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Home My WebLink AboutApplication and WC TOWN OF YARMOUTH BOARD OF HEALTH APPLICATION FOR LICENSE/PERMIT-2020 2O *Please complete form and attach all necessary documents by December 13,d01-97 Failure to do so will result in the return of your application packet. NOTE:ALL BUSINESSES WITHLIOUOR LICENSES MUST RETURN FORMS BY NOVEMBER 1.0. ESTABLISHMENT NAME: E�''Ot ui\.% '14CbtA ' 9 Fi SGcvca TAX ID: LOCATION ADDRESS: 02.05-018 iMcelyt . ^� '-/O v rtt 1.� TEL.#: SU' - c'i 4-( CEa._a MAILING ADDRESS: E-MAIL ADDRESS: C Q ceZ_ '-JCILk/`z s 14 a�3—_ Cin (e-S1/4'6. n,e.-- OWNER NAME: ("' CORPORATION NAME(IF APPL CABLE): MANAGER'S NAME: MAILING ADDRESS: CDL/3 — CA(i3t -etToi .-- POOL CERTIFICATIONS: DThe Pool pool Operator(s)and attach a copyor must be ified as a Pool of the certification otthis foras required by State law. Please list the designated [i i( 1. 2. 1Ti Pool operators must list a minimum of two employees currently certified in standard First Aid and Community H CC) Cardiopulmonary Resuscitation(CPR),having one certified employee on premises at all times. PIease 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. 7 3. 4. FOOD PROTECTION MANAGERS-CERTIFICATIONS: j All food service establishments are required to have at least one full-time employee who is certified as a Food k 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. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $110 INN $55 —CAMP $55 =SWIMMING POOL$l I Oea. _LODGE $55 TRAILER PARK $105 _WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT S 0-100 SEATS $125 _CONTINENTAL $35 I 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: :I RED FEE PE _<50 sq.ft. $50 >25,000 sq.ft. $285 V '0 NG-FOOD $25 <25,000 sq.ft. - $150 =FROZEN DESSERT$40 '•BACCO $110 NAME CHANGE: $15 AMOU'' DUE = $ 3n.QQ *****PLEASE TURN OVER AND COMPLETE OTHER SID OF FORM***** ACORE) DATE(MM/DDIYYYY) CERTIFICATE OF LIABILITY INSURANCE September17, 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 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: Tracey Parent The Church Insurance Agency Corp PHONE FAX 210 South St,Suite 2 (NC,No,Ext):(800)293-3525 (NC,No):(800)557-1395 Bennington,VT 05201 E-MAIL ADDRESS: PRODUCER CUSTOMER ID#: INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A: Liberty Insurance Corp Diocese Of Massachusetts INSURER B: INSURER C: INSURER F 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. R SADDL SUER POLICYEFF POLICY EXP _ TYPE OF INSURANCE INSR WVD POLICY NUMBER (MM/DD ) (MM/DD/YYYY) LIMITS GENE�IBILITY EACH OCCURRENCE $ DAMAGE TO RENTED COMMERCIAL GENERAL PREMISES(Ea occurrence) $ CLAIMS-MADE OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE _$ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ LPOLICY PRO-CT LOC $ u I VmUbII-ABILITY COMBINED SINGLE LIMIT (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE HIRED AUTOS (Per accident) $ _ NON-OWNED AUTOS $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION WC STATU- OTH- A AND EMPLOYERS'LIABILITY Y/N Y X WC7625900009019111 9/30/2019 9/30/2020 TORY LIMITS ER PROPRIETOR/PARTNER/EXE E.L.EACH ACCIDENT $1,000,000 CUTIVE r1FFIr:FR/MFPARFR FXr:I I Inpno (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If vea rinenrihn i,nd DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS J LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space is required) CERTIFICATE HOLDER CANCELLATION St Davids Episcopal Church SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 205 Old Main St THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN South Yarmouth,MA 02664-4529 ACCORDANCE WITH THE POLICY PROVISIONS. The Commonwealth of Massachusetts Department of Industrial Accidents - ai Office of Investigations 1 Congress Street,Suite 100 11rf= Boston,MA 02114-2017. www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly 11 � s Business/Organization Name: / , ' T G . 1s. ( _'g Address: +a 05- 0\a rna o 0P-q City/State/Zip: . \ia,041b14l 1 YY16-• "Phone#: A • an employer?Check the appropriate box: Business Type(required): toam a employer with Le employees(full and/ 5. ❑Retail or parttime).* - 6. 0 Restaurant/Bar/Eating Establishment 2.U I am a sole proprietor or partnership and have no 7. ❑ Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers' comp.insurance required] 8• on-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 o employees. [No workers' comp.insurance required]** 4.grd We are a non-profit organization,staffed by volunteers, 11.0 Health Car e with no employees. [No workers' comp..insurance req.] 12.0 Other rikt tkek *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 employee&Below is the policy information. Insurance Company Name: Th€, C Lust .Lt_ I\i&-t,ut-QuA)- r c j l' Insurer's Address: () ; D11�,•1'� S1 • A ` Q City/State/Zip: (,.nn U-o�l VT' Policy#or Self-ins.Lic.# U VIC- 9 D b o b 9 D C S I l 1 Expiration Date:INV ° 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 - fore ulster$1,500.00 and/or one-year imprisonmeai,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 ofperjury that the information provided above is true and correct. Signature: l S • din.... Date: i 1/ P it • Phone#: 61A 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 5.Selectmen's Office 6.Other Contact Person: Phone#: www.mass.govldia