HomeMy WebLinkAboutApplication and WC ^� TOWN OF YARMOUTH BO OF HEALTH ��������
��� APPLICATION FOR LICEN T +`��� , uAN � O YO1.r1
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* Please complete form and attach all nec � ;,� c ber IS 2014. �
Failure to do so will result in the return o your applicahon P� !
ESTABLISHMENT NAME: "s -/�/L,U - �T • / /
LOCATION ADDRESS: 37 1�(�,(/f/,f�f7�,(� A✓E' S�R,P./�IUUTff NAOZGG'�TEL#• -s�8 39y O'74�
Ma1LI�rG.9DnREss: �ir�f �� M� . o2��c/ -SaarE�fs ��u�
E-MAIL ADDRESS:��i�lG�co S13L��G1.4IL L'D/L1 �
OWNER NAME: .si,/�
CORPORATION NAME (IF APPLICABLE): B/i/ R/I,r�7'/G-5 USFJ -A2ti'oc�D SAccS-
MANAGER'S NAME: fJG � c/Lif� 'rEL.#: �D�-39y ax�/
MAII,INGADDRESS: 6A.K.� A� .f,�0(Q7� Sd&' �ZZr-G'I2�
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. N�/1 � � 2. � I
Pool operators must list a minimum of two employees currently certified in basic water safety, standazd First Aid �
and Community Cazdiopulmonary 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£ile at your place of business.
1. N�� 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.
�.��� 2.
PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
1. NlA- 2.
ALLERGEN CERTIFICATIONS:
All food service establishments are required to have at least one full-time employee who has Allergen certificaUon,
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. /V�6/ 2.
HEIMLICH CERTIFICATIONS:
All food service establislunents with 25 seats or more must have at least one employee trained in the Heimlich I
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. N�A 2.
_3. - - -- _ ---- - _ -- —�. --- , _ _
RESTAURANT SEATING: TOTAL#
LODGING:
L[CENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
B&B $55 CABIN $55 MOTEL $110
�NN $55 CAMP $55 - � � SWIMMING POOL$110ea
- LODGE $55 7RAILERPA2K $105 WHIRLPOOL $110ea
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
0-100 SEATS $125 _CONTINENTAL $35 NON-PROF[T $30 �
>I00 SEATS $200 _COMMON VIC. $60 =WHOLESALE $80
. � —RES[D.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 _ $ 8�. OO
*****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°x�� r��enewal
of any license or permit to operate a business if a person or company does not have a Certificate ofzWorker's
Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSITRANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR
CERT. OF INSURANCE ATTACHED ✓ �
OR _ .
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yannouth 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, sha11 generally be considered Transient.
POOLS
POOL OPEIVING:All swunming,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 aze 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 standazd plate count i
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 Deparhnent prior to opening. Please contact the
Health Deparhnent 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.varmouth.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 Pernut unril the above terms have been met.
OUTSIDE CAFES:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Boazd of Health.
�
OUTDOOR COOHING:
Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited.
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 15, 2014.
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 CONIMENCEMENT. RENOVATIONS MAY�A T AN.
DATE: I d 1� SIGNATURE:
PRiNT NAME &TITLE: AI1�N � C�if/1(/,fl�'.' 1JEPOTt SALES .fi1La�..
Rev. 11/03/14
� The Commonwealth ofMassachusetts �
Department oflndustrial Accidents
O�ce of Investigations ;
, ` I Congress Street, Suite I00
i Boston, MA 02114-2017
www.mass.gov/dia
IWorkers' Compensafion Insurance AfSdavit: General Businesses
Apnlicant Information Please Print Legiblv
Business/Organization Name: Q/N1L� /j�!�/LiGS p,5/f -f12x-'U�D 5/1C.�3`
A'ddress: 37 /�UN7/�UG1D.c.� A✓� I
City/State/Zip: S �!9/�rl�vi7�� Nj/} p2�6� Phone#: 5J8 �39°1-079/ o,� .SuB-Z2/-07Z�
Are you an employer?Check the appropriate bos: Business Type(required):
1.� I am a employer with�_employees(full and/ 5. ❑Retail
or part-time).' 6. ❑RestaurantlBaz/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. I
[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 �0.❑ Manufacturing
no employees. [No workers' comp. insurance required]*
4.❑ We aze a non-profit organization, staffed by volunteers, ll.�Health Care
with no employees. [No workers' comp. insurance req.] 12. '✓[]�Other �IIKC-p 6��5 lv/IDLC-C.SR[.E
'Any applicant that checks box#I must also&ll out the section below showing[heir worke=s'compensation policy information.
