HomeMy WebLinkAboutApplication and WC . , a�c�o�
� TOWN OF YARMOUTH BOARD OF HEALTH
��� APPLICATION FOR LICENSE�`�' -�Ql� . �E� 1 y 'LU14
* Please complete form and attach all necess�dOcuments by Dece er DEPT,
Failare to do so will result in the return of your application pa .
ESTABLISHMENT NAME•�' a v Y C I , �c "�:�,;�.� S�<. TAX ID:
LOCATION ADDRESS: �� `-I•es� �-v. w� +'F S TEL#•5'oR-��+{-'74 s�
MAILINGADDRESS: Ser.�Q
E-MAIL ADDRESS: �Q r ,.Q oQ.�+�i,�. � ,.�.i
OWNERNAME:Z,•,�pf�ln c., 1•`µ
CORPORATION NAME (IF APPLICABLE): f Q :,N�N .n •
MANAGER'S NAME: L ��,�I3�i M C�r� L.#: �og- �4�{-Zy sl
MAILINGADDRESS: a. Wk;� 1 5. ��`u+�� M� 0 4y
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 basic water safety, standazd 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 years' records. You must provide new copies and maintain a file at your place of business.
1. Z•
3. 4•
FOOD PROTECTION MANAGERS - CERTIFICATIONS:
All food service establishments aze 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 estabiishment.
�.1 �� ��� C�-Q � _2.
PERSON IN CHARGE:
Each food establishment must have at least one Person In Chazge (PIC) on site during hours of operation.
_. 1•����L`aJ J�/� / ra� - - - - Z. I 1 c-Innra� —�� ���.-��� ----- --- �-- . .
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.� nr � � 6 �l�YLS 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-chokmg 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.
RESTAiIRANT SEATING: TOTAL# �f7 _
OFFICE USE ONLY
_—. _-I:6DGING:�- � - - - - _. __.___ _ --- ---_ __--l--
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
B&B $55 CABIN $55 MOTEL $I10
INN $55 CAMP $55 SWIMMINGPOOL$110ea.
LODGE $55 TRAILERPARK $105 _WHIRLPOOL $110ea.
FOOD SERVICE:
LICENSE REQUIRED FEE P RMIT It LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
�0-100 SEATS $125 S- I � CONTINENTAL $35 NON-PROFIT $30 .
>100 SEATS $200 �WMMON VIC. $60 . ��'� _��DEKITCHEN $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,OOOsq.ft. $150 —FROZENDESSERT $40 _TOBACCO $il0
NAME CHANGE: $15 AMOIJNT DUE _ $ �S.OO �
RQcd /�/6�0ny
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** �/Q�` �
�-!� ?�f0 / � `�
� s ,
� � � � ADMINI57`RATION � �
LJnder Chapter 152,Section 25 C,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 aot have a Certifieate of Worker's
Compensarion Insurance. TIIE ATTACHED STATE W012KER'S Ct1MPENSATIQN INSiJRANCE
AFFIDAVIT M[JST BE COMPLETFD AND SIGNED, 012 '
CERT. OF INSURANCE ATTACHED �
OR
WORKER'S CONIP. AFFIDAVIT SIGNED ANI3 ATTACHED
Toum of Yarmouth ta�ces and liens must be paid prior to renewal or issnance of your permits. FLEASE CHFCK
APPROPRIATELY IP PAID:
YES� Nd
MOTELS ANA OTHER LODGING ESTABLISHMENTS
TRANSIENT OCCUPANCY: For purposes ofthe limitazions of Motel or Hotel use,Transient occupancy shall be
fimited to the kemporaty and short term occapancy,ordinarily and customarrily associated with motel and hotel use.
Transient occupants must have and be able to demonstrate thaY they maintain a grincipal place of residence
elsewhere.Transient occupancy shall generally refer ta continuous occupancy of not more than thiriy(30)days,and
an aggregate of not more than ninety(90)days wiChin any six(6)month period. Use of a guest unit as a residence or
dwelling unit shall noi be considered transient. Occupancy that is subject to the eollection of Room Occupancy
Excise, as defined in M.G.L. c. 64G or 834 CMR 64G, as amendcd, shall generally be considered Transient.
PO{}LS
POC3L OPENING:All swimming,wading and whirlpaols which have been closed for the season must be inspected
by the Health Department pzior to opening. Contact ihe Health Departrnent to schedule the inspection three(3)
days prior to opening. PLEASE NOTT:: People are NC1T allowed to sit in the poo] area until the pool has been
inspected and opened.
