Loading...
HomeMy WebLinkAboutApplication and WCI GL3ECEIVED TOWN OF YARMOUTH BOARD OF HEALTH � � ' APPLICATION FOR LICENSE/PERMI' 20 5f . NOVA 2 6 2014 * Please complete form and attach all necessary documents y ece ber . Failure to do so will result in the return of your application p. 'SPT ESTABLISHMENT NAME: r{ wtr w a,� 1.ObSEer Nd �hC , TAX ID: LOCATION ADDRESS: 1335 ..c,q,14-€. p4'j S Trmod1-i /nn 0z004 TEL.#:50g `3Q -;,14712 MAILING ADDRESS: E-MAIL ADDRESS: Su2r-1asu r, 4_ 0_Orv1e_4.51-,rulfrl.rj tI/£0/I I 'Aa2I ?QoS!S 'Q UOS j, :TULL2S'av vm mud �2In L�'NJIs h I NVI - � — :�L�Q ' V \ IYAIIIDNIIYAIAIO3 0.L NORM H1'IVIIH AO Q2IVO8 MIL AS QIIA02IddV(INV OZ QIIDIOdII2I IIS ISnbAI `('3.LII`.LNIIY\IdI.l AON `DNIINIVd "0'9 1OOd WO 'III1OLAI `.LNIIJAIHSI"IHYZSII QOOA ANY OZ SNOIZYAONII2I TIV I OZ `S 12IHHIATHD Q AS(S)Had M11In6II1I(INV(S)NOI.LYDnddV QII.LII'IdIY\I03 IIH,I. N2In.LII2I 01A.LPIIfISNOdSII2I 2If1OA SI.LI 'I£a0q1113oaQ of I Aannuup uzoal AIlnnuu2 mu siiuuad:�DIZON •pa;Igigoad si Iuauigsilg2ls0 aoin cas pooj JO pl.012 Aq ionpoad pooj icui jo ifnldsip JO`uo921nda1d Tui}l000 aoopin0 :ONINOOD 1100111110 'IRFaH Jo 1/Moi"agi wag Innoaddd aoud 0224 isntu`(aoinaas ssali umpalrum Blinn 5uii2as loopino"al)sapo amnia :Sa31(D IIQIS.Lf10 •iaui uaaq OARLI suuol anogn alp jun iiuuad ilassau uazoa3 anoif Io uoiinoonai JO uoisuadsns agi ui ilnsaa Il m os op oI alnli2J 'IuauiiandaQ wail am of paiuuigns silnsaa aldui2s `aailnalagi Ajgiuotu pun 2uivado of loud qui pampa°alms 2 Aq paisai aq isntu silassap uazoJA :SZaIaSSHQ NIIzo2I,4 •stuaod algnpnoluMoQ `Iuauip2daQ gilnaH aapun sn•ntu•ginouu2ic•MMM i2 aiisgann sJunno'am uioal 10`Iuauziamda j gilnaH am 12 paun qo aq u2o suuoJ magi •ivana palal2o am of loud smog ZL uuol uoiinoilddy aotnlag pool Al2aoduia1 paainbaa 01.13 OLIO Aq Iuamia1daU gil2all glnouu2A am Aiiou isntu glnouU2A Jo umo,I, am uitliinn saal2o 014M auoicuy :ADI'IOd 0NIIIHIVD •2utuado of aoud sic-up (£) aaagi uoiloadsui am alnpagos oI IuauxiaedaQ gilnaH am ionluoo asnald tuivado o;.Diad IuauuaudaU twat'am Aq paioadsui aq isnui sluautgsilg2lsa aoinlas pool IIY :3MINIIdO HDIAlIHS QOOd 'IVNOSVHS IIDIAIIIIS QOO:d • utsolo jo sA2p(L)uanas mligm palanoo JO pauinlp aq isnua food UiWWTMS punolO ui aoopino Anna :3NI5013'IOOd •aall23aatl1 Alaaia2nb pun `Ouivado of aoud sA2p (£) .0141 uatandaQgnH am oIpa ns pu2 paljpiao awls 2 Aq Iunoo al2ld panpunis pun uuoliloo Iniol`s2uouzopnasd.oJ paisai aq isnui 1012nn atl.L :ONIISa.L 2IIIZVM'IOW 'pauado pun paioadsui uaaq snq food am 'pun 2012 lood 01p.ui its of paMojI2 ION 012 aldoad :JZON IISVII'Id •2uivado oI aoiad &fup (£)aa. D uoi;aadsui aq;ainpagas of IuatuuudaQ gilnaH alp IoniuoD •2uivado of loud Iuatuia2daU gilnaH am Aq paioadsur aq isntu uosnas agi aoJ pasolo uaaq.2214 go!gm sloodmgm put Suip2m`211iuiuiiMs IIY:ONIIsIIIdO'IOOd S'IOOd Iuaisu2JI paaapisuoo aq AII21au30 Hugs 'papuauzn 52 `0f9 Igo 0£8 a0 9i79 'o •TJ'JAJ ui pamjap s2 `asioxII iiou2dnoo0 woo 'jo uoiloalloo am of ioafgns s! I2gl Aou2dnoo0 •ivaisuau paaapisuoo aq lou II2Ils iiun Buillamp JO aouapisaa 2 52 pun son 2jo asn •pouad gluotu(9)xis Aun uigp t&inp(06)Alautu mil WOW Ioujo ai22aag2 u2 put`siinp(0£)1 !ql amp wow Ioujo Aou2dn000 snonuiluoo of 1aJa1 All2aaua2 Hugs ifou2dn000 Iuaisu2JZ•aaagmasla aouapisaa jo amid I2diouud 2 ui2iuium Aagi i2gi ai2alsuomap of alg2 aq pu2 anal isntu sluIdn000 Iuaisu2mZ •asnalo u2 a i g plow p i i gl?M pal2iooss2 iflia2uiolsno put Xlia2uiplo giCouedn000 uual dogs pun A121oduzai am of paiiLLTil aq Hugs AouIdn000 Iuaisu2JZ`asn IaioH Jo!OWN JO suoii2iiuiil agilo sasodmd ao j :ADNVdf1330 INaISNV LL SINaJAIHSI RIVZSII 9AIIOQO'I 2IIIHIO QAIV slalom' ON SEA :QIVd 3I A'III.LYRIdo2IddV DRHD IISVII'Id sliuuad ano/f Io aouInssi JO l2nnauaa of aoud mud aq Ism snail pun saxni Illnotua2A Io uMo1 QIIH3YIIV(INV QIINDIS IIAVQId3Y 'dFAIOD Sc2IIIN lOA. XO J► QIIH3V1.LV HDNVIlfISNI 3O '.L2III3 2IO `QIINOIS QNV aa1 L'IdLAIo3 IIB ZSf1JAI .LIAVQI33V II3NV2If1SAII NOI,LVSNIIdIAJO3 SaIII)RIOM HIV.LS QIIHJV.L.LV IIH1 •aoUBansui uoilBsuaduzoj ma)laorn Io a3Io1iilaD 2 .2214 ion scop Aundtuoo 10 uosaad n IT ssauisnq B Naiado oI ittuzad asuaoil /cm Io Inman..JO aounnssi plog of paambaa mon si ginouuBAlo uMoI am'9 uoiloasgn5 `)SZ uoiioa5`ZS I JaldntJJ aapu f NOI1.V2I15INIRIGV The Commonwealth of Massachusetts Department of Industrial Accidents �1 = Office ofInvestigations , �=4 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: i\ er w , _u Lis Address: (3 a [)U 2 c-g City/State/Zip: S. ar©u.,--h m A 07/462 q Phone#: 508 3cn -c 1-3'02 Are yqu an employer? Check the appropriate box: Business Type(required): 1.D I am a employer with tie b employees (full and/ 5. ❑ Retail or part-time).