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HomeMy WebLinkAboutApplication and WC TOWN OF YARMOUTH BOARD OF HEALT tAPPLICATION FOR LICENSE T a� Y ,. ® .,� , ry DEC 02 2019 * Please complete form and attach all neces a"`jrtdgcu l i • .1£° ; i ''t c• ber 13 2019. Failure to do so will result in the rete f your dip ication pa. et.HEALTH p 4-T NOTE:ALL BUSINESSES WITH LIOUOR LICENSES MUST RETURN FORMS BY '0 ' • . ESTABLISHMENT NAME: A,otcc //0 /✓%1c Ei2,y TAX ID: LOCATION ADDRESS: 9'// , di-S 5-ou41 ydr„,,j-g. d?-4.4 TEL.#: 5o8 67V- SC65 MAILING ADDRESS: 496 4 sok-, .Y . .Ak Di Anil huL, cr)-64 E-MAIL ADDRESS: OWNER NAME: "I rriji OLJ S C4 P/cc/IJO CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: /12A y7 to ,5 //cC/i/) TEL.#: 7 9 y-o2/72--'X $ MAILING ADDRESS: 1,6 A 49r,. 5o. Jz. d' /'h4_ POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Opera'toT(s)andatta+- py 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 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 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. 71447 W 1'J c5€6,/ 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC)on site during hours of operation. 1."Frriiiiv2. 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. Mir----/011 YMP/C .4//a 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 _LODGE $55 CAMP $55 _SWIMMING POOL$I 10ea. _TRAILER PARK $105 _WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 1 0-100 SEATS $125 z.9.0 toe CONTINENTAL $35 NON-PROFIT $30. >100 SEATS $200 1 COMMON VIC. $60 `b U j�j —WHOLESALE $80 ' RETAIL SERVICE: RESID.KITCHEN $80 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 = $ /8540 *****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 ito 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 t/ 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 tinted-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 SITE PLAN. DATE: ,4 fir, /P, g-oj q SIGNATURE: /7h2 =ei,e-.2-jef,e- e----- PRINT NAME&TITLE: /AI 77 /ak/ 5c/fie/caiit "ene-, a e Rev.10/15/19 The Commonwealth of Massachusetts i Department of Industrial Accidents • Office of Investigations 1 Congress Street, Suite 100 r.- n Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: c4 P/CGh(/& S /0/9/e--(i4 Address: ?V/ 47% City/State/Zip: �.7.c.)(../� yai'th v41 A/ Mad a?- Phone#: 61V - 1 Are you an employer? Check the appropriate box: Business Type(required): 1. n I am a e Toyer with 7 employees (full and/ 5. 1] Retail or art-time * 6. ❑ Restaurant/Bar/Eating Establishment 2. I 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. ❑ 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.❑ Other .3/9 - % 7- 47/L *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. **lithe 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: /-)4a,•.7t ur-/ ' J,—t e (am", off' � e Z Insurer's Address: 3(,66 /ll uem eV /3'14, City/State/Zip: "4 a c c s `?4r--..25 / Policy#or Self-ins.Lic.# CJ (k) c..4 C ci/e G k Expiration Date: 7/1 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$1,50f.00-and/or one-year imprisonment,as well as civiFpenalties in theTorm of aSTOP 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. Si atur- --- _/ Date: r Phone#: /.Z — L// 3 I 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 ^", SCAPBAK-01 MVAUGHAN ACORO' CERTIFICATE OF LIABILITY INSURANCE DATD/YYYY) �� 3/15/2019 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 NAME: Rogers&Gray Insurance Agency,Inc. PHONE FAX 434 Rte 134 (ac,No,Ext):(800)553-18011 (NC,No(877)816-2156 South Dennis,MA 02660 E-MAILDSS:mail@rogersgray.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Twin City Fire Insurance Company 29459 INSURED INSURER B:Hartford Insurance Company of the Southeast 38261 Scapicchio Bakery,Inc. INSURER C:9 340 W ileMan_ /3/'d - 66 Asack Drive INSURER D: 5 y,, Aden,b 7((4'c 7 6111 South Dennis,MA 02660 INSURER E: 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. INSR TYPE OF INSURANCE ADDL SUER POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD WVD (MM/DD/YYYYI (MM/DD/YYYYI A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR 08SBAAC3612 12/11/2018 12/11/2019 DAMAGE TO RENTED PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GE 'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ _ AUTOS ONLY AUUTOSONLYY (PerracEcidentDAMAGE $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ B WORKERS COMPENSATION PER OTH- ANDEMPLOYERS'LIABILITY STATUTE ER Y/N 08WECAC9RGX 3/15/2019 3/15/2020 500,000 OFFICER/MEMBERANY /EXCLUDED?ECUTIVE I N/A E.L.EACH ACCIDENT $ ' (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) ***RETAIL BAKERY LOCATED AT 941 ROUTE 28,UNIT C,SOUTH YARMOUTH,MA 02664*** CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE ***FOR INFORMATIONAL PURPOSES*** THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE7 I C .