HomeMy WebLinkAboutApplication and WC —TioT.1,3'33W11
a TOWN OF YARMOUTH BOARD OF HEALTH 1 '` 4. 1. O O19
s APPLICATION FOR LICENSE/PERMIT-2020 : ','10
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*Please complete form and attach all necessary documents by embe 13,3019. H ATh bEPr
Failure to do so will result in the return of your application packet. - —
NOTE:ALL BUSINESSES WITH LIQUOR LICENSES MUST RETURN FORMS BY NOVEMBER 15t. f�,
ESTABLISHMENT NAME: E MWelt��'qlc AX ID: . '`'
LOCATION ADDRESS: r ._ F, R ha h r , TEL.#: Cs'o. 3 - Sl 0
MAILING ADDRESS: Y Fnni 1 u . _
E-MAIL ADDRESS: lou i S•e pp e a s4 e s cc. ;• `,
OWNER NAME:
CORPORATION NAME(IF APPLICABLE): E(4�,t. sc itustc, 0'F Lit, Cod 1-+6c I SIda,ls
MANAGER'S NAME: A Clf I u TEL.#: t`
MAILING ADDRESS: y Q i 134 is. beAm c S1 M A 0140 , 1
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POOL CERTIFICATIONS: i
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 I
Cardiopulmonary Resuscitation(CPR),having one certified employee on premises at all times. Please list the 4i
employees below and attach copies of their certifications to this form.The Health Department will not use past •f
yearsrecords. 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. I
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.i
PERSON IN CHARGE:
Each food establishmentlmust have at least one Person In Charge(PIC)on site during hours of operation.
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ALLERGEN CERTIFICATIONS: fi
All food service establishments are required to have at least one full-time employee who has Allergen certification, i
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
providevinew copies and maintain a file at your establishment. '.
1. !1tCac1 1-1 eiusc.k ( 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. I
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3. 4. 1
RESTAURANT SEATING: TOTAL#_ ak „,80APA5-.io33- 6-
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# i
B&B $55 _CABIN $55 _MOTEL $110
INN $55 CAMP $55 SWIMMING POOL$110ea.
_LODGE $55 TR.',ILERPARK $105 _WHIRLPOOL $110ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LIIENSE REQUIRED FEE P IT# 1
0-100 SEATS $125 _CONTINENTAL $35 of NON-PROFIT $30 a
_>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 = $ 1 et)
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** •
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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 /1"j// •
OR
WORKER'S COMP.AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth taxes and liens must be paid prior renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID: ffi
YES NO
MOTELS AND OTHER LODGING ESTABLISHMENTS a
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 .r
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 m 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.
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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.11RENOVATIONS MAY REQUIRE A SITE PLAN.
DATE: aa/a41/j SIGNATURE: C/ ;
PRINT NAME&TITLE: Lai,. [was Aloig,Akaa raM tkoihv9A._
Rev.10/15/19
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The Commonwealth of Massachusetts
iNNW I Department of Industrial Accidents
ee►= 1 Congress Street,Suite 100
t.=44—= Boston,MA 02114-2017
www.mass.gov/dia
1.1
Workers'Compensation Insurance Affidavit:General Businesses.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Business/Organization Name: 1 C,9.1)1,r,S G c l.Lr: C4fQ (La-Kt- 15 la AAS
Address: G c., Q.-k. \ ' -
City/State/Zip: S 0 0 kV hdtiN IS im OatA hone#: ( JOO 3C1L1 Lit 36
Are you an employer?Check the appropriate box: Business Type(required):
1.❑ I am a employer with employees(full and! 5. 0 Retail
or part-time).* 6. ❑RestaurantBar/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. 121Non-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.❑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 providinwo kers'compensation insurance for my employees. Below is the policy information.
Insurance Company Name: HI) 1 v}L A1 ,)-,bkl it t Naw hi I t y1, LL L
Insurer's Address: abs 0 Rif u,,,s
City/State/Zip: N_ 0,4h..h ! 0 4 6 CO
Policy#or Self-ins.Lic.# G S(p 0 V 1 i H iO3 Oct 3 ii . Expiration Date: 7/1/c
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' ante coverage verification.