POOL WATER TESTING: The water must be tes#ed for pseudamonas,total coliform and standard plate caunt
by a State certified lab, and submitted to the Health Department ttuee (3) days prior to opening, and quarterlg
tktereaf[er.
POOL CLOSING: Bvery autdaar in ground swimming paol must be drained ar eovered within seven{7}days of
closing.
FOOD SF:RVICE
SEASONAL FOOD SERVICE OPENING:
All food service establishments must be inspected by the Health Bepartment prior to opening. Ptease contact fhe
Health Department to schedule the inspection three{3) days prior to opening.
CATERING POLICY:
Anyone who caters within the Town of Yarmouth must notify t7ie Yarmouth Health Department by filing the
required Temporary Food Service Application form 72 hours priar ta the catered event. These forms can be
obtained at the Health Department,ar from the Town's website at www.yarmouth.ma.us under Health Department, ,
Downlaadable Farrns.
FRCIZEN DESSERTS:
Prozen desserts must be tested by a State certified 1ab prior to opening and monthly thereafter,with sample results
submitted to the I-Iealth 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 CAF�S:
Outside cafas(i.e.,outdoor seating with waiter/waitress service),must have prior approval frorn the Boazd of Health.
OUTDOOR COCIHING:
Ot�tc�c�nr ceakingz�ueparation,or display of anyfood product by a retail or food service esCablishment is prohibited.
NOTICE:Permits run annually from January 1 to December 3 I. IT IS YOUR RESPONSIBILITY TO RETURN ;
THE COMPLETBD RENEWAL APPLICATION{S}AND REQIJIRED FEE{S}BX DECEMBER 15, 2014. i
ALL RENOVATIONS TO ANY P�t3D ESTABLISHMENT, MOTEL OR POOL (i.e., PAIN'1'ING, NEW
EQUIPMENT,ETG}, MIJST F3E REPORTED T{}AND APPROYED B1'THE BOAR.D OF HEALTH PRIQR
TO COMMENCEMENT. 12ENOVATIONS MA,���EQU RE A SITB PL
I7ATE:�S�-��"S"�� J.�__SIGNATURE: JJ
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PRINT NAME& TI"1"LE: .� ���t�� �a ��4�.',,__ Q u;..0 PSC"' ;
Rev. i1103114 �'�'
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� � The Commonwealth ofMassachusetts
Department oflndustrialAccidents
O�ce oflnvestigations
' l Congress Street, Suite I00
Boston,MA 02I14-20I7
www.mass.gov/dia
Workers' Compensation Insurance Af�idavit: General Businesses
Aunlicant Information Please Print Leeiblv
Business/Organization Name: � �e�� 'S
Address: �.'�i f ��n��e S N'a�
� n y
City/State/Zip: �_ �a�c'�+no J 1M N�I� a"1�Phone#: �p�-�q y-7`���
Are yop an employer? Check the appropriate box: Business Type(required):
1.�I am a employer with�_employees(full and/ 5. ❑ Retail
__�r�art-time)* _ __ 6. �tauranUBaz/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.
[No workers' comp. insurance required] 8• ❑ Non-profit
3.❑ We aze a corporation and its officers have exercised 9. ❑ Entertainment
their right of exemption per c. 152, §1(4),and we have �0.Q Manufacturing
no employees. [No workers' comp. insurance required]* 11.0 Health Caze
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 mus[aLso 51l out the section below showing their workers'compensation policy information. �
-**If the coxporate officers 6ave exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an �
organization should checkbox#1. ��.
I am an employer that Bs providing�rker��ensa ' n insurance for my employees. Be[ow is the policy information.
Insurance Company Name: 1 (n
' f /� �`_c � 1 �(,.
Insurer's Address: �`lo�� ��cX �9 ✓�v�ecT, C_t5� � f�F o.r'1 �Jc� ��a.�'E.
City/State/Zip: �a�1� � �
Policy#or Self-ins.Lic. # r Q 5�'�x'v� �ta 5 �X^�X Qa hEx�iration Date:
Attach a copy of the workers' compensation policy declaration page howing the policy number nd espiration date).
_ Failure to secure coverage as iequiied�de�Se�ti4tL25A QfMGL c;152_ca�lead t4 th_e_im�osition of criminal penalties_of a _____ ,
fine up to$1,500.00 and/or one-yeaz imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine I
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwazded to the Office of
Invesrigations of the DIA for insurance coverage verificauon.
