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HomeMy WebLinkAboutApp-License-Certifications TOWN OF YARMOUTH`B`"OARD OF HEALTH 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: 'Jcrirmou i per' V i II aces 5+ # TAX ID: LOCATION ADDRESS: 32,o 9,4e. f; •Iaa-mou+F,pru+ rr 452A-4-.s TEL.#: Sag-362-24 0 o MAILING ADDRESS: 33C9 Q±e 6& Yap-m/14A por rn 0 O 9 t E-MAIL ADDRESS: 0 i s�G( _'4-2-1"1-6 £ *Ado_ Cofl OWNER NAME: "1/1 Slicx.L Shu_K 14.. CORPORATION NAME (IF APPLICABLE): N p y cr2rr m ;t I t Go'a 9 MANAGER'S NAME: 't/ S1,1 e41-_ S hu< et_ TEL.#: Soe-5 'Lq 3 3 k(,f MAILING ADDRESS: 3 `h-icie , up&Li PE)6--P5 - ,Je.._ to ft- 02 44 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. 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. 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 Establish•-- • _ I _ '' X00. Please attach copies of certification to this application. The Health Department will n i t us -eco ds. You must provide new copies and maintain a file at your establishment. 1\101e2021 1. IsigatiVitg ? i-I-i i 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. CLtsti i g Pa-I-e- 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. \J 1S}1 Shu.K 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._ 2. 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# LICENSE 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 PENDING-FOOD $25 7<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 1/ Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES V 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 BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY RE•UIRE A SIT.'LAN. DATE: L — 4 - 2 1 SIGNATURE: Tar PRINT NAME & TITLE: 1' . a • , S s 4 S/ Rev. 10/15/19 The Commonwealth of Massachusetts Fee (--' Town of Yarmouth $150.00 Food Establishment License Number: BOHF-14-0358-03 Issue Date: 1/1/2022 Mailing Address: Location Address: NEW YARMOUTH CORP. 330 ROUTE 6A YARMOUTHPORT VILLAGE STORE YARMOUTH PORT. MA 02675 330 ROUTE 6A YARMOUTHPORT, MA 02675 IS HEREBY GRANTED A 2022 LICENSE TO OPERATE: Food Service; Retail; 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. Conditions SEATING: 0 Board Hillard Boskey, M.D.,Chairman Mary Craig, Vice Chairman of Charles T. Holway, Clerk Debra Bruinooge Health Eric Weston / it Bruce G. Murphy, MPH, R.S.,CH•'/Jaitl . Gardiner Health Director/Assistant Health Director The Commonwealth of Massachusetts Fee i.' Town of Yarmouth $110.00 Tobacco Product Sales License Number: BOHTP-14-0750-03 Issue Date: 1/1/2022 Mailing Address: Location Address: NEW YARMOUTH CORP 330 ROUTE 6A YARMOUTHPORT VILLAGE STORE YARMOUTH PORT, MA 02675 330 ROUTE 6A YARMOUTHPORT, MA 02675 IS HEREBY GRANTED A 2022 LICENSE 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 G. Murphy, MPH, R.S., CHO/James G. Gardiner Health Director/Assistant Health Director The Commonwealth of Massachusetts _� Department of Industrial Accidents / cffl� 1, Office of Investigations t 1 Congress Street, Suite 100 !~ ='Et_E=t Boston, MA 02114-2017 w www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name:New Yarmouth Corp. D/B/A Yarmouthport Village Store Address:330 Route 6A City/State/Zip:Yarmouthport, MA-02675 Phone#:(508) 362-2900 Are you an employer? Check the appropriate box: Business Type(required): 1.1=1 I am a employer with 3 employees (full and/ 5. ❑■ Retail or part-time).* 6. 0 Restaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7. 0 Office and/or Sales (incl. real estate,auto,etc.) employees working for me in any capacity. [No workers' comp. insurance required] 8. 0 Non-profit 3.❑ We are a corporation and its officers have exercised 9. 0 Entertainment GuWD their right of exemption per c. 152, §1(4),and we have 10.0 Manufacturing NOV 1 6 2021 no employees. [No workers' comp. insurance required]** 11.❑ Health Care 4.❑ We are a non-profit organization, staffed by volunteers, HEALTH DEPT. 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'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:Massachusetts Retail Merchants WCSIG,Inc.(RogersGray, Inc.) Insurer's Address:63 Smith Lane City/State/Zip: Kingston, MA-02364 Policy#or Self-ins. Lic. # 014005034124121 _ Expiration Date:01/01/2022 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 an nalties of perjury that the information provided above is true and correct. Signature: Date: 11/02/2021 Phone#:(508) 524-3344 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#: www.mass.gov/dia ACRO CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 10/21/2021 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 po icy'(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 RogersGray, Inc. -Kingston Branch PHONE FAX 63 Smith Lane (Avc.No,Eaq;508-746-3311 (ac,No:877-816-2156 Kingston MA 02364 E-MAIL o RIESS : mail@rogersgray.com INSURER(S)AFFORDING COVERAGE NAICM INSURER A:Vermont Mutual Insurance Company 26018 INSURED NEWYARM 01INSURER B:Massachusetts Retail Merchants WCSIG,Inc. 0 New Yarmouth Corp 330 Route 6A INSURER C:Mount Vernon Fire Insurance Company 26522 Yarmouth Port MA 02675 INSURER D: INSURER E: INSURERY COVERAGES CERTIFICATE NUMBER:1158601860 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 I INSD WVD POLICY NUMBER IMM/DDIYYYY) (MMIDOIYYYYI UMI TS A COMMERCIAL GENERAL LIABIUTY BP11046844 10/31/2021 10/312022 EACH OCCURRENCE $2,000,000 CLAIMS MADE OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $50,000 MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $2,000,000 GEN'L AGGREGATE LIMIT APPUES PER: GENERAL AGGREGATE _ S4,000,000 _ POLICY E T LOC PRODUCTS-COMP/OP AGG $4,000,000 OTHER: $ AUTOMOBILE UABIUTY COMBINED SINGLE LIMIT $ (Ea ecddent) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per acadent) S AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per acddent) s UMBRELLA LIAB _ OCCUR EACH OCCURRENCE __ $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ I DED RETENTION$ _ $ g WORKERS COMPENSATION 014005034124121 1/1/2021 1/12022 PER OTH- AND EMPLOYERS'LIABILITY Y/N _- STATUTE ER _- _ ANYPROPRIETOR/PARTNER/EXECUTIVE ❑ E L.EACH ACCIDENT $500,000 OFFICER/MEMBER EXCLUDED? NIA (Mandatory in NH) E L DISEASE-EA EMPLOYEE $500,000 If yee describe under - DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT S 500,000 C Liquor Liability CL 2704946E 10/28/2021 10/282022 Occurrence $1,000,000 Aggregate $2,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS i VEHICLES (ACORD 101,Additional Remarks Schedule may be attached it more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of Yarmouth Building Dept. 1146 Route 28 IJT AED REPRESENTATIVE S Yarmouth MA 026664 _ �— r� C Jac /i/ ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD ft - , . 1 - IL .^.74 a. fl i p .i I o•.. k i i 1 1 f f ., a, a . . . • 8 "i I f ,. 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