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Home My WebLink AboutApplication and WC 7.9-°-Nti --`) TOWN OF YARMOUTH BOARD OF HEALTH APPLICATION FOR LICENSE/PERMIT-2020 .00, ./ *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 LIQUOR LICENSES MUST RETURN FORMS BY NOVEMBER Ism. ESTABLISHMENT NAME: F:Cb'yo\Dam_ TAXii LOCATION ADDRESS: 55 .14ju tr...tj „pg \M. avolotAitATiL.#: 509,441-OC.99 ,.., MAILING ADDRESS: #6,,s Co6ay 0 E-MAIL ADDRESS:,,r ,, (4 . el( 4, • ,, AA OWNER NAME: Dersirre CORPORATION NAME(I .PPLICABLE): li:)1i)i--i LLC.. MANAGER'S NAME: \-Wevirti 640,614.1".. TEL.4: MAILING ADDRESS: 5kcelivle q_s \J rtlna4e POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated otey0-1 Pool Operator(s)and attach a copy of the certification to this form. I. S\lcvrv.:r( 4 . PatO 2. Pool operators must list a minimum of two employees currently certified in standard First Aid and Community eili3no 0‘)06 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 Or 0 years'records. You must provide new copies and maintain a file at your place of business. 0 t I. k-A-,--...,„ 2, ',4.e\kci Rkitte elVf°1‘,.) \33C1 3 4. w 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. 2. PERSON IN CHARGE: I r\-) Lull; Ic-=, Each food establishment must have at least one Person 1.nN)Charge(PIC)on site during hours of operation. 0 Fri C:3 C -1 !M ;1 1. 2. H c ALLERGEN CERTIFICATIONS: Al!food service establishments are required to have at least one fill-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. /. r-- a : HEIMLICH CERTIFICATIONS. ' ..... 2, 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 ,—"77t, 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. -:`-, , - ookkt--N- 65-13-0(0 RESTAURANT SEATING: TOTAL# . 13 W-59-41‘4--059q--03.(40 OFFICE USE ONLY 66,..v.e_tt.4.-ciscivo-6(0 LODGING: LIC'ENSE REQUIRED FEE PERMTE 4 LICENSE RE QUM!D lit PERM11 P LICENSE REQUIRED EH PEI2t!b# I3&B $55 CABIN $55 . MOTEL $110 —INN $55 CAMP $55 -1-swtmmi NG POOL.SIICea. -LODGE $55 —— MAILER PARK $105 WHIRLP001, S I 10ea FOOD SERVICE: IACENSE RE,QUIRED FEE PERMIT# LICENSE REQUIRED IT't PERMI r# LICENSE REQUIRED FEE PERMIT A 0-100 SEATS $125 J....CONTINENTAL $35Sti___11,1 NON-PROFIT $30 —>100 SEATS $200 COMMON VIC, Sot 'WHOLESALE $80 --RESID KITCHEN $50 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT 4 LICENSE REQUIRED PEE PERMITS LICENSE REQUIRED FEE PERM!Ft ,50 sot. $50 25.000 gq.ft. $285 VENDING-FOOD 825 <25,000 sql, $150 _FROZEN DE S SERT $40 TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE ,--- S ,955,.00 * ***PIA:ASE 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 RE 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: YESLV. 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.64G or 830 CMR 640,as amended,shall generally be considered Transient. POOLS POOL OPENING:All swithming,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 wvvw.yannouthana.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 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 Ito 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 HEALTII PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: I k q (1 SIGNATURE: PRINT NAME&TITLE: 11(EA, 6/1ctiC IctMelineif Rev 10115/19 The Commonwealth of Massachusetts n orm Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 �.,� Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: p TI 1_L C f1 ECS► L Address: S8 EZ.9. > \IAct/Nipdti Tn A 0,7 6y43 City/State/Zip: ( - oa(043 Phone #: g - 4-1- o G99 Are you an employer?Check the appropriate box: Business Type(required): 1.El'I am a employer with 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 3.0 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 4.0 We are a non-profit organization,staffed by volunteers, / with