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HomeMy WebLinkAboutApp,WC, License & Certifications The Commonwealth of Massachusetts Fee Town of Yarmouth $30.00 Food Establishment License Number: BOHF-15-5955-06 Issue Date: 1/1/2021 Mailing Address: Location Address: ST. PIUS PARISH LIFE CENTER STATION AVE 5 BARBARA STREET SOUTH YARMOUTH, MA 02664 SOUTH YARMOUTH, MA 02664 IS HEREBY GRANTED A 2021 LICENSE TO OPERATE: Non-Profit; This license is granted in conformity with the statutes and ordinances relating thereto, and expires December 31, 2021 unless sooner suspended or revoked and is not transferable. Conditions LOCATION: Parish Life Center, 25 Barbara Street, South Yarmouth Board Hillard Boskey, M.D., Chairman Mary Craig, Vice Chairman of Charles T. Holway, Clerk Debra Bruinooge Health Eric Weston LA.A.IJVAAdisf.40°Bruce G. Murph , MPH, R.S., . r allory R. Langler, R.S. Health Director/A sistant Health Director Sr Pcus Lr f c e-, (-c, TOWN OF YARMOUTH BOARD OF HEALTH APPLICATION FOR LICENSE/PERMIT - 2021 * Please complete form and attach all necessary documents by December 18, 2020. Failure to do so will result in the return of your application packet. ESTABLISHMENT NAME: ID: LOCATION ADDRESS: ZS i&Oncir S\-. S- Lkacrncx0 . MA TEL-#: 56fs ,391c• EZ4k MAILING ADDRESS: 5 r\-c,2 s\ S. `tae fi\, pAA 02.c,6 E-MAIL ADDRESS: of,c c6cs}.cue} OWNER NAME: 1 zxese oc cad` ZKec CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: v. TEL.#: Z L MAILING ADDRESS: S.E.ar\Ocr,.. S S. mctjlwn. rc' OZC.C,'--/ POOL CERTIFICATIONS: 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. (114\ 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 busi ess. l' A I DEC 1 5 2020 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. C rc-3-t r1 2. ,S Ue SUZcr,Sk PERSON IN CHARGE.: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. 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. 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. 3. ..->\kms ccer,c 4. RESTAURANT SEATING: TOTAL Il OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE Pi-RMrr Ii LICENSE REQUIRED FEE PERMIT It LICENSE REQUIRED FEE PERMIT II B&B t55 rt IUN 'SSS AA/ a i i„ ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town ofYarmouth 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 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 -OTHI. LODGING-t;STABLI-S-HttfiENT TRANSIENT OCCUPANCY: For purposes ol'the limitations of Motel or I lotel 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 amended, shall-generally be considered "Transient. POOLS P001, OPENING: All swimming, wading and whirlpools which have been closed for the season must he inspected by the I lealth Department prior to opening. Contact the Health Department to schedule the inspection three (3) clays 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 I lealth Department'thrce(3) clays prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven (7) clays of closing. FOOD SERVICE SEASONAL.. FOOD SERVICE OPENING: All -food service establishments must he inspected by the I lealth Department prior to opening. Please contact the Health Department to schedule the inspection three(3) clays 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 I-lealth 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 I lealth 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 tailed 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 I to December 3 I. IT IS YOUR RESPONSIBILITY TO RETURN -r,rr i'r enr rmrr' n171,1C /A 1 A 001 Ir.Amrnxiic\ nKin nGni linun i:I I IQ\ RV n C'PAA FR I R 'n7n The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations — �— A 1 Congress Street, Suite 100 �• -=-;.= Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: 3 Q:vC. X Cum N �aCsh Address: S ( cam: S . , Qrr�,} , MA b 2 GC, Lai City/State/Zip: S. c.c 3c 4\1 A- CZ Li Phone #: So 3 Z Z kl�C Are you an employer? Check the appropriate box: Business Type (required): 1.❑ I am a employer with employees (full and/ 5• ❑ Retail _ or part-time).