I do hereby erti ,under the pains a penalties ofperjury that the information provided above is true and correct.
ti_
Si ature: Date: 1� I
Phone#:
Officia[use only. Do not write in this area,to be completed by city or town offtciaL
City or Town: PermitlLicense#
Issuing Authority(circle one):
1.Board of Health 2. Building Department 3. City/1'own Clerk 4.Licensing Board 5. Selectmen's Office '
6. Other
Contact Person: Phone#:
www.mass.gov/dia '
2014/12/17 14: 46:09 2 /2
,aco° CERTIFICATE OF LIABILITY INSURANCE onre�Mmiooirvvr�
�..�� 12�1,�2�14
THIS CERTIFIGATE IS ISSUED AS A MATTER OF INFORNIATION 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 N0T CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER�S�, AUTHORIZED
REPRESENTATVE OR PRODl10ER,AND THE CERTIFICATE HOLOER.
IMPORTANT: If the certificate holder is an ADDIl10NAL INSURED, the policy(ies) must be endorsed. If SUBROGAi10N IS WAIVED, subject to
Ihe terms and condilions oi ihe policy,certain policies may require an endorsemeM. A slatement on ihis certificate does not conier righ�s to lhe
certificate holder in lieu oisuch enAorsement(s�.
PrtooucER a�o Eacr Select Dept.
Eastern Insurance Group LI.0 PM�No x�: (800)333-7234 x66607 q�C Na.
. p8l)586-BN4
233 WESt CBRtYdl Si E'MA�� .selecLwork@ea5[eYninsurarice.Com
INSIIRER�S)AFFOROWCCOVERACE NAICi
Natick tA 01760 INSURERA:H]LCfOTf3 Ins Co of MidWest 37478
INSURED
INSUREPB: .
IDGYS Q,UTEN FREE RESTAUAANT, INC INSURERC:
23 5 WHITES PATH INSURERD:
INSURER E:
SOUTH YAAMOUTH FA 02669 INSURERF:
COVERAGES CERTFICATE NUMBER:�ster 14-15/WC Only REVISION NUMBER:
THIS IS TO CERTIFY 7HAT THE POUCIES OF INSURANCE LISTED BELOW NAVE BEEN ISSUED TO THE INSURED NAME�ABOVE FOR THE POLICY PERIO�
INDICATE�. NCNJITHSTANDING ANV RE�UIREMENT,TERM OR CONOITION OF ANY CIXJTRACT OR OTHER COCUMENT WfTF1 RESPECT TO NhiICH THIS
CERTIFICATE MAV BE ISSUE� OR MAV PER7AIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRBED HEREIN IS SUBJECT TO ALl THE TERMS,
EAClU510N5 ANO CONDI710NS OF SUCH POLICIES.LIMITS SHOWN Nw`Y HAVE 9EEN REDUCED BYPAID ClAiMS.
INSR TyPE OF INS6'RANCE A�a SlffiR pOLICV EFF POLICV EMP
LTR POLICV NUM6ER MMI�OIVYV MMIODIVVVY LIMITS
GENERNLLINbILITY E^GHOfNRRENCE 5
C�.SMAGE-0�'_NTED
COMMERCIN.GENEFqLW161L1iY PqENISES�E20iv1rtBnCB �
CLaIM'sMq]E � OCCUR MEO E:(F'yM/one pason7 S
FERGpNP18FL�IN,A1Rl' S
GE�FRPLAG6GEG9TE $
� C-EIV'LPG��R-r�q1-LIMI-PP=�155PE� FFCDLCTS-CCMP/OPAGG $
FpLICY 'RO-
E�7 LOC b
AUTOMOBILE LIABILITY CGM6INED SiNfLE LIMIT
Ea acci�snli
AVY'aUTD EODILY'NJUF'��,Perpersor� 5
A_L JNNED SCHEDULED
AJTOS AUTOS BO�ILY N.IURr�Ps;emicenp $
NON-CVdJED FRCFERiY pPMPGE
HIGECAIJl05 ,qUiOa Parecadenl t
$
�MBRELLALIAB OCN4 EPCHUCNRRENCE b
ENCE$$LI0.9 ��q��ycry�qp� eC-GR[�4T[ $.
DEJ �ETENiIJN$
j� WORKERSCDMPENSAiION 'J�1`ST4P,i- pTK , �
AN�EMPlOVERS'LIABILIN ��N 'Y TnPV IrdTS E?