no employees. [No workers' comp. insurance req.] 12. they_ %y,k t k — 4oke /( a . *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy informjtion. Z **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: }AcAs evk iV�St�C.o'vi(0 Cs i — ` )0/4V lmei 1Nic� 'l� Insurer's Address: tt 1 City/State/Zip: N ( v_S k A_ - 0?6 O\ Policy#or Self-ins. Lic. CO�3SS Expiration Date: NAy r A �J 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 pains and penalties of perjury that the information provided above is true and correct. Signature: � Date: i 06, 20:1A Phone#: $-41-1.0 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 A Worker's Compensation and Employer's Liability Policy NorGUARD Insurance Company - A Stock Co. �V;Berkshire Hathaway � Policy Number DIWC070355 ��r Insurance Renewal of DIWC966617 4'A GUARD Companies NCCI No. [25844] Policy Information Page 1[1]Named Insured and Mailing Address Agency Dipti, LLC DOWLING &O'NEIL INSURANCE AGENCY DBA/TA Econolodge 973 Iyannough Road 59 Route 28 West Yarmouth, MA 02673-8105 ya HBox 1990 Hyannis, MA 02601 Agency Code: MADOWL10 Federal Employer's ID Insured is Limited Liability Co. (LLC) Additional Names of Insured (N2) Econolodge [2] Policy Period From November 24, 2019 to November 24, 2020, 12:01 AM, standard time at the insured's mailing address. [3] Coverage A. Workers' Compensation Insurance - Part One of this policy applies to the Workers' Compensation Law of the following states: Massachusetts B. Employer's Liability Insurance - Part Two of this policy applies to work in each of the states listed in item [3]A. The limits of our liability under Part Two are: Bodily Injury by Accident - each accident $500,000 Bodily Injury by Disease - each employee $500,000 Bodily Injury by Disease - policy limit $500,000 • C. Other States Insurance - Part Three of this policy applies to all states, except any state listed in item [3]A. and the states of North Dakota, Ohio, Washington, and Wyoming. D. This policy includes these endorsements and schedules: See Extension of Information Page - Schedule of Forms [4] Premium The Premium Basis and, therefore, the premium will be determined by our Manual of Rules, Classifications, Rates, and Rating Plans. All required information is subject to verification and change by audit. (Continued on another page) Total Estimated Policy Premium $ 1,524 Total Surcharges/Assessments $ $39.00 Total Estimated Cost $ $1,563.00 INTERNAL USE XX Page - 1 - Information Page MGA : DIWC070355 Date : 10/20/2019 WC 000001A MANOTE Issuing Office: P.O. Box A-H,39 Public Square, Wilkes-Barre, PA 18703-0020 • www.guard.com ,f. ..e Worker's Compensation and Employer's Liability Policy 7 tit 1 Berkshire Hathaway NorGUARD Insurance Company - A Stock Co. a Policy Number DIWC070355 GUAR® CoInsuranm anies Renewal of DIWC96661 P NCCI No. [25844] • Policy Information Page r4] Premium (cont.) Massachusetts Classification Code Premium Basis: Rate per Estimated Total Estimated $100 Annual Annual Remuneration Premium Remuneration Effective: 11/24/2019-11/24/2020 " HOTEL-ALL OTHER EMPLOYEES 9052 78 719.00 111111111111111111E1 1 173 ncreased Limits Em• Liabili 500 500K/500K 9807 1.0% 12 mt to Bal Inc Lim 38 Merit Modification 0.95 -61 otal Estimated Annual Premium for MA 1 162 Policy Totals Total Estimated Standard Premium for Massachusetts 1,162 Expense Constant 338 Total Terrorism MA 9740 0.03 78,719 24 Minimum Premium MA $281 Total Estimated Annual Premium 1,524 MA State Assessment 11/24/2019-11/24/2020 3.5100% 39 Total Estimated Cost for DIWC070355 1,563 INTERNAL USE XX Page - 3 - MGAInformation Page : DIWC070355 Date : 10/20/2019 WC 000001A MANOTE Issuing Office: P.O. Box A-H, 39 Public Square,Wilkes-Barre, PA 18703-0020 • www.guard.com