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HomeMy WebLinkAboutApp-License-Certifications a TOWN OF YARMOUTH BOARD OF HEALTH E. '►'\ ` APPLICATION FOR LICENSE/PERMIT -2022 * Please complete form and attach all necessary documents by December 18, 2021. Failure to do so will result in the return of your application packet. ESTABLISHMENT NAME: % tar Ci q f4.14�1't4ick I TAX ID: LOCATION ADDRESS:2?3 Rte. As. !J. r•,ri. O 23 TEL.#: MAILING ADDRESS: dam r E-MAIL ADDRESS: t.J Y CC c C @ rn.5 ». m OWNER NAME: _ C8r.r�`d d e‘,42.1 Chu"-a CORPORATION NAME(IF APPLICABLE,): /V/ MANAGER'S NAME: '.gyi . �- TEL.#: eon 2.-776 --F' /O MAILING ADDRESS: 3p'd "kr Z7 [.), �Qry,�► ill 04 (1,2‘ s POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State la . Please list the designated Pool Operator(s)and attach a copy of the certification to this form. 1. `,la... 2. UE1 14 2021 Pool operators must list a minimum of two employees currently certified in standar Firr kNi ,�t C'nhnmu pity 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. /1/62--- 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. CI SO i led S J ; 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: 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. 4.ren 77t/ 2. 5'08 50)k-c)6 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $110 _INN $55 CAMP $55 SWIMMING POOL$110ea. LODGE $55 TRAILER PARK $105 WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LIC SE REQUIRED FEE PERMIT# 0-100 SEATS $125 _CONTINENTAL $35 ,/NON-PROFIT $30 >I00 SEATS $200 COMMON VIC. $60 WHOLESALE $80 —RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 -<25,000 sq.ft. $150 _FROZEN DESSERT $40 TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE = $ � *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** 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 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 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 THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 18, 2020. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED B E BOARD OF HEALTH PRIOR TO COMMS CEM NT. RENOVATIONS MA ' !UIRE A SIT' 'LA► . DATE: U al SIGNATURE: PRINT NAME&TITLE: . , / - Rev. 10/15/19 The Commonwealth of Massachusetts Fee Town of Yarmouth $30.00 Food Establishment License Number: BOHF-15-1500-07 Issue Date: 1/1/2022 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 2022 LICENSE TO OPERATE: Non-Profit; This license is granted in conformity with the statutes and ordinances relating thereto, and expires December 31, 2022 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 Bruce Ci. Murphy, MPH, R.S., C O/ mes G. Gardiner Health Director/Assistant Health Director ;�.: 'fie Commonwealth o apopcm ; � Department artment o P " t Office oflnve rir al Accidents : t: ;r • -•... g tions ='::I_ 1 Congress Street,, Suite 100 ^k, -i Boston, MA 02114-2017 www. Workers' Compensation Insurance Affidavit: General Businesses A 'leant Information Business/Organization N Please Print Le ibl ame: { Y� , ,+11 co, Address: 3 � ( re, c, r 4c ur City/State/Zip: s`4 Yarmv th Are you n em to er? Phone #: �0. _ C . P Y Check the appropriate box: Business Type7 i . _ ,� or part-time).* -- employees(full and/ 5 (r 1.21 1 am a employer with ? (required): • ❑Retail L.Li i am a sole proprietor or partnership and have no y.. 6. Restaurant/Bar/Eating Establishment [No workers'com 7• 0 Office and/or Sales(incl. real estate, auto p. insurance required) officers have exercised �Oerpr° 3.0 We are a corporation and its of9. m , etc.) employees working for me in any capacit their right of exemption per c. 152, §I(4)'and we have no employees. [No workers' co 0 Entertainment 4-❑ We are a non-Droftt or 'nP insurance re•uir * I 0'0 Manufacb. 1r111 ) 1 I Y ,f I • ion,staffed by volunteers, i i•b Health Care With no employees. [No workers' comp. insurance req.] 12.0 Other *Any applicant that checks box#1 must also fill out the section below showing their workers'comPen sation policy infor .. **If the cotpdtate officers have exempted themselves,but the corporation has other employees,a workers'compensation mation orBaniZation should check box#I, p on policy is required and such an I am an employer that is providing workers'compensation insurance for my employees Below is the policyinformation. Insurance Company Name: _ f mation. P Y ihr' � � �.r � c7 � rA Insurer's Address: 3 (,,p 0 J �r � � e �' U��ci rt C �ti �smc;n B pf _ - • City/State/Zip: S e n AnJ. t o `C X 7 ' —_b t (Acct' F uC(k C` 6 6t5 Policy#or Self-ins. Lic. # 0 F ' E c, tNi N Set S . Expirationate: 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) line up to$1,500.00 andior one-year imprisonment,as well as civil penalties in the form ofa STOP WORK ORDER and a fa ine of up to$250.00 a day against the violator. Be advised that a cony of th;. ...e.. _� ' �� 'a 4o oonNZ ^ • fA ti' ,, #.11:)ii (1) p� c,.E;.6'�,+,:rte: t • -,5---a ill `V ly f•a O NCO tp N Q m m O r �� �. ▪YOy L/) .. B , N 9 a3,p�K^ v, OO :fi' O ','.1'5''''' r D t. y 3 — • CD -IF cck 8 g CD _ `^ CD zIn qfi> N 0 O V/ �' 10 LO 7 C " .,-,..7,,,,,., 0 CJS sn 1% CO " T A s Pk. irtiL. O O o ii.a o —O fl r— a ,� Q— 0 1- !. A C_ r 4V...7 CD X a CL cM } = .1.'''4-4 " k.y '.' ., 3 r+ .r •- .c• *+ + 'i4,44:0, . . . ..:,,t . •. .