AN\ FP�J=FIETORppFT�lEF4EYEQTIYE
pFR[EPlNEN3FFE:'�Il1C�E�� � N/A ELEu'.4A[CIGENT ,L 100 �0p
(ManmmryinNH� BHECEG0734 9/16/2014 9/16/2D15 �� GIG F^-
u�zs.aesume mder
C _[-[q[wv�nvL� R 100 000
oescai„ioNOFo>eeniiou<neiow E.�.Disee:e-couCv�unir 5 500 000
DESCW VTI ON OF OPERATIONS f LOCATION51 VEHICLES (Atlae�ACOR0101,Atltlitional Remarks Schetlule,if mare spaee is require0)
Restaurant
CERTIFICATE HOLDER CANCELLATION
(50 B)7 fi 0-3472 SMOULD ANY OF TME ABOVE DESCRIBED POLI CIES BE CANCELLED BEFORE
THE E%PiRATION DNTE THEREOF, NOTICE WILL BE DELIYEREO IN
TOWiI of YHSInOuth ACCORDANCE WITH THE POLICY PROVISIONS.
Board of Health
1146 Ate ZB AVT�����E�REPRESEM�INE
South Yaanouth, M4 02664
John Koegel/QJt12 ���S�?
ACORD 25(2010105) �O 1988-2010 ACORD CORPORATION. All�ights reserved.
IN5025�?mU05i p1 Thn AOORn nama anA Innn arn roniciorod mahc of ACORII
2014/12/17 14:46:09 1 /2
�F.astern Insurance A�������
233 West Central Street ��� � �2014
Natick, MA 01760
i�'(��i.
To:
Company / Insurer: Town of Yarmouth
Contact Fax Number: 5087603472
Contact Phone Number:
From: Cynthia Holland
Direct Fax Number: 5086514642
Direct Phone Number: 508-620-3342
Notes: Attn: 8oard of Health
Please see attached.
Thank you.
Date and time of Fax transmission: 12/17/14 2:45:25
Number of pages including this cover sheet: Z
The info�mation contained in this facsimile message is privileged and confidentia/. It is intended only for the
use of the individual named above. If you are not the intended recipient, you are hereby noGfied that any
distributibn or copy of rhis communicatian is strictly prahibited, ff you have received this communication in
e�ror, p/ease notify us immediale/y at the above/isted phone number. Thank you.
NORFOLK & DEDHAM MUTUAL FIRE INSURANCE COMPANY
�� < ComPak� BUSINESSOWNERS POLICY
RENEWAL DECLARATIONS
POLICY#: R1335687A
A. POLICYHOLDER AND AGENT INFO
Insured: IDGY'S GLUTEN FREE INC Agent: EASTERN INSURANCE GROUP LLC
23 WHITES PATH STE S Phone: (781)245-3700
SOUTH YARMOUTH, MA 02664-1236 Agent#: 20193
Business Form: CORPORATION Policy Period: 1 YEAR
Business Description: Cafes From: 01/03/15 To: 01/03/16
.__ _ _ _Cov�rag�begia�aL12111A.M_EasterrLStandardTime.
Payment Plan: DIRECT BILL-NON EDP 4 PAY
B. POLICY PREMIUM
Annual Suhject To State Taxes Prior Annual Additional/Return
Premium Audit or Fees Premium Premium
$2,074 0 Yes ❑ No
C. BUILDING AND BUSINESS PERSONAL PROPERTY COVERAGES AND LIMITS
LOCATION 1, BUILDING 1: 23 WHITES PATH STE S,SOUTH YARMOUTH, MA 02664
Limit(s) Premium
Building ACV Option: No $ S
Business Personal Property $ 54,000 $ 700
Mortgage Holder None
D. LOCATION COVERAGES AND LIMITS
LOCATION 1: 23 WHITES PATH STE S,SOUTH YARMOUTH, MA 02664
_ _ _ _ - -- --- -—
Limit(s) Premium
Outdoor Property $ 25,000 $ Included
Outdoor Signs $ 25,000 $ Included
Money&Securities On Premises/Off Premises $ 15,000/15,000 $ Included
E. POLICY INFO
Policy Deductible Applicable to Section I •Praperty $ 1,000
Optional Coverage Deductible $ 500
Building Coverage Limit Automatic Increase 8%
BOP-1 (0912) Insured Copy Issue Date: 11/25/14
^--- , _� �