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HomeMy WebLinkAboutApplication and WC ... TOWN OF YARMOUTH BOARD OF HEALTH • APPLICATION FOR IACENR .. •Please trandote farm and attach all areaseswy o Fal to tb ao will kill* of , a )'I �il�i � d.:- / d Falba) f f 6gA§n ALL O�J `� ESTABLISHMENT NAME: t *. ,o L. ,# ✓ LOCATION ADDRESS:' I"!• ' l� "s, f h e rN Te: #: �"rT' 3, . MAILING ADDRESS: EMAIL ADDRESS: 'WO i b;cl Qv g1/4-C gc.kot7i......_ *^ OWNER NAME: CORPORATION NAME /7CAtILE) MANAGERS NAME: IL, Tilt' MAILING ADDRESS: POOL CERTIFICATIONS: a I ili The Pt be i as a Pod Operatar,as dared by Serie law.Pleaaaih E c_ ( , Pool Ope ar(s)and steams ofdre on m this fent —� = N L,il cosies o2 operators moot list a minimum of two. oes r certified in standard Fad Aid Pool v o In! and suede to The Cardiopulmonary Resuscitation(CPR),hawk one testified serepielog°almonds al atheimativM st t me t �Ple 6t -1 Cominuinty ca years'rereard& Yoe awlp aid*sew esp s and<—a Rhe at yaw pipes past 1. 2. 3, 4. 3 k � FOOD PROTECTION EC7ION MANAGERS-CERTIFICATIONS: :Qiii.. , All food service eafai disMileses we lid to invest least sae who i : ihilleablaidalli r.as defined in the State Sanitary Code for Food Service Estallashataide,103 000, Please attach copies ofoartifl tions m Tell a nett itparit Bain'P L Yon provide new espies aid_adataaln a Ma at your 1. lAd...- /IC C Cot,ktil 2. 17'7', . -... PERSON IN CHARGE: _ Each food mutt have a#least one Person In Chop(PIC)on site during howl otepeaahca. �� I. t.""z-- fr4e C4G ati 2. ALLERGEN€ERtTIFICATIONS: All food service establisisnelES an togahred to have at least orate fatl.id s as defined in the Side Sanitary Code forFood Service 105 CMR S copies of crtifc tionmthis ViteHalms �( !tae. . You Hepar win Rant tae pie!Imo'eaaand !Far mist rnavide> ,r establishment. 1. Cie rCaLei t t C4 2. illiRvILICH CERTIFICATIONS: AU food service"eats Mangover with 25 seats or more must have at least one employee teamed in the HeimEarth on the premises at all times. Please list your meted below and You nest ofemployee certification's)this ken. The want*alae karat pun'reeor ds. oviiie� +ajend��!file at year �. I. /"`e 2 /Y`c l4. C't ' 3. Rik e,_.,. 4. ti-VI M fJ i'i RESTAURANT SEATING: TOTAL# 'S 1'x?i4F-14-04k7-e6 LODGING: OFFICE OPEN REQUIREDLICENSE FSE PERMIT_ _ _ t REOB FEE PERMITS L -L�NN"''" $GE $5s33 —CAMP 5.13 a .: rim 1 T L --- sm. PARR MOS tY a.rea I fess MOD MDIVICT.: LICENSE IIMCLUIRED FEE PERMIT I tx FEE PERMITS UCENIE__.. , R ,. PERMITS M.100 0.100 ESEATS /�S'.7t marl Ri $35 NON. yj CORISION VIC, sbo ...-7E-1� _ ,;a BREAM.aayevrcR: --RBMti LICEISBE SEGIMIED PEE PERMIT 0 y M 'i,a 6 fill>5 pFERBOTS ^__'<y5rn a. :iso WN DEEREEr$10 IL Bi.L� b a; NAME MANGE: $15 AIMMIII * N f Florio, Mary Alice From: Florio, Mary Alice Sent: Monday, December 2, 2019 12:51 PM To: St. Pius X School (dkostecki@spxschool.org) Subject: 2020 License Application Attachments: Yarmouth 2020 General Business License App.pdf Good afternoon. Hope you had a nice Thanksgiving. Thank you for sending the renewal application,certifications and payment for the St. Pius X School food service licenses. However,the first page of the application is missing. I have attached another blank application. Would you please fill out the top section to confirm licensing information (you don't have to bother with the second side since I received that from you)and return it to me at your earliest convenience. Thank you. MaryAlice Florio Principle Office Assistant Yarmouth Health Division 1146 Route 28 South Yarmouth, MA 02664 508-398-2231,ext. 1241 1 ADMINISTRATION S PXS Rt$5.1N*-- v 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 Wwkcr ___ Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSUIEL- 1 ==' AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR DEC 0 2 2019 CERT.OF INSURANCE ATTACHED OR HEALTH DEPT. WORKER'S COMP.AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid pri to renewal or issuance of your permits. PLEASE CHECK 1. APPROPRIATELY IF PAID: / *` , l` °• H ll/J 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.MG or 830 CMR MG,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 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 RE UIRE A SITEIPLAN. /�� DATE: 1111'711-9 SIGNATURE: �I .9A0 r'-" d R _ PRINT NAME&TITLE: 1-)' 1-(f 167 O i ci&t / i u c we3s 11 '1 & _ Rev.10115/19 The Commonwealth of Massachusetts _ Department of Industrial Accidents `c_�+ � ' Office of Investigations Q 1 Congress Street,Suite 100 Boston,MA 02114-2017 •r•F,• 4t' www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Or anization Name: c+'. 1I LAS K Address: 2l 1,)e 12-1 S_ Yoty-vl.,,ar4A-l1/4_ frt4 0266 City/State/Zip: Phone#: 57g 3 ( e g (IL Are y I u an employer?Check the appropriate box: Business Type(required): 1.g 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.❑ We are a corporation and its officers have exercised 9. 0 Entertainment their right of exemption per c. 152, §1(4),and we have 10.0 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 *My 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 employees. Below is the policy information. Insurance Company Name: R S Sack,)S, -ft CcA (`c c}€-I v7 S�^✓c kc e Gr Insurer's Address: 66 1 �(IS&V. L,1�. c City/State/Zip: �`'`'i+k''ev M o2 l a9`r Policy#or Self-ins.Lic.# ,000 00 (Q ZA( I Expiration Date: 3 ) 3 j I 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$1,500.00 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: C " Date: 11 1 (� [ / 9 Phone#: -b 3q Q 611 2— Official 12— 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 } 1 AC Rd CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 1/4.4....---- 07/08/2019 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: Massachusetts Catholic Self Insurance Group PHONE a : 617-746-5742 F .No): 617-779-4572 66 Brooks Drive moRLEss: losscontrol@masscatho1ic.org INSURER(S)AFFORDING COVERAGE NAC* Braintree MA 02184 INSURER A: Massachusetts Catholic Self Insurance Group NSURED INSURER B: Diocese of Fall River,MA INSURER C: Office of The Chancery INSURER D: 450 Highland Avenue/POB 2577 INSURER E: Fall River MA 02722 INSURER F: :OVERAGES 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. .7'R TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS AMID WSJ„ _(AIMNDIYYYY)�IMDD/YYYY1_ COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PROpi - JECT LOC PRODUCTS-COMP/OP AGG $ OTHER:- $ AUTOMOBILEUABILRY CO INEoDtSINGLELIMIT $ (Ea accid ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY _ AUTOS ONLY (Per accident) - $ $ UMBRELLALIAB _ OCCUR EACH OCCURRENCE - $ EXCESS UAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X PERATUTE ET AND EMPLOYERS'LIABILITY Y/N Certificate of Approval 03/31/2019 03/31/2020 I, ANYPROPRIETOR/PARTNER/EXECUTIVEN/A Commonwealth of E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBEREXCLUDED7 (Mandatory In NH) Massachusetts E.L.DISEASE-EA EMPLOYEE $ 1,000,000 Irdescribe under 3000001012019 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 ESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) 2e:St.Pius X School 321 Wood Rd So.Yarmouth,MA 02664 Evidence of Workers Compensation :ERTIFICATE HOLDER CANCELLATION Town of Yarmouth, MA SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 1146 Route 28 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. South Yarmouth, MA 02664 AUTHORIZED REPRESENTATIVE I at''. 140.4***t.Lr ©1988-2015 ACORD CORPORATION. All rights reserved. CORD)25(2016/03) The ACORD name and logo are registered marks of ACORD )