HomeMy WebLinkAboutApp-License-Certifications IIF:.`oF.....�.. TOWN OF YARMOUTH BOARD OF HEALTH
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1 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: L d )1 Al a/I, I 0 IfigioY ZZ70 TAX ID:
LOCATION ADDRESS: 76 GUTE ze TEL.#: SGB- 7J7-/Sj'1f
MAILING ADDRESS: /76 GZ 2._€)
E-MAIL ADDRESS: e,ty, 2270 69 riud.s. zbu/`ZS. (9/7
OWNER NAME: A- 0YALL (1Z0e)l o/1 /9100$e Po Z270
CORPORATION NAME (iF APPLICABLE):
MANAGER'S NAME: /'C j--6155 -e/_AJ TEL.#: 5 -737—/8(PS
MAILING ADDRESS: 54 C Ano L/C
POOL CERTIFICATIONS:
The pool supervisor must be cc ified as a Pool Operator, as required by Smite la% . Please list the designated
Pool Operator(s) and attach a - py of the cci0lication to this form.
1. 2.
Pool operators must -t a minimum of two employees currently ertified in standarc Fir: zi3O-81 •mm unity
Cardiopulmonary suscitation (CPR), having one certified ei ployee on premises - ,. " t the
employees below end attach copies of their certifications to th.: form. The Health Dep tment will not use past
years' records. ou must provide new copies and main in a file at your place o usiness.
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. ,SOS-eph.Q ctsci-eu )
2.1-6:011 .k) °y
PERSON IN CHARGE:
Each food estab
lishment must have at least one Pers( 1 In Charge (PiC) on site during hours of operation.
1 I (tbauh, rn o u-41 'Pa/ 61-00s-i)
ALLERGEN CERTIFICATIONS:
Alf 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.
I. J 05e 01 -eft. 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 newc
opiesand maintain a file at your place of business.
I. . j0 h 2.
3. 4.
RESTAURANT SEATING: TOTAL it
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. TI-IE 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
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, shall-generally be considered Transient.
POOLS
POOL OPENING: All swimming, wading and whirlpools which have been closed fir the season must be inspected by the
l lealth Department prior to opening. Contact the I lealth 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•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 FOOL) SERVICE OPENING:
All food service establishments must be inspected by the I lealth Department prior to opening. Please contact the Health
Department to schedule the inspection three(3) days prior to opening.
•
CA'T'ERING 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 I Icalth 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.
The Commonwealth of Massachusetts Fee
Town of Yarmouth $30.00
Food Establishment License
Number: BOHF-14-0357-07 Issue Date: 1/1/2021
Mailing Address: Location Address:
LOYAL ORDER OF MOOSE 769 ROUTE 28
YARMOUTH LODGE#2270 SOUTH YARMOUTH, MA 02664
769 ROUTE 28
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, 2020 unless sooner suspended or revoked and is not
transferable.
Conditions
SEATING: 115
RESTRICTIONS: Board of Health meetings, March 15 &April 5, 2010:
Septic system to be inspected yearly, with Title 5 Report submitted to the Health Department by December
1st.
Board Hillard Boskey, M.D.,Chairman
Mary Craig, Vice Chairman
of Charles T. Holway, Clerk
Debra Bruinooge
Health Eric Weston
Bruce G. Murk y
�S., CHO
Health Director
Route 28 South Yarmouth Building location is 769 Main St.Rte 28
Drive Way Entrance I
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NOVA Casualty ompalrry Rr w:� \T:
DIVA A STOCK INSURANC COMPANY
NOVA CASUALTY COMPANY 726 Exchange Street,Suite 1020,Buffalo,NY 14210 NAV 7.02.37.02.31-866-633-69'45 `' 2:
LICE
WORKERS COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE-POLICY':''
INFORMATION PAGE
NCCI Company No. 14191 POLICY NO. LFR-WK-10001421-01
RENEWAL OF: LFR-WK-10001421-00
ITEM 1. NAMED INSURED AND MAILING ADDRESS: AGENT NAME AND ADDRESS:
YARMOUTH MOOSE LODGE #2270 LOICKTON AFFINITY, LLC.
769 ROUTE 28 P. . BOX 410679
SOUTH YARMOUTH MA 02664-5101 SAS CITY, MO 64141
LODGE2270@MOOSEUNITS.ORG A ENT NO. 10071
LEGAL ENTITY: NON PROFIT ORGANIZATION
OTHER WORKPLACES NOT SHOWN ABOVE: SEE NAME N D LOCATION SCHEDULE
ITEM 2. POLICY PERIOD: From: 06-13-2020 To: 06-13-2021
Effective 12:01 A.M. Standard Time at the Insured's mai ing address.
