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HomeMy WebLinkAboutApplication and WC *Ali TOWN OF YARMOUTH BOARD OF HEALTH 0111 APPLICATION FOR LICENSE/PERMIT-2019 7, yy��QQ p teary NOTE: S complete so will QUQILI Ent MUSTEMcati ER1so, Failure ESTABLISHMENT NAME: . - - ._ . . . n• — LOCATION ADDRESS: I I' e� t',a tl ' D ' fro .#: I 4 MAILING ADDRESS: 1'')19 ► 0 t&.io ' ' i C,f(i rAi 071-1. t,,'"' 02 C64 E-MAIL ADDRESS: 8.0(CA 4() q die' cc OWNER NAME: V eiFro 1i foe 1 j orKe CORPORATION NAME(IF APPLI LE): V _ MANAGER'S NAME: cit r•4 f. TEL#: ' /4 35 MAILING ADDRESS: 1)() Ay4131 (1)e5÷ 3 f LtOtl �11 ()7 (,'-5 POOL CERTIFICATIONS: The supervisorsanmust be acertified as a Pool Operator,as required by State law. Please list the designated Operator( ) copy of the certification to this form. 6 1. 2. i Pool operators must list a minimum of two employees currently certified in standard First Aid and Communi• �� �' Cardiopulmonary Resuscitation(CPR),having one certified employee on premi at all times. Please list D emplyees below and attach copies of their certifications to this form.The HealthsDepartment will not use o years'records. You must provide new copies and maintain a file at your place of business. 1. 2. o rt.-) 3 4. H cD FOOD PROTECTION MANAGERS-CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food .V Protection Manager,as defined in the State Sanitary Code for Food Service Establishments,105 CMR 590.000. r;,: , 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. 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. I. 46°11 rP)urke, 2. ALLERGEN CERT)FICATI N : O S All food service establishments are required to have at least one find-time employee who has Allergen certification, as defined in the State Sanitary Code for Food Service Establishments,105 CMR 590.009(GX3Xa). 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. 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 i t t loyees trained in anti-choking procedures below and attach copies of employee certifications to this form. The :alb 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# Wi lei F I s" 1642-05 OFFICE USE ONLY LODGING:LICENSE REQUIRED $55FEE 110 S5 PERMIT 6 LICENSE REQUIRED FEE PERMIT S LICENSE REQUIRED jFEE PERMIT N —LODGE $55 TRAILER PARK $105s _SWIMMING POOL$I IOa _WHIRLPOOL SI roes. FOOD SERVICE: D -tom SEA1S $ O LICENSEENU REQUIRED FEE PERMECi CONTINENTALPERMrf# LICENSEBSEOTT FEE REQUIRED ED FE PERMITS >too SEATS goo ',COMMON VIC. $60 !Td.ENS --WHOLESALE $80 RETAIL SERVICE —RESID.KITCHEN$80 LI <30 CENSE REQUIRED FEE PERMIT 6 LICENSE REQUIREDg _ FEE PERMITS LICENSE REQUIRED FEE PERMIT 0 d5,o00 sq.& $150 RO?EP1 DESSERT$40 —TOBACCO VENDING-FOO gl1 W NAME CHANGE: $ls AMOUNT DUE = S 185.bb PLEASE TURN VER AND COMPLETE OTHER SIDE OF FORM ADMINISTRATION i 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 OR .V. 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 balanced by the Health Deportment prior to opening. Contact the Health Department to schedule the inspection three(3)days prior to opening. :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 hones,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 coveted 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 yy filing the Temporary Food Service Application form 72 hours prior to the catered event These forms an be olbtaumed at them Department,or from the Town's website at www,yarmouth.ma.uss 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 theH tert ms have beenfailure to do so will result in the s spension or revocation of your Fromm Dessert Permit until the aboveOUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Bond 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 15,2018. 