* 6. Restaurant/Bar/Eating Establishment 2._ 1 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. n 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 10.0 Manufacturing no employees. [No workers' comp. insurance required)* ' 11.E 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 l 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 I. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: Insurer's Address: City/State/Zip: Policy # or Self-ins. Lic. # 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. I do hereby certif t, der the pains and penalties of perjury that the information provided above is true and correct. Sig.-nature: 1 `\ \" Date: �� k Za? () Phone #: S0(C 3°& ZZ 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 #: 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 anycontract for --- the-�rf�.�,.c„„fpublie work until-azccptable evidence of czsmpt��ce With tt�einsurance 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 4-06 or 1-877-MASSAFE Fax # 617-727-7749 www.mass.gov/dia Form Revised 7/2010 ''°i:'(`i1R TOWN OF YARMOUTH fir; c O ti -y BUILDING DEPARTMENT ':� MAT7A M S, 44, '-..f< ..-LI� 3.' 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1260 APPLICATION FOR CERTIFICATE OF INSPECTION DATE: 12/03/2020 PAYABLE UPON RECEIPT (X) Fee Required $100.00 ( ) No Fee Required In accordance with the provisions of the Massachusetts State Building Code, Section 110.7, I hereby apply for a Certificate of Inspection for the below-named premises located at the following address: Street and Number: Z.S &(opq rcl .SV S. y 4( mqJ , (" Name of Premises: .Rus )(, - c)c c c S L SC CC/ \ Tel: 5O -T - 2.Z `&- Purpose for which permit is used: cisct ccs\\ / Corrmrw n,1"\-+ J Sc -oc�1 e— i- v . License(s)or Permit(s)required for the premises by other governmental agencies: License or Permit Agency Certificate to be issued to . Pus )C c.\,,..,(-cls Tel: Spm 3') Zz Address: ,5 &(loa r Sti- , S. 10,c c-no.. --1',. o\P‘ aZ��y Owner of Record of Building ?,c,rx- ,\ moo\,c_ gcS ,Q F2,l\ R;,.re r Address H S o i-kgln\�„a. 11 R�\sec, MA DZ 1 Z Z Present Holder of Certificate �ev. Pc,l A- C c-a r• /1 Signature of person to whom Title Certificate is issued or his agent 12.( 176?_c) Date Email Address: S1s1)0 5,Xa4 ce e Cor—,s\-,r e-k- Instructions: Make check payable to: Town of Yarmouth 1146 Route 28, South Yarmouth, MA 02664 Return this application to: Building Inspector's Office Please note: Application form with accompanying fee must be submitted for each building or structure or part thereof to be certified. Application must be received before the certificate will be issued. The building official shall be notified within ten(10) days of any change in the above information. PLEASE SEND US A COPY OF YOUR WORKER'S COMPENSATION INSURANCE FORM WITH THIS APPLICATION OR WE CANNOT ISSUE YOUR CERTIFICATE OF INSPECTION. Certificate of Inspection# 01/17/2021 -01/17/2022 A.!'� DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 12/08/2020 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 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 (a/c°°,No.Ext): 617-746-5742 FAX No): 617-779-4572 66 Brooks Drive E-MAIL losscontrol@masscatholic.org ADDRESS: C g INSURER(S)AFFORDING COVERAGE NAIC# Braintree MA 02184 INSURER A: Massachusetts Catholic Self Insurance Group INSURED 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: 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 IADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ PERSONAL&ADV INJURY _ $ GE 'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ PRO- POLICY JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) 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) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X STATUTEPER EORH AND EMPLOYERS'LIABILITY Y/N Certificate of Approval 03/31/2020 03/31/2021 A ANYPROPRIETOR/PARTNER/EXECUTIVE Commonwealth of E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBEREXCLUDED? N/A (Mandatory in NH) Massachusetts E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes, Nunder 3000001012020 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Re:St. Pius X Church,5 Barbara St.So.Yarmouth, MA 02664 Evidence of Workers Compensation CERTIFICATE 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 *142"Ditot ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD