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HomeMy WebLinkAboutApplication and WC .�l!��,, TOWN OF YARMOUTH BOARD OF HEALTH ery .. ►s�_ APPLICATION FOR LICENSE/PERMIT -2 )�i_ „� :4 0 9 2019 * Please complete form and attach all necessarydocume" ') :i I' c• ,' YR p � �. :t'H DEPT. Failure to do so will result in the return of your appliolatio pac et. NOTE:ALL BUSINESSES WITH LIOUOR LICENSES MUST RETURN FORMS BY NOVEMBER I S`"'. ESTABLISHMENT NAME: So.N\N \1ar(vnaA\\ ac ct N\ectiodiSA-CVu.n1,TAX ID: LOCATION ADDRESS: 3'ai-\ D\d 0\d. M°.'m TEL.# O 3°1$.9 H 8 a MAILING ADDRESS: 3a4 ord VAck Wit.) 5.\\acv o \A Oa-(o(`i E-MAIL ADDRESS: bA0,-cw•a r>,h..vn yr \oc .cs v@> u�\e Goer OWNER NAME: 3 -\r‘ \\a<.r ovM\ V,r: Mcar w5\ c •cc). CORPORATION NAME (IF APPLICABLE): 1, MANAGER'S NAME: A ,- 6, anc‘\ `1"v‘h. .4ce- TEL.#:.MS.31t3,°1Ut`3a, MAILING ADDRESS: .6' '\C\ 3aL\ 0\. N\coN sk,1 S, �ctrM�vZ MSR Ga(g6)4 POOL CERTIFICATIONS: The pool supervisor must be certiljedas a Pool Operator,as required by State law. Please list the designated Pool Operator(s)and attach a copfof 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 copi of their certifications to this form.The Health Department will not use past yearsrecords. You must p ide 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. Co -�rvz -d\ur\X 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. 1. Co wed kAn G1 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. .G` r\\ Swed "" 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. 5a``"^ W.e\.\e 2. 3. 4. RESTAURANT SEATING: TOTAL# 1304F—r1-406%.,03 OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $110 —TINN $55 CAMP $55 SWIMMING POOL$1 l0ea. LODGE $55 TRAILER PARK $105 _WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 __CONTINENTAL $35 J_NON-PROFIT $30 -0f0 >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 _ $ *****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 ATTACHED V 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 V 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. 640 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 COMPLE 11,D 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 REQU A SITE PL N. DATE: I 1 ' ,� — j g SIGNATURE: (1,4, /rd& PRINT NAME& TITLE: �\ -c6• Seel\e. -TYas 4i Rev. 10/15/19 The Commonwealth of Massachusetts Prfot korn Department of Industrial Accidents Office of Investigations aht 4 1 Congress Street,Suite 100 "rtNitz1Boston,MA 02114-2017 40. www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: South Yarmouth United Methodist Church Address: 324 Old Main Street(office) 318 Old Main Street(church) City/State/Zip: S. Yarmouth MA 02664 Phone #: 508.398.9482 Are you an employer?Check the appropriate box: Business Type(required): 1.El I am a employer with 7 employees(full and/ 5. 0 Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2.❑ 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. 2 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.❑ 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 *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 employees. Below is the policy information. Insurance Company Name: Fred C. Church Insurance �hv5cu %ovvvik- c_a\\..1 evkew.eA a•v`+• 1\y� b Vl\e- Uq.v..) £ \avi Insurer's Address: 41 Wellman Street 1\vw,4\. CaK Yem . osc vd w City/State/Zip: Lowell MA 01851 "``n` Policy#or Self-ins. Lic.# 026125007177048 Expiration Date: 1/1/2020 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 a d penalties of perjury that the information provided above is true and correct. �I�,C'/L.c f' / Q Signature: 4e _ Date: 1 ' " I Phone#: 508.398.9482 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 Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However,the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." { Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary,supply your insurance company's name,address and phone number along with a certificate of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials • Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number.In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture(i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax# 617-727-7749 www.mass.gov/dia Form Revised 7/2010 a- ACCORD DATE(MMIDDIYYYY) CERTIFICATE OF LIABILITY INSURANCE 7,2,2019 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: Patty omim Fred C.Church Insurance PHONE FAX 41 Wellman Street (A/C.No.Ext):800-225-1865 (A/C,No):978 54-1865 Lowell MA 01851 ADDD°ReSS: psmith@fredcchurch.