Ido hereby certify, er th pains and pen f perjury that the information provided above is true and correct
Signature: Date: I1./5`/111
Phone#: ( 1) 3 t LI- LI 3 O
e
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
io
1 v1/4.
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ACO® CERTIFICATE OF LIABILITY INSURANCE DATE(MMJDD1YYYY) 'i/
`.+----- 10/29/2016 ,
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
i
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(les)must be endorsed. If SUBROGATION IS WAIVED,subject to ' '?C
the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the 'M
certificate holder In lieu of such endorsement(s).
PRODUCER CONTACT Anne Sanzo
HUB INTERNATIONAL NEW ENGLAND LLC NAME;
PHONEime ,air (508)945-7863 _FAX
No):
ADDRESS: anne.sanzo@hubintemational.com
285 ORLEANS RD INSURER(S)AFFORDING COVERAGE NAIC U A
NORTH CHATHAM MA 02650 INSURER A: HARTFORD UNDERWRITERS INS CO 30104
INSURED INSURER B: ..
ELDER SERVICES OF CAPE COD ANDTHE ISLANDS INC INSURERC:
INSURER D: e
68 ROUTE 134 INSURER E: i
S DENNIS MA 02660 INSURER F: ,
COVERAGES CERTIFICATE NUMBER: 466285 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 .144
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 ADM OF INSURANCE ADSUBR POLICY EFF POLICY EXP a
LTR INSD wilD POLICY NUMBER •IMMIDDIYYYYI.(MMIDDIYYYYI LIMITS ,,
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $
CLAIMS-MADE OCCUR DAMAGE TO RENTED — r'
PREMISES(Ea occurrence) $
MED EXP(Any one person) S
N/A PERSONAL&ADV INJURY $ _
GE 'L AGGREGATE LIMIT APPLES PER: GENERAL AGGREGATE $
POLICY JECT LOC PRODUCTS-COMPIOP AGG $
OTHER: $
AUTOMOBILE LIABILITY - COMBINED SINGLE LIMIT $ t, '
(Ee accident)
ANYAUTO BODILY INJURY(Per person) $ , ^aALL . ,�
AUTOS AUTOS
OWNED SCHEDULED N/A BODILY INJURY(Per accident) $ —
NON-OWNED {
HIRED AUTOS AUTOS PROPERTY DAMAGE $ I t '
(Per accident)
$ t,.,,
UMBRELLA LIAB —
OCCUR EACH OCCURRENCE _ 5 1'
EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ i i
a
DED RETENTION S $
r ,:.IWORKERS COMPENSATION PER m O
AND EMPLOYERS'LIABILITY YIN X STATUTE ER
ANYPROPRIETOFVPARTNERIEXECUTIVE EL EACH ACCIDENT $ 1,000,000
A OFFICERA EMBEREXCLUDED7 NIA N/A 6S60UB8H2O309319 07/07/2019 07/07/2020 4
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 i
It yes,descrthe under •6
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000
w
N/A
DESCRIPTION OF OPERATIONS!LOCATIONS!VEHICLES(ACORD 101,Additional Remarks Schedule,maybe attached if more space is required)
Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 8,no authorization is given to pay
claims for benefits to employees in states other than Massachusetts If the Insured hires,or has hired those employees outside of Massachusetts. ''4
This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the ;
Issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification 1
Search tool at www.mass.gov/Iwd/workers-compensationrnvestigations/.
4
CERTIFICATE HOLDER CANCELLATION
i4
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Elder Services of Cape Cod and the Islands ACCORDANCE WITH THE POLICYPRDVISIONS.
68 Route 134
AUT HORIZED REPRESENTATIV E
S Dennis `�w P t
I MA 02660 Daniel M.Cry,CPCU,Vice President—Residual Market—WCRIBMA
®1988-2014 ACORD CORPORATION. All rights reserved. i
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
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