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HomeMy WebLinkAboutApp, License & Certifications w yc►-,ri & S-‘o5cdx. ( 0 - TOWN OF YARMOUTH BOARD OF HEALTH sE`0APPLICATION 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. r4,,,&1 ESTABLISHMENT NAME: W. 4,2.."--nit,u-)--1 Cen re 9a4ed hQi TAX ID: E 41 O <��9 S' LOCATION ADDRESS: (37 3 Ile 0ek� tJ. J ,,ted 6)&73 TEL.#: (508.- 77- d? ' MAILING ADDRESS:. E-MAIL ADDRESS: lvyc c c/CC € Alen. e. o fr.,' OWNER NAME: In/. y2rrn to c..4-11 Co ti..1',el a-AL O.1 / n,c4 CORPORATION NAME (IF APPLICABLE): (/ 11//4 MANAGER'S NAME: cT 'RL:4--- TEL.#: ZIP ff"Z76 "v2/O MAILING ADDRESS: eye 7f2i.r. tzei &J- )4,.',,p,JM, AM d 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. A/a— 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 yearsrecords. You must provide new copies and maintain a file at your place of business. 1. /Vag 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 590.110. Please attach copies of certification to this application. The Health Department will no use past years'reco •s. You must provide new copies and maintain a file at your establishment. 1. Uusan. (Su) kOs/c d 2 MAR 0 1 2021 HEM_-_ 'F77. PERSON IN CHARGE: "a"`�' -- Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. 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. 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. UQ-,el �Ul;k- a. 2. /4reA 3. ,64" sJ1C k` CS I 4. RESTAURANT SEATING: TOTAL # '7,5 OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# r/2.n ecc 0ADIM ecc 1\A/1TUI Qi 1n 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 X 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 x 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 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 TT1D r,rik iTDT DTDTI D ENT CAI/A T A DDT Tr'A TTr1RT/C'1 A ATT-1 D D(1T TTD DT 1 DDD'/C'1 DV 1-\D0D1ki1DDD 1 4 111111 The Commonwealth of Massachusetts Fee Town of Yarmouth $30.00 Food Establishment License Number: BOHF-15-1500-06 Issue Date: 1/1/2021 Mailing Address: Location Address: WEST YARMOUTH CONGREGATIONAL CHURCH 383 ROUTE 28 383 ROUTE 28 WEST YARMOUTH. MA 02673 WEST YARMOUTH, MA 02673 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. Board Hillard Boskey, M.D., Chairman Mary Craig, Vice Chairman of Charles T. Holway, Clerk Debra Bruinooge Health Eric Weston4IP truce G. Murphy, MPH, R.S. CH P Mallory R. Langler, R.S. Health Director/Assistant Health Director The Commonwealth of Massachusetts Department of Industrial Accidents 4_ Office of Investigations 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: V yarmoti 72.2 6 h . e4 Address: 3£s c a City/State/Zip: _ ,e L Phone #: - 77f- ©� 7 / Are you an employer? Ch•ck the appropriate box: Business Type(required): 1. I am a employer with a employees (full and/ 5. ❑ 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. 8r— r r [No workers' comp. insurance required] Z o,•-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 1 o.n Manufacturing no employees. [No workers' comp. insurance required]** 11.0 Health Care 4.7 We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.7 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: —(",`;,,;A L t) 1,4 1:'c"l c e_ Insurer's Address: e C0.r City/State/Zip: l-\ek rtC cc cot c j 0 (, t `; Policy#or Self-ins. Lic. # O Yi \,Ji C. N tv L;c t b?; Expiration Date: i o lI 2_1 Attach a copy of the workers' compensation policy declaration page(showing the policy number and ex iration 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 .erti , under th' .ains and penalties of perjury that the information provided above is true and correct. ySignature: i Date: 45 Phone#: e®/9 77c, 9/ Official use only. Do no: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#: wwv,.mass.gov/dia DATE(MM/DD/YYYY) LJ CERTIFICATE OF LIABILITY INSURANCE 02/05/2021 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: FITTS INSURANCE AGENCY INC PHONE (508)620-6200 FAX (508)481-0227 08088026 (A/C,No): (aC,No,Ext): 2 WILLOW STREET SUITE 102 E-MAIL ADDRESS: SOUTHBOROUGH MA 01745 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: Twin City Fire Insurance Company 29459 INSURED INSURER B: WEST YARMOUTH CONGREGATIONAL CHURCH INSURER C: 383 ROUTE 28 WEST YARMOUTH MA 02673-4721 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. INSR TYPE OF INSURANCE ADDL SUBS POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSR WVD (MM/DD/YYYY1 (MM/DD/YYYYI COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) MED EXP(Any one person) PERSONAL&ADV INJURY GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE POLICY PRO- LOC PRODUCTS-COMP/OP AGG JECT 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 LIAB OCCUR EACH OCCURRENCE EXCESS UAB r CLAIMS- MADE AGGREGATE DED RETENTION$ WORKERS COMPENSATION X PER OTII- AND EMPLOYERS'LIABILITY STATUTE ER ANY YIN E.L.EACH ACCIDENT $1,000,000 A PROPRIETOR/PARTNER/EXECUTIVE WA 08 WEC NN5968 10/01/2020 10/01/2021 OFFICER/MEMBER EXCLUDED? I E.L.DISEASE-EA EMPLOYEE $1,000,000 (Mandatory in NH) If yes,describe under E.L.DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if mom space Is required) Those usual to the Insured's Operations. CERTIFICATE HOLDER CANCELLATION West Yarmouth Congregational Church SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 383 ROUTE 28 BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED WEST YARMOUTH MA 02673 IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD ! ty .k...,-,..:.-41.,-,4.,..--4-4,, : F M ., r4 l -t 4 . 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