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Church Mutual Insurance Company 18767 INSURED NEWENGL-11 The New England Annual Conference of INSURER B The United Methodist Church INSURER C: 411 Merrimack Street INSURER D: Methuen MA 01844 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:594276675 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 SUBR POLICY EFF POLICY EXP LIMITSLTR JNRD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) A X COMMERCIAL GENERAL LIABILITY 026125002138573 8/1/2018 8/1/2019 EACH OCCURRENCE $1,000,000 CLAIMS-MADE X OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $300,000 MED EXP(Any one person) $15,000 PERSONAL&ADV INJURY $1,000,000 GE 'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $3,000,000 POLICY JET LOC PRODUCTS-COMP/OP AGG $1,000,000 OTHER: $ A AUTOMOBILE LIABILITY 026125009138574 8/1/2018 8/1/2019 (EOa aoceDtSINGLE LIMIT $1,000,000 ANY AUTO BODILY INJURY(Per person) $ X OWNED SCHEDULED BODILY INJURY(Per $ AUTOS ONLY AUTOS accident) HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident) A X UMBRELLA LIAB X OCCUR 026125081138575 8/1/2018 8/1/2019 EACH OCCURRENCE $10,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $10,000,000 DED X RETENTION$1n nnn $ A WORKERS COMPENSATION 026125007177048 1/1/2019 1/1/2020 PER 0TH- AND EMPLOYERS'LIABILITY Y I N STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $500,000 OFFICER/MEMBEREXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached it more space Is required) Evidence of insurance for the South Yarmouth United Methodist Church which is part of the New England Annual Conference of the United Methodist Church 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. South Yarmouth United Methodist Church 322 Old Main Street South Yarmouth MA 02664 AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD ' + 1 f F00DS14, NATIONAL REGISTRY OF te�� FOOD SAFETY PROFESSIONALS® CERTIFIES CONNIE SWEDLUND HAS SUCCESSFULLY SATISFIED THE REQUIREMENTS FOR THE FOOD SAFETY MANAGER UNDER THE CONFERENCE FOR FOOD PROTECTION STANDARDS PRESIDENT: ANSI __ LAWRENCE J.LYNCH,CAE Ncf.NmREp PROGRAM ISSUE DATE: JUNE 19 2017 n r.iw,,i si�neanx.o-sinun EXPIRATION DATE: JUNE 19, 2022 M)656 CERTIFICATE No: 21 361697 51 Forum Drive,Suite 220,Orlando,FL 32821 TEST FORM: EXE67 )1)446-0257 F(407)352-3603 www.NRFSP.com This certificate is not solid for more than fire sears from date of issue. ational Registry of Food Safety Professionals' � . Y 4 1 k i1 f E 4 • : . . e . . tif. .,V..1 4: Ih. ..Z. 4 NV • ''l .VL, t V . 4:- %VI, i •i 4'1. - -,-, .....0 ili '',..,....t. 4 •34-•4••C• ii./ 'Y.,ft,•••e 4 ").., ,.....e 4 :3-.. ..-c- hi "3.,/4C• 10 5.4.14-1.C4lit A • ..likk a '''e 'act--•.-,_9,-;e___ c----,_9;Q:_/')‘-' ,9;;e:_...i-DC --,..5:;e_i-a c‘<:_,94e.ji-)c--- __9.; C--,L9 a ly :-,?., •,- k,-, CERTIFICATE OF 0- cy, -.'. ALLERGEN AWARENESS TRAINING ...-c- ,t..) -\ Z .,C.,,:.• Name of Recipient: RLFY ACKEE Certificate Number: 2963627 in Date of Completion: 6'9'2°1- CI- /. Date of Expiration: a 1S'2C22 to L''T ..,...•. 4•,›.. -.4,, •7,-F 4 ' r•0 c.. 'IN, •..4.) ‘k. ,.....1 Issued By: 7h,ahcve-named persf,n is hesehv is,ated'hi.-certificate ,_ WRO 'NATION N.i. , C.> 1,,,, for completing an allergen aLareness t-a:hing program RESTAUFANT - r,,c5gnize'd vthe llassachusett.Department of Ptiblic Head!: i hmet.tambs. '. 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