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HomeMy WebLinkAboutApplication and WC Z 2-, TOWN OF YARMOUTH BOARD OF HEALTH (f 60 APPLICATION FOR LICENSUPEIUVIIT-2020 *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 LICEIVSES MUST RETURN FORMS BY NOVEMBER 15'1'. ESTABLISHMENT NAME:54-0p4 Shop 5 u..p efrnarikel- -44rap.. TAX ID: LOCATION ADDRESS:SS- 1-( r), Porta D r't v t 5 la.r mou.4-4-, TEL.#: 5 o 8- 391-1- t 2-.. 9 MAILING ADDRESS:1.4C-e0S\rucl:5-E,0: I 3 RS H WIC of.k 5-f-• Qt.ti..nc..1 m4 0,214A E-MAIL ADDRESS: 5 tts a n•Fox g) 12-tA-GZA NOLA sin.tss 9•erv'tcr'S•core) OWNER NAME:"Tile S 4-c,p 4-Shop S v.p e r mos P..e 4- C._a rrvari.1 LL-C.. --3 ) CORPORATION NAME(IF APPLICABLE):-the 54-op t-Shop 5 Li><2 i Akcsi_ci<e A- Co. L.• LC MANAGER'S NAME: TEL.!: ,5-09-3 q4/-/2 3/ MAILING ADDRESS: So-rn e a 5 ck- bovC POOL CERTIFICATIONS: Iib,, 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 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 50: c--) 111111 employees below and attach copies of their certifications to this form.The Health Department will not use past _r_71 (...'' years' records. You must provide new copies and maintain a file at your place of business. T P-, /-.) 1. 2. ." cz, [lull 3. 4. -0 .._. co ') 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. --•-e 60.4 'b e S 10,r-e z._ 2. P&L&Q_ ID trci -c ke— $g PERSON IN CI IARGE: ..--0 • Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. 04.70 1. Pcm.xl ID e p r€ 7- 2. ALLERGEN CER'TIFICAT1ONS: All food service establishments are required to have at least one full-time employee who has Allergen certification, 0 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 pr vide new copies and maintain a file at your establishment. I. CO..k\ 64r Sp ft_2-- 2. C-POLLa Sr HEIMLICH CERTIFICATIONS: /11/A 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# A)/A (3,64f.-15-103(0—05-- 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 $55 SWIMMING POOL$I 10ea —LODGE $55 TRAILER PARK $105 —WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMI r 8 LICENSE REQUIRED FEE PERMIT 8 LICENSE REQUIRED FEE PERMIT# 0.100 SEATS $125 CONTINENTAL S35 NON-PROFIT $30 _ >100 SEATS $200 COMMON VIC $60 WHOLESALE $80 —RESID.KITCHEN $80 - - RETAIL SERVICE: LICENSE REQUIRED LEE PERMIT# LICENSE REQUIRED FEE P' I r# 0 LICF,NSE REQUIRED FEE FERMI r 8 <50 sq ft $50 i >25,000 sq ft $285 Cose VENDING-FOOD $25 —<5,000 sq.11. $150 _ _FROZEN DESSERT $40 TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE = $ 2-155.00 *****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 A 1 I ACHED / 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 640,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 colifonn 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 he 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 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 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 REQ RE A SITE PLAN. DATE: ///-7//9 SIGNATURE: PRINT NAME&TITLE: c - CS (-(7-(1( OrAl--CN,r Rev.10/15/19 The Commonwealth of Massachusetts 1,,_;-a Department of Industrial Accidents rk� t Office of investigations _`°, 600 Washington Street ` Boston, MA 02111 *'° www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: The Stop &Shop Supermarket Company LLC Address: 1385 Hancock St City/State/Zip; Quincy MA 02162:. Phone#: 800-288-8415 Are you an employer?Check the appropriate box: Business Type(required): 1.1 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.teal estate,auto,etc.) employees working for me in any capacity. [No workers'comp.insurance required] g- QNon-profit 3.❑ We are a corporation and its officers have exercised 9. [1 Entertainment their right of exemption per c. 152,§1(4),and we have 10 0 Manufacturing no employees.[No workers'comp.insurance required)* 11.❑Health Care 4.0 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. /am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: Ahold Delhaize America Holding,Inc.and its subsidiaries Insurer's Address: 1385 Hancock St City/State/Zip: Quincy MA 02169 — Policy#or Self-ins.Lic.# 576 Expiration Date: IS D 2..0 Attach a copy of the workers'compensation policy declaration page(showing the policy number an* 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 cerci u. the pains and penalties of perjury that the information provided above is true and correct ,r-,4'. if - , r imonsr 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 oat): 1. Board of Health 2.Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office 6. Other 4. Contact Person Phone# www.mass.g*' iiia r +.''mill Page 1 of 2 ACGREPm CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY) �' 09/13/2019 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 Willis Towers Watson Certificate Center Willis of North Carolina, Inc. PHONE pq)( c/o 26 Century Blvd (A/C.No.Ext): 1-877-945-7378 �A/C,_No): 1-888-467-2378 P.O. Box 305191 E-MAIL ADDRESS: certificates@willis.com • Nashville, TN 372305191 USA INSURER(S)AFFORDING COVERAGE NAIL# _ INSURERA: ACE American Insurance Company 22667 INSURED INSURER B: Allianz Global Risks US Insurance Company 35300 The Stop and Shop Supermarket Company LLC 1149 Harrison Pike INSURERC: Indemnity Insurance Company of North Ameri 43575 Carlisle, PA 17013 USA • INSURERD: ACE Fire Underwriters Insurance Company 20702 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:W12636142 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. INSR1 TYPE OF INSURANCE ADM SUER" I POLICY EFF POLICY EXP LTR INSD WVD POLICY NUMBER I(MM/DD/YYYY):(MM/DDIYYYY)1 LIMITS X COMMERCIAL GENERAL LIABILITY i EACH OCCURRENCE $ 2,000,000 CLAIMS-MADE X OCCUR ; DAMAGE TO RENTED PREMISES(Ea occurrence) $ 2,000,000 A MED EXP(Any one person) $ Excluded HDO G71210650 10/01/2019'12/01/2019 PERSONAL&ADV INJURY $ 2,000,000 GE 'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 PRO- X POLICY JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: _ AUTOMOBILE LIABILITY . COMBINED SINGLE LIMIT (Ea accident)_ $ 10,000,000 X ANY AUTO BODILY INJURY(Per person) $ A OWNED (— SCHEDULED ISA H25268349 110/01/2019112/01/2019 BODILY INJURY(Per accident) $ AUTOS ONLY 1 AUTOS HIRED - NON-OWNED - PROPERTY DAMAGE $ AUTOS ONLY L AUTOS ONLY (Per accident) $ B X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000 EXCESS LAB CLAIMS-MADE USL00169518U 12/01/2018',12/01/2019 AGGREGATE $ 5,000,000 X DED RETENTION$ 10,000 I i $ WORKERS AND EMPLO CPERS'LIABILITY Y/N , X PER OTH- STATUTE 1 l ER C ANYPROPRIETOR/PARTNERJEXECUTIVE E.L.EACH ACCIDENT1,000,000 9 OFFICER/MEMBEREXCLUDED? No N/A WLR C66042595 ;10/01/201 12/01/2019: $ (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below I i E.L.DISEASE-POLICY LIMIT $ 1,000,000 D Workers Compensation SCF C66042674 10/O1/2019!12/01/2019'1E.L. Each Accident $1,000,000 and Employers Liability --WI !E.L. Disease-Ea Empl $1,000,000 • Per Statute ,E.L. Disease-Pol Lim $1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Umbrella policy follows underlying in regard to Additional Insured and Waiver of Subrogation wording. SEE ATTACHED 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. The Stop 6 Shop Supermarket Company LLC AUTHORIZED REPRESENTATIVE 1149 Harrisburg Pike /� )) ,�-JJ���� Carlisle, PA 17013 sr f</.G3 4 ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD SR ID: 18510561 BATCH: 1367599 AGENCY CUSTOMER ID: LOC#: ARL ADDITIONAL REMARKS SCHEDULE Page 2 of 2 AGENCY NAMED INSURED Willis of North Carolina, Inc. The Stop and Shop Supermarket Company LLC 1149 Harrison Pike POLICY NUMBER Carlisle, PA 17013 USA See Page 1 CARRIER NMCCODE See Page 1 See Page 1 EFFECTIVE DATE: See Page 1 ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance INSURER AFFORDING COVERAGE: ACE American Insurance Company NAIC#: 22667 POLICY NUMBER: WCU C66042637 EFF DATE: 10/01/2019 EXP DATE: 12/01/2019 TYPE OF INSURANCE: LIMIT DESCRIPTION: LIMIT AMOUNT: Excess Workers Comp. E.L. Each Accident $1,000,000 Per Statute E.L. Disease-Ea Empl $1,000,000 E.L. Disease-Pol Lim $1,000,000 INSURER AFFORDING COVERAGE: ACE American Insurance Company NAIC#: 22667 POLICY NUMBER: WLR C66042716 EFF DATE: 10/01/2019 EXP DATE: 12/01/2019 TYPE OF INSURANCE: LIMIT DESCRIPTION: LIMIT AMOUNT: Workers Compensation E.L. Each Accident $1,000,000 and Employers Liability-MA E.L. Disease-Ea Empl $1,000,000 Per Statue E.L. Disease-Pol Lim $1,000,000 • ACORD 101 (2008/01) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD SR ID: 18510561 BATCH: 1367599 CERT: 9712636142 The Stop &Shop Supermarket Company LLC Officers and Managers Title Name President Gordon Reid Secretary Mark Messier Assistant Secretary Maria Silvestri Managers: Steven Kienzle Manager Gordon Reid Manager Stacy Wiggins Manager Robert Yager Manager