HomeMy WebLinkAboutApp, License & Certifications I ml -Z.eil ( r cu vCOs
TOWN OF YARMOUTH BOARD OF HEALTH
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l`, APPLICATION FOR LICENSE/PERMIT - 2021
J,/ * 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: vilate 'duke ( beivoa TAX ID:
LOCATION ADDRESS: 02.3 i2Owe 28--,Smut'', yet mouth 'n4- (Ng TEL.#: 5.061 3. d,2/2s
MAILING ADDRESS:
E-MAIL ADDRESS: _
OWNER NAME: 00111'2 Chiu
CORPORATION NAME (iF APPLIIc`�.ABLE):
MANAGER'S NAME: OM/ CIthA TEL.#: .5)g - C .2/., S
MAILING ADDRESS: /323 POof2 2-k 1�l 9avvnoutli /71,40-6k
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator, as required by State law. Plcasc Iist 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
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 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 EstablishmR 5Q0 n( 0.
Please attach copies of certification to this application. The Health Department will no use-pasfytars Decor s.
You must provide new copies and maintain a file at your establishment.
DEC 1 1 2020
I. 2.
PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge (PiC) on site during hours of operation.
1. 2.
ALLERGEN CERTIFICATIONS:
Ali 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 Ilealth Department will not use past years' records.
You must provide new copies and maintain a file at your place of business.
I. 2.
3. 4.
RESTAURANT SEATING: TOTAL #
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT If LICENSE REQUIRED FEE PERMIT 11 LICENSE. REQUIRED FEE PERMIT If
RX•R 4:55 ('AKIN 4;55 M(1Ti i 4;1 In
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
Olt /
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 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, shalt generally be considered Transient.
POOLS
POOL OPENING: All swimming, wading and whirlpools which have been closed for the season must be inspected by the
I lcalth Department prior to opening. Contact the I lealth 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 colilorm and standard plate count by a State
certified lab, and submitted to the I lcalth Department'three(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- I,• VIC nncNING — — —
All food service establishments must be inspected by the I lcalth 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 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 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 3 I. IT IS YOUR RESPONSIBILITY TO RETURN
TI IF r`rINAPI FTFn F? NIFUU/A I A not IC'ATtrINI/c1 A Nin P FnI III?Fn GGirc\ nrr'r,nnru?n r 4 wyn
The Commonwealth of Massachusetts Fee
Town of Yarmouth $110.00
Tobacco Product Sales License
Number: BOHTP-14-0060-07 Issue Date: 1/1/2021
Mailing Address: Location Address:
WATERWHEEL 28 INC. 1323 ROUTE 28
WATERWHEEL LIQUORS SOUTH YARMOUTH, MA 02664
1323 ROUTE 28
SOUTH YARMOUTH, MA 02664
IS HEREBY GRANTED A LICENSE
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.
Board Hillard Boskey, M.D.,Chairman
Mary Craig, Vice Chairman
of Charles T. Holway, Clerk
Debra Bruinooge
Health Eric Weston gib
ruce G. Murphy, MPH; R.S., C y 0 allory R. Langler, R.S.
Health Director/Assistant Health Director
Workers Compensation and Employers Liability,
Insurance Policy
Insurer ID No(s): 34355
MA Retail Merchants WC Group Inc. Carrier Policy#: Policy Period
PO Box 859222-9222 014005030531120 01/01/2020 to 01/01/2021
Braintree, MA 02185-0000
Information Page Renewal Poli
FEIN: 043615346 Carrier Prior Policy#: 0140050305311'
Item 1: Named Insured and Address Agency
Waterwheel 28, Inc. Wm F Borhek Insurance Agency, Inc.
Waterwheel Liquors 311 Plymouth Street
1323 Route 28 Halifax, MA 02338
South Yarmouth, MA 02664
Other Workplaces Not Shown Above: No Other Workplaces for this Policy
Additional Named Insured: See Additional Named Insureds if Applicable
Type of Business: Corporation Federal ID#: 043615346
Risk ID: 000000000 NCCI/Bureau#: 34355
Unemployment ID#: File#: 014005030531120
item 2. Policy Period The policy period is from 12:01 AM on 01/01/2020 to 12:01AM on 01/01/2021 based on the insured's mailing
address time zone.
Item 3.Coverage:
A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed:
MA
B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits of our liability under Part
Two are:
Bodily Injury by Accident $ 100,000.00 each accident
Bodily Injury by Disease $500,000.00 policy limit
Bodily Injury by Disease $ 100,000.00 each employee
C. Other States Insurance:
D. This policy includes these endorsements and schedules:
WC000000C(01/15),WC000414A(01/19), WC000422B(01/15), NOE(01/01), WC200102(01/14), WC200301(04184),
WC200302A(09/08),WC200303D(08/10),WC200306B(06/13), WC200405(06/01),WC200601A(07/08)
Item 4: Premium
The Premium for the policy will be determined by our Manual of Rules,Classifications, Rates and Rating Plans. All information required below
is subject to verification and change by audit.
Classifications Code# Premium Basis Rate Per$100 of Estimated Annual Premium
Total Estimated Remuneration
Annual Remuneration
See Schedule of Operations on Following Page(s)
Minimum Premium Prorated Premium Estimated Annual Premium Expense Constant Deposit
$210.00 $776.00 $776.00 $0.00 $0.00
Issuing Office: 35 Braintree Hill Office Park Ste 206 Date Printed: Countersigned by:
Braintree MA 02185-0000 01-16-2020
Form#WC 00 00 01 C
(Ed.)
CE)Coovnaht 2013 National Council on Cmmnpnsatinn Inaurannv tnn All Rinhts RacoNari
' The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
N —_*1_ p
M 1 Congress Street, Suite 100
• —.II.--1 . j Boston, MA 02114-2017
►_.�,. www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information4-ten/vm/ Please Print Legibly-
Business/Organization Name: .2, c?C
Address: /.,.3 got* 28
City/State/Zip: 1t`1 5atmui/i mi 076 Phone #: ) 3G�rf 125
Are you an employer? Check the appropriate box: Busin ss Type (required):
I cg I am a employer with employees (full and/ 5. Retail
t 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. ❑ 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]` '
11.0 Health Care
4.Li We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp. insurance req.] 12.n 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 aad such an
organization should check box rl.
I am an employer that is providing workers' compensation`�insurance for my em, loyees. Below is the policy information.
Insurance Company Name: 127/) /Cera// ge,%761/27 h76.1.. l/Jvt/, ..kc
7
Insurer's Address: f
0 fox g S9 22 - q22 z
City/State/Zip: ,befki4Te/ /VA 01 o'St
Policy 4 or Self-ins. Lic. 4 0/400503 p 53 / /Zd Expiration Date: //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 enalties of perjury that the information provided above is true and correct.
Sicrnature: Kkni;e C / a Date: /c)/772.--C))-0
Phone 4:
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 #:
I