* 6. 'Restaurant/Bar/Eating Establishment 2.0 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. 0N0n-profit 3.0 We are a corporation and its officers have exercised 9. 0 Entertainment their right of exemption per c. 152, §1(4), and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]** 11.0 Health Care 4.❑ We are a non-profit organization, staffed by volunteers, 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: ()1j) +a,c I 1(1 LQrcXwwk 5 V}(C_ Gsiatkp Insurer's Address:-PO -6ak gaaa- 'aas (�,ir �'� City/State/Zip: t5 ,n` ,Q � M {q al Policy#or Self-ins. Lic. # 014 Expiration Date: 01 0 I f 0)-(71 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 25Auf 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 °er he pains and penalties of perjury that the information provided above is true and correct. Signature: Date: 1/ Phone#: 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 • ACGREP CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 11/17/2014 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 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 Mark Sylvia Insurance Agency,LLC NAME: Kris A 404 Main Street I / .PHONE.Ezn:(508)957-2125 FAX No):(508)957-2781 E-ML ADDRESS:markamarksylviainsurance.com Centerville,MA 02632 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Ma Retail Workers Comp Gr Inc INSURED INSURER B: Riverway Lobster House,Inc. 1338 Rt 28 INSURER C: South Yarmouth,MA 02664 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 WTH 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 AODL SUER POUCY EFF POLICY EXP LTR TYPE OF INSURANCE INSR wvo POUCY NUMBER (MM/DDFVYYYI (MM/DD/YYYY) UMITS GENERAL UABIUTY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES(Ea occurrence) $ CLAIMS-MADE OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY PRO- JECT LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ _ AUTOS _ AUTOS NON-OWNED PROPERTY DAMAGE HIRED AUTOS _ AUTOS (Per accident) UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ A WORKERS AND EMPLOYERSEUABIUTY Y/N 014005032222114 1/1/2014 1/1/2015 O TORY LIMITS X ER ANY PROPRIETOR/PARTNER/EXECUTIVE 014005032222115 1/1/2015 1/1/2016 E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? n N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,it more space is required) Restaurant Jason Siscoe is covered under the workers compensation policy. 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. AUTHORIZED REPRESENTATIVE -- I ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD Florio, Mary Alice From: Florio, Mary Alice Sent: Monday, December 01, 2014 12:12 PM To: Riverway Lobster House(suemasure@comcast.net); jason.riverway@comcast.net Subject: Licensing Fee Payment Good morning. Hope you had a good Thanksgiving holiday. I tried calling, however,the restaurant is closed on Mondays, and I thought it would be better to send an email vs. leaving a voice mail message. Thank you for submitting your food service application for 2015.There was a cover letter attached which explained how many of the Health Department fees are increasing effective January 1st,2015. If you pay for the food service and common victualler licenses PRIOR TO DECEMBER 31,2014,you are able to pay the old fee amounts. Check#11891, which was submitted with the license application, is in the amount of$260.00.This is the amount which would be payable after January 15L. If you would like, I will hold off depositing Check#11891 so that you can replace it with another check in the amount of$220.00,which is the current fee amount owed. Please let me know as soon as possible if you would like to do this,otherwise, I'll just process Check#11891. Thank you for your immediate attention to this matter. MaryAlice Florio, Principal Office Asst. Yarmouth Health Department 1146 Route 28 South Yarmouth, MA 02664 508-398-2231,ext. 1241 1