AGENCY NAMED INSURED Aon Risk Services Central, Inc. Albertsons Companies, Inc. POLICY NUMBER See Certificate Number: 570077666367 CARRIER NAIC CODE See Certificate Number: 570077666367 EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM ISA SCHEDULE TO ACORD FORM, FORM NUMBER: ACORD 25 FORM TITLE: Certificate of Liability Insurance INSURER(S)AFFORDING COVERAGE NAIC# INSURER INSURER INSURER INSURER ADDITIONAL POLICIES If a policy below does not include limit information,refer to the corresponding policy on the ACORD certificate form for policy limits. POLICY POLICY LIMITS INSR ADDL SUBR POLICY NUMBER EFFECTIVE EXPIRATION LTR TYPE OF INSURANCE INSD /VD DATE DATE (MM/DD/YYYY) (MM/DD/YYYY) WORKERS COMPENSATION C N/A EWr320330000 08/01/2019 08/01/2020 WY ACORD 101(2008101) ®2008 ACORD CORPORATION.All rights reserved. The ACORD name and logo are registered marks of ACORD y4 1