ITEM 3. COVERAGE:
A. Workers Compensation Insurance: Part One of the is licy applies to the Workers Compensation Law of the
states listed here:
MA
B. Employers' Liability Insurance: Part Two of the policy .pplies to work in each state listed in Item 3.A. The
limits of liability under Part Two are:
Bodily Injury by Accident: $ 100, 000 each accident
Bodily Injury by Disease: $ 500, 000 policy limit
Bodily Injury by Disease: $ 100, 000 each employee
C. Other States Insurance: Part Three of the policy applie to the states, if any, listed here:
ALL STATES EXCEPT ND, OH, WA, WY STATES DESIGNATED IN ITEM 3A
D. This Policy includes these Endorsements and Schedule:
SEE SCHEDULE OF FORMS AND ENDORSEMENTS
ITEM 4. PREMIUM: The premium for this Policy will be determined by our Manuals of Rules, Classifications, Rates
and Rating Plans. All information required on the Work rs Compensation Classification Schedule is subject
to verification and change by premium adjustment or au it.
Minimum Premium: $ 211 (MA) Tot Estimated Policy Premium: $ 333
Audit Period: ANNUAL De sit Premium: $ 333
Issuing Office: WINDSOR, CT
Issued Date: 03-24-20
WC 00 00 01 A 0615 "Includes copyrighted material of National Cou it on Compensation Insurance
with it's permissi n"
INSURED
Policy No. LFR—WK-10001421-01
N riiTNA
NOVA CASUALTY COMPANY
EXTENSION OF INFORMATION PAGE
NAME AND LOCATION SCHEDULE
Named Insured YARMOUTH MOOSE LODGE #2270 Effective Date: 06-13-20
Agent Name LOCKTON AFFINITY, LLC.
Agent No. 10071
Entity Code: 1
YARMOUTH MOOSE LODGE #2270
FEIN: 042622104
NAICS Code: 813410
769 ROUTE 28
SOUTH YARMOUTH, MA 02664-5101
# EMP: 1
WC 000001A0615
INSURED
�� NAPolicy No. LFR—WK-10001421-01
N�L
NOVA CASUALTY COMPANY
INSTALLMENT SCHEDULE
Named Insured YARMOUTH MOOSE LODGE #2270 Effective Date: 06-13-20
Agent Name LOCKTON AFFINITY, LLC. Agent No. 10071
IT IS HEREBY AGREED AND UNDERSTOOD THAT THIS POLICY IS
PAYABLE ON INSTALLMENTS AS FOLLOWS:
REVISED
DUE PREMIUM SURCHARGE INSTALLMENT
TOTAL
06/13/2020 $ 328 . 00 $ 5 . 00 $ 333 . 00
Failure to pay the Installment Premium by the Date Due shown shall constitute non-payment of premium for which we may
cancel this policy.
WC990610A0615
INSURED
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joseph Hagen
has successfully completed ASH! C:.-ire Trai4tirg for:
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Blended learning consists of computer-based, online lessons i,-,1 .
combined with hands-on skill practice and performance evaluation. !
This documen. confirms that the above-named individual has [: -
completed the required online lessons and is now eligible for hands- II
on skill practice and performance evaivaiion by a current and ti$
properly authorized ASHI Instructor. =F
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The Commonwealth of Massachusetts
Department of Industrial Accidents
— Office of Investigations
_Y =_I 1 Congress Street, Suite 100
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Boston, MA 02114-2017
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` z� www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name: ,,4 0Y4C Id?fl C� / 2270
Address: 7/2 7 4U/E 20
City/State/Zip: S 5rnw/Y-7' /45 t2L hone #: c*2 7 /z9�
Are you an employer? Check the appropriate box: Business Type(required):
1.n I am a employer with employees (full and/ 5. ❑ Retail
or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment
2.n I am a sole proprietor or partnership and have no 7. ❑ ice 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.n Manufacturing
o employees. [No workers' comp. insurance required]**
4. We are a non-profit organization, staffed by volunteers, 11.0 Health Care
with no employees. [No workers' comp. insurance req.] 12.❑ 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: r- ) I
f ILL
Insurer's Address: ,U
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 - '#, •er e pains and penalties of perjury that the information provided above is true and correct.
Signature: 4 Date: /2 - 3- ? 2 6}
Phone#: /e- 7. 7- /Q 9 c
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):
I. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office
6. Other
Contact Person: Phone#:
win A.mass.gov/dia
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