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 COMMEN EMENT. RENOVATIONS MAY RE UIRE A.. DATE: 1(1 '2b) SIGNATURE: PRINT NAME&TITLE: c/ nor.10/23/11110/23/111l��4.a i The Commonwealth of Massachusetts — — Department ofIndustrialAccidents _" Office of Investigations = '"_ 1 Congress street,Suite 100 Boston,MA 02114-2017 www.ntassgov/dla Workers' Compensation Insurance Affidavit: General Businesses ,Applicant Information Please Print Legibly Business/Organization Name: t_ ,: _fat' i1 G Ate: 19 Pjuk•e 2g ti City/State/Zip:50144 art�.�.on(i 4'A ©2 ' ' l e#: 503 3 L 5A / 4 Are you an employer?Check a appropriate box Business Type(required): 1.0 I am a employer with employees(full and/ 5. 0 Retail or part-time).* 6. el RestaurentiEtarlEating Establishment 2.Q 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. 8. ❑Non-profit [No workers'comp.insurance required] 3.0 We are a corporation and its officers have exercised 9. 0 Entertainment their right of exemption per c. 152,§1(4),and we have ion manufacturing no employees.[No workers'comp.insurance required]'* 4.Q We are a non-profit organization,staffed by volunteers, with Health Care with no employees.[No workers'comp.insurance req.] 12.Q Other 'Any applicant that cbedcs box!i Hetet also 8n out the section below showing their wodoers'compensation policy int rmadon. **If the corporate offices have exempted themselves,but the corporadon has otter employees,a workers'compensation policy is requited and such en orgeoela tion should check box M. I am an employer that is proWdhig workers' insurance for my employees. Below is the policy information. IMMO!Company Name: lk Insurer's Address: City/State/Zip: Policy#or Self--ins.Lie.# I I f*X Expiration Date: 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. Ido hereby cat , der the pains and penalties of perjury that the hifontudion provided above is true and cored $ig ture: Date: /71 26 2 61 Phone#: Official use only. Do not write in this era,to be completed by dty or town of iciaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Licensing Board S.Selectmen's Office 6.Other Contact Person: Phone#: wwwmaes.gov/dia CERTIFICATE OF LIABILITY INSURANCE DATE01/10/2020 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 be endorsed. If SUBROGATIONIS 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: MCSHEA INSURANCE AGENCY INC 08088402 PHONE (508)420-9011 FAX (508)420-9010 1645 FALMOUTH RD IST 28 BLDG D (A/C,No,Ext): (A/C,No): CENTERVILLE MA 02632 E-MAIL ADDRESS: INSURER(S)AFFORDING COVERAGE NAICB INSURER A: Hartford Insurance Comparry 37478 INSURED INSURER B :JERK CAFE,INC 39 JOE LINCOLN RD INSURER : JAN WEST HARWICH MA 02671-1416 INSURER D. INSURER E: H'7,1_7-4 r 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.NOTWTTHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS of 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 _DISR WVD.. IMMIDD/YYYY) , IMM/DD/Y YYYI COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) MED EXP(Any one person) PERSONAL&ADV INJURY GENII AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE POLICY ��O LOC PRODUCTS-COMP/OP AGG OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ® (Ea accident) ANY AUTO BODILY INJURY(Per person) ALL OWNED SCHEDULED - AUTOS AUTOS BODILY INJURY(Per accident) HIRED NON-OWNED PROPERTY DAMAGE AUTOS AUTOS (Per accident) UMBRELLA LIAR OCCUR EACH OCCURRENCE EXCESS LIAR CLAIMS- — MADE AGGREGATE DED RETENTION$ _ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY X STATUTE ER ANY - - Y/N E.L.EACH ACCIDENT $500,000 -.. A PROPRIETOR/PARTNER/EXECUTIVE I Hi.A 08 WEC CN0740 06/26/2019 06/26/2020 OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $500,000 — If yes,dean-the under E.L.DISEASE-POLICY LIMIT $500,000 _DESCRIPTION OF OPERATIONS Wow DESORPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) _ Those usual to the Insured's Operations. CERTIFICATE HOLDER CANCELLATION Town of Yarnouth SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 