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HomeMy WebLinkAboutApplication and WC TOWN OF YARMOUTH BOARD OF HEALTH ft- APPLICATION FOR LICENSE/PERMIT +x292 i ; , NOV 2 2 2019 * Please complete form and attach all necessa ., Qu p 0/,2:_;.,,< be •i: EPT Failure to do so will result in the return o ur ttpplica ion pac - NOTE:ALL BUSINESSES WITH LIOUOR LICENSES MUST AZTURN FORMS BY NOVEMBER 15th. ESTABLISHMENT NAME: da- r n TAX ID: LOCATION ADDRESS: C,G Mcuc) Q.* a8 Wee0areflov.A, MA o TEL.#: c -T4s ( 2, MAILING ADDRESS: e- E-MAIL ADDRESS: da js+(V) 0de5 Maa. cwM OWNER NAME: `D 0-r4-1) CORPORATION NAME(IF APPLICABLE): MANAGER'S NAME: N o-' e-\ TEL.#: . 810 E,o34+ MAILING ADDRESS: POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designate ' Pool Opeiator(s)and attach a-copy of the certifica�n J 1. 3 �O + 2. .�� r ' `j- Pool operators must list a minimum of two employees currently certified in standard First Aid and Co unity , 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. ] O 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 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: Each food establishment must have at least one Person In Charge (PIC)on site during hours of operation. 1. 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 file at your establishment. 1. 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. 2. 3. 4. dots C.-15-l508-06- RESTAURANT SEATING: TOTAL# BOy. 547-1Gi- 7912A QUI LODGING: OFFICE USE ONLY 6014F-19-1S09-05- LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT it B&B $55 INN $55 —C� $55 f MOTEL $110 a0-' t $55 LODGE $55C� T SWIMMING POOL$110ea. . TRAILER_ PARK $105 WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 .L CONTINENTAL $35 *2040O 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 _<25,000 sq.ft. $150 -FROZEN DESSERT $40 _TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE = $ a 55.00 *****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 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,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 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 REQUIRE A SIT AN. DATE: ///?2 2 /i / SIGNATURE: PRINT NAME&TITLE: 0 Rev.10/15/19 The Commonwealth of Massachusetts Department of Industrial Accidents E='' t Office of Investigations c. _ 4�1__ 1 Congress Street, Suite 100 Boston, MA 02114-2017. 4,,,z.� www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: P 'ti `�P\tci."-.)03 LLC cDeA 72---,\5 inn Address: q .2 4=6 W Get cz,(-rec-)fin (AA (:),,9- -i ." City/State/Zip: NI\ P., 0' 2(c Phone#: ,.-- -S Are you an employer? Check the appropriate box: Business Type(required): 1.0 I am a employer with employees(full and/ 5. 0 Retail or part-time).* 6. ❑ Restaurant/Bar/EatingEstablishment 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. 0 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]** 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#l. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: t,..\or (5w '--'IkA-c am C-cxn?awn - A enC L1 - ` 1: , O( 4,:rte Ce .. Insurer's Address: 6;1-4'3n a. n ©�C5 -� 6A1 City/State/Zip: sAn-e-sc< INA #s C) 9 "- Policy#or Self-ins.Lic. # XG 2.13--i}‘9 0 Expiration Date: 6v f S l O lO 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 ofcriminalpenalties_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 ththains and penalties of perjury that the information provided above is true and correct Signature: /e — Date: /1 .�2 i � l l Phone#: q -ii SI O G IT 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 Client#:40115 2DAYSINN ACORD„. CERTIFICATE OF LIABILITY INSURANCE DATE(MM/°INYYYY) 08/22/2019 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 any rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: The Hilb Group of N.E.dba PHONE 508 775-1620 1 Marc,No): 5087781218 Dowling&O'Neil Insurance Agy (A/C,AIL EXt). - P.O.Box 1990 ADDRESS:_-- — _ INSURER(S)AFFORDING COVERAGE NAIC# Hyannis,MA 02601 — _ i INSURERA 1 Lloyds of London LLOYDSINSURED 1 INSURER B:NorGuard Insurance Company 31470 Pari Devang Corp.NO Meshwa Corp. INSURER c:Scottsdale Insurance Company 25496 69 Main Street West Yarmouth,MA 02673 INSURER D INSURER E: --- -- ---- ---- --_ — - INSURER F: --- 1 COVERAGES CERTIFICATE NUMBER: 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 N.OL SUBRI POLICY EFF I POLICY EXP - — LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER (MM/DDIYYYY)I(MM/DD/YYYY) LIMITS A X COMMERCIAL GENERAL IABILITY X I XSZ137490 06/2812019 06/28/2020 EACHEAqMS?Ea p OCCURRENCEC $1,000,000 CLAIMS-MADE I Xi OCCUR PREMIS occu encs) $50,000 X BI/PD Ded:500 MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $1,000,000 GEM_AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 X POLICY I JE T LOC ( PRODUCTS-COMP/OP AGG $included $ OTHER: . AUTOMOBILE LIABILITY I COMBINED SINGLE LIMIT Ea accident ANY AUTO BODILY INJURY(Per person) $ OWNEDSCHEDULED - AUTOS ONLY i__ AUTOS BODILY INJURY(Per accident) $ HIRED i NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY ' AUTOS ONLY (Per accident) $ C X UMBRELLA LIAB 1 X OCCUR 173743G191ALi 04/30/2019104/30/2020 EACH OCCURRENCE $4,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $4,000,000 DED X RETENTION$10000 B WORKERS COMPENSATION PAWCO9O134 03/1 l2 r; PER OTH AND EMPLOYERS'LIABILITY O 019 03110/202 X STATUTE i ER ANY PROPRIETOR/PARTNER/EXECUTIVE Y!N OFFICER/MEMBER EXCLUDED? NJ N/A 1 E.L.EACH ACCIDENT $500,000 (Mandatory in NH) i E.L.DISEASE-EA EMPLOYEE $500,000 If yes,describe under DESCRIPTION OF OPERATIONS below - - -- E.L.DISEASE-POLICY LIMIT $500,000 I I DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Loc#1 -69 Main Street,West Yarmouth,MA 02673 Certificate holder has been included as an additional insured on the general liability policy.Umbrella Liability Policy is Follow Form to General Liability Policy. Insurance coverage is limited to the terms,conditions,exclusions,other limitations and endorsements. Nothing contained in the certificate of insurance shall be deemed to have altered,waived,or extended the coverage provided by the policy provisions. CERTIFICATE HOLDER CANCELLATION Days Inns Worldwide,Inc. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Wyndham Hotels&Resorts,Inc ACCORDANCE WITH THE POLICY PROVISIONS. Wyndham Hotel Group,LLC 22 Sylvan Way AUTHORIZED REPRESENTATIVE Parsippany,NJ 07054 .n...4: "1,7 C,t::.nr..-. ":.""w„ ©1"9988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) 1 of 1 The ACORD name and logo are registered marks of ACORD #S241847/M238911 RPSW1