„.. . -4. 4,... 4 .-- ., . •, .1' ' - 1 • - . —4 •, *i. *•• ...••.......•,... ,.,...... .. ....-4 . , .. : SUPPORT _ - i BASIC LIFE SU - ,..... ri• . . ,.. , , ; BLs . . IHeart Provider . ':.:,...7'.,...:',,.. .:-. 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FU 3 N Q 0 H Jam % i. a) tie ,C in p C W O E Q T C N U c° I& e..) 2ar, o 3 -73 ,-- im O cl -o cy5 OQ r czUi -i-5 CCI c p g. I4Cif) ) ra) b" -= a- aL -D a) o w . 64 W cn a = N� 0co E —4 U) t� c :° cid = >, a) al E-4 cin C a) 0 0 Mil) U cn V U (n U `s 73 < O I- Q o a N 4p z DATE(MMND/YYYY) AC1012 a°. CERTIFICATE OF LIABILITY INSURANCE 12/10/2021 THIS E CERTIFICATE HOLDER.THIS CERTIFICATE DOES MATTER TTT AFFIIRMAmE OF INFORMATION ORNONLY NEGATIVE AND CONFERSAMENDEXTEND OR ALTERNO RIGHTS UPON TMTHE 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 l( 08088026 (A/C,No,Eat): (NC,No): 2 WILLOW STREET SUITE 102 E-MAIL ADDRESS: SOUTHBOROUGH MA 01745 — INSURER(S)AFFORDING COVERAGE NAICs 29459 INSURER A: Twin City Fire Insurance Company INSUREDINSURER B: WEST YARMOUTH CONGREGATIONAL CHURCH INSuRERC: 383 ROUTE 28 INSURER 0: WEST YARMOUTH MA 02673-4721 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 BBEN REDUFF CED BY PAID CLAIMS. LAWs LTR DIP TYPE OF INSURANCE ADDL SUB. POLICY NUMBER t11t11DD h IMWDD/Y YYYI LTR RISK WVD EACH OCCURRENCE COMMERCIAL GENERAL LWBILITY DAMAGE TO RENTED ICL/UMS-MADEI (OCCUR PREMISES(Ea occurrence) MED EXP(Any one person) PERSONAL&ADV INJURY GENERAL AGGREGATE (POLICY PRO' AGGREGATE LIMIT I LOC UES PER: PRODUCTS-COMP/OP AGG I —'— JECT OTHER: COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY (Fa accident) BODILY INJURY(Per person) ANY AUTO —ALL OWNED _SCHEDULED BODILY INJURY(Per accident) — AUTOS — AU AUTOS PROPERTY DAMAGE HIRED (Per accident) AUTOS AUTOSOS EACH OCCURRENCE UMBRELLA UAB OCCUR CLAIMS. AGGREGATE ,— EXCESS LIAR MADE DEDI (RETENTION$ WORKERS COMPENSATION X IS RTUTE I 1ER AND EMPLOYERS'LIABILITY EL FACE{ACCIDENT $1+x,000 ANY YM A PROPRIFTOR/PARTNERIEXFCUTIVE ( N/A 08 WEC NN5968 10/01/2021 10/01/2022 E.LDISEASE-EAEMPLOYEE $1,000,000OFFICER/MEMBER EXCLUDE $1,000,000 (Mandatory in NH) EL DISEASE-POLICY LIMIT $1,000,000 I yes,describe under DESCRIPTION OF OPERATIONS below — DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remar*s Schedule,may be attached I more space Is required) Those usual to the Insured's Operations. __- CERTIFICATE HOLDER CANCELLATION Town of Yarmouth SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 1146 28 BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED SOUTH YARMOUTH MA 02664 IN ACCORDANCE WITH THE POLICY PROVISIONS. S —A REPRESENTATIVE J7u49ztn o3' £ 1 ©1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD (Policy Provisions: WC000000C) INFORMATION PAGE WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY INSURER:Twin City Fire Insurance Company ONE HARTFORD PLAZA HARTFORD CT 06155 THE HARTFORD NCCI Company Number: 14974 Company Code: 7 Suffix LARS RENEWAL POLICY NUMBER: 08 WEC NN5968 16 Previous Policy Number: 08 WEC NN5968 1. Named Insured and Mailing Address: WEST YARMOUTH CONGREGATIONAL CHURCH (No., Street, Town, State,Zip Code) 383 MAIN STREET WEST YARMOUTH MA 02673 FEIN Number: 04-6069898 State Identification Number(s): The Named Insured is: Non Profit Business of Named Insured: Religious Organizations Other workplaces not shown above: 2. Policy Period: From 10/01/21 To 10/01/22 ANNUAL 12:01 a.m., Standard time at the insured's mailing address. Producer's Name: FITTS INSURANCE AGENCY INC 2 WILLOW STREET SUITE 102 SOUTHBOROUGH MA 01745 Producer's Code: 08088026 Issuing Office: THE HARTFORD BUSINESS SERVICE CENTER 3600 WISEMAN BLVD SAN ANTONIO TX 78251 (877)853-2582 Total Estimated Annual Premium: $1,214 Deposit Premium: Policy Minimum Premium: $276 MA(Includes Increased Limit Min. Prem.) Audit Period: ANNUAL Installment Term: Eleven Pay(16.7%Down+10@8.33%) The policy is not binding unless countersigned by our authorized representative. Countersigned by 6' ,) 08/22/21 Authorized Representative Date Form WC 00 00 01 A (1) Printed in U.S.A. Page 1 (Continued on next page) Process Date: 08/22/21 Policy Expiration Date: 10/01/22