1146 ROUTE 28 BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED SOUTH YARMOUTH MA 02664-4463 IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE (Y�,� 03" tt ?a%zL _9 Cc?1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD THE HARTFORD BUSINESS SERVICE CENTER THE 3600 WISEMAN BLVD HARTFORD SAN ANTONIO TX 78251 January 10, 2020 MB 01 000563 62922 H 6 A 111111111111111"111111111111111111111111111"11111101"11111 Town of Yarnouth 1146 ROUTE 28 SOUTH YARMOUTH MA 02664-4463 0 0 a 0 Account Information: t4;) Contact Us Policy Holder Details : JERK CAFE, INC Business Service Center Business Hours: Monday- Friday (7AM 7PM Central Standard Time) Phone: (866)467-8730 _ Fax: (888)443-6112 .-a----- Email: Email: agency.services(&,,thehartford.com =- Website: https://business.thehartford.com Enclosed please find a Certificate Of Insurance for the above referenced Policyholder. Please contact us if you have any questions or concerns. Sincerely, Your Hartford Service Team WLTR005 � 1 THE HARTFORD BUSINESS SERVICE CENTER THE 3600 WISEMAN BLVD HARTFORD SAN ANTONIO TX 78251 January 10,2020 f JERK CAFE,INC 39 JOE LINCOLN RD WEST HARWICH MA 02671 Policy Information: �Q Contact Us Policy Number 08 WEC CN0740 Business Service Center Business Hours: Monday-Friday (7AM-7PM Central Standard Time) Phone: (866)467-8730 Fax: (888)443-6112 Email:agency.servicesethehartford.com Website: https://business.thehartford.com Enclosed please find information pertaining to your policy. Please contact us if you have any questions or concerns. Thank you for selecting The Hartford for your business insurance needs. Sincerely, Your Hartford Service Team • 0 111001111i. - WLTR001 a EM ` REIr CERTIFICATE OF LIABILITY INSURANCE D01/101ATE 2020 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 be endorsed. If SUBROGATIONIS 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: MCSHEA INSURANCE AGENCY INC 08088402 PHONE (508)420-9011 FAX (508)420-9010 pvc :1645 FALMOUTH RD RT 28 BLDG D 'No,Ext) DR ( No):AID CENTERVILLE MA 02632 EMAIL ADDRESS: INSURERS)AFFORDING COVERAGE NAI INSURER A: Hartford Insurance Company of the Midwest 37478 INSURED INSURER B: JERK CAFE,INC INSURER C: 39 JOE LINCOLN RD WEST HARWICH MA 02671-1416 INSURER D 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. DOR TYPE OF INSURANCE ADDL SUER POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR MSR WYVR IhMUDDNYYYI (MMIDD/y YYYI COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE CLAIMS-MADE E OCCURDAMAGE TO RENTED PREMISES(Ea oawrrencel MED EXP(Any one person) PERSONAL 8 ADV INJURY GEN.AGGREGATE LIMIT APPLIES PER: GENERAL.AGGREGATE PRO- POLICY❑JECT LOC PRODUCTS-COMP/OP AGG OTHER: AUTOMOBILE LIABILITY COMBINED SINGE LIMIT Ma accident) ANY AUTO BODILY INJURY(Per person) r ALL OWNED ..._SCHEDULED _AUTOS AUTOS BODILY INJURY(Per accident) HIRED -NON-OWNED PROPERTY DAMAGE AUTOS AUTOS (Per accident) _ UMMELI A LIAR __ OCCUR EACH OCCURRENCE EXCESS LIAR CLAIMS- MADE AGGREGATE DED( RETENTION$ WORKERS COMPENSATION PER OTH- AND EINPLOYERS'LIABILITY X STATUTE ER ANY YM EJ..EACH ACCIDENT $500,000 A PROPRIETOR/PARTNER/EXECUTIVE C NIA 08 WEC CN0740 06/26/2019 06/26/2020 — OFFICER/MEMBER EXCLUDED? L_ E.L.DISEASE-EA EMPLOYEE $500,000 (Mandatory M NH) _ II yes describe under E.L.DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS below DESCRPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Those usual to the Insured's Operations. CERTIFICATE HOLDER CANCELLATION Town of Yamouth SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 1146 ROUTE 28 BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED SOUTH YARMOUTH MA 02864-4463 MI ACCORDANCE WITH THE POLICY PROVISIONS. /AUTHORIZED REPRESENTATIVE ..f/€45-Ltd")C:134. Ldarf&024042_> ®1988-2015 ACORD CORPORATION.All rights reserved. ACORb 25(2016/03) The ACORD name NOli iars twietered marks of ACORD