-.);—rotri‘l ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD THE COMMONWEALTH OF MASSACHUSETTS Department ofIndust i'al Accidents '= � Office of I Congress Street,Suite 100 Boston,Massachusetts 02114 March 12,2019 Scapicchio Bakery,Inc. 66 Asack Drive South Dennis,MA 02660 Notice of Decision Regarding = -- =--- Affdavtt_of_Exemption.for Certain-Corporate-Officers-or Directors-__:__ Pursuant to the provisions of MGL 152, Section 1 (4)as the amended by Ch. 169 of the Acts of 2002 your affidavit has been reviewed and the Office of Investigations has determined the following: NOTE: It is your obligation to submit an approved affidavit to your insurance carrier in order to complete this process. X The affidavit was approved on 3/12/2019 . Attached please find your approved affidavit. The affidavit was rejected on . Your affidavit was rejected for the following reason(s): Related SWO Case ID#: Affidavit ID#: 189372 Tel.g(617)727-4900 - www.nnass.govidia FORM 153 The Commonwealth of Massachusetts . .z: e . Department of Industrial Accidents MAR 12 2019 II, Office of Investigations-Dept.153 '''---.77218',47,-7)' ='/ 1 Congress Street,Suite 100,Boston,Massachusetts 02114-2017 •,,,�:-r.-r--.+--T,r,--ma, —::n_ Industrial ccidente _,t,;_ >ittp://wrrwarw�.gav/diu •'i'� —__ ' _=-• AFFIDAVIT OF EXEMPTION FOR CERTAIN CORPORATE OFFICERS OR DIRECTORS Chapter 169 of the Acts of 2002 amended MG L. c. 152, §1(4)by adding the following paragraph: "This chapter shall be elective for an officer or director of a corporation who owns at least 25 percent of the issued and outstanding stock of the corporation.Notwithstanding section 46,these provisions shalt apply only if the corporate officer provides thecommissioner of industrial accidents with a written waiver of his rights under this chapter.Said commissioner shall promulgate regulations to carry out the purpose of this paragraph.Violations of this paragraph shall subject the corporation to the penalties set forth in section 25C." • .._ _ Pursuant-to M G.L.c.152,§1(4)as amended;UW'e the undersigned officers c Setzpicciiio ZediP-t11 ►c) ti)toAs&t1c, Drive. &&ut- .beinist% AO2-.(O (Name of Corporation and Address) each holding at least 25%of the issued and outstanding stock in said corporation,do hereby invoke the right to be exempt from the provisions of M.G.L.c. 152, §25A and therefore are not required to carry a workers' compensation policy covering the undersigned corporate officer(s)or director(s). IfWe the undersigned do also waive any and all rights to make claims for benefits as defined in M.G.L.c. 152 for any injuries that may be sustained while in the employ of the above-named corporation. Further,Uwe the undersigned do understand that,should the above-named corporation hire or have in its employ any employee(s)in addition to the undersigned corporate officer(s)or director(s),said corporation is required to obtain workers' compensation coverage for the employee(s)as prescribed by M.G.L. c. 152, §25A. I/We the undersigned have read and understand the statements and obligations as delineated above and I/we have checked the appropriate box below my/our name(s)indicating my/our desire to be exempt or not to be exempt from the provisions of M.G.L.c. 152. Signed under the pains and penalties of perjury: , Signature Print Name&Title Dia( dd 'yyy) Dill I wish to exercise my right of exemption or ❑_I wish NOT 17o exercise my right of exauution = Signature Print Name&Title Date(mmiddfyyyy) ❑ I wish to exercise my right ofexemption or ❑I wish NOT to exorcise my right of exemption , Signature Print Name&Title Date(mm/ddlYyyyy) ❑ I wish to exercise my right of exemption or ❑ I wish NOT to exercise my right of exemption Signature Print Name&Title Date(mm/dd/yyyy) ❑ I wish to exercise my right of exemption or ❑1 wish NOT to exercise my right of exemption • Note:ALL ELIGIBLE CORPORATE OFFICERS MUST SIGN. THERE CAN BE NO MORE THAN 4 SIGNATURES Instrudians on back. Form 153-7/2010