*'If the coxporete officecs have exempted themselves,but the corporation has other employees,a wockers'compensation policy is Iequired and such an
organization should check box#1.
I am an employer that isproviding workers'compensation insurance for my emp[oyees. Be[ow is thepolicy information.
Insurance Company Name:
Insurer's Address:
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 eapiration 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwazded to the Office of
Investiga6ons of the DIA for insurance coverage verificarion.
I do hereby certify,under the pains and penalties of perjury ihat the information provided above is true and correct
Signahue: ��%� �� Date: �,S�cS
Phone#: .S�' -�/'�'/1/ oe ,�xi8 -2Z/-U725
Official use orely. Do not write in this area,to be completed by city or town officiaG
City or Town: Permit/Licease#
Issuing Authority(circle one):
1.Board of Health 2. Building Department 3. City/'1'own Clerk 4.Licensing Board 5. Selectmen's Office
6.Other
_ _- - -- _ _ _ —_
Contact Personc Phone#:
www.roass.gov/dia �
� �
f • ' '
'`�c R� CERTIFICATE OF LIABILITY INSURANCE °"'�,"""°°""""'
- 2/a/zo15 1/15/2014
THI$ CERi1FICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON TF1,E CERTIFICATE HOLDER. THIB �
CERTIFICA7E DOES NOT AFFIRMATNELY OR NEGATNELY AMEND, EXTEND OR ALTER THE COVERAG�'/CFFORDED BY THE POLICIEB �.
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BE7WEEN THE'fSSUING INSURER(S�, AUTHORIZED '.
REPRESENTATNE OR PRODUCER,AND THE CERTIFICATE HOLDER. '.
IMPORTANT: ,H the eertiflcate holder is an ADDRIONAL INSURED,!he policy(les)must be endorsed. H SUBROGATION IS WAIVED,subject to �'
the terms ant�'eondklons of the policy,eertain pollcles may require an endorsement. A sWtement on this certifleale does not confer rights to the '.
certifleate holder in lieu of such endorsement(s). '�
��W�� LOCK4�ON COMPANIES CONT ��
NAM :
21QORD}S.,�S AVGNUE,.SUITE 1400 Pxw+E �.
DALI��J TX�SZO� E-WJL AIC No: :
' 214-969-6700 �oorsess: �.
�� . INSURE S AFFORDINGCOVEItAGE NqICM I
iNsunean: CE Am ri ce Com an 22667
ixauneo BBU,Inc.on behalf of itself and iNsursve a: �,
1359436 U.S.subsidiaziesincluding � iNsurtexc: '
(see ariached addendum) � ruurten o: '�.
255 Stisiness Center Dr. �� wsu2ers e: �
Horsham�PA�19044 ;
` " INSURERF: I
COVERAGES �:� CERTIFICATE NUMBER: 12160299 � REVISION NUMBER: XXXJCXXX ��'��
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD '�.
INDICATED. NON/1THSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH 7HI5 �
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 BV PAID CLAIMS.
WSR qpD BUBR POLICYEFF POLICVEXP �
�� TPEOFINSURANCE POLICYNUMBER EypD MMIO LIMITS ,
A �.X COMMERCVLLGENERALLUI<' N N EIDpG2733037A 2/1/2014 2/1/2015 �.
CWMS-MADE �OCCUR PREMSES(Eaoaaurence) S ] OOOOOO
MEDEXP arie
PERSONALSADVIWURY $ ]�(�O�OOO I
i
GEN'LACaGREGATELIMRAPPLIESPER: GENERALAGGREGATE $ �
POLICY �jE�a �LOC PRODUCTS-COMP/OPAGG i
OTHER: E �
A auror�oei�uneam p N ISA H08818757 2/12014 2/1/2015 8 i
(Ee ecd0enl)
X �'AUTO BOOILVIWURY(Perperson) $
FLLOWNED SCHEDULEO BODILVIWURY Pereccitlent
AUT0.5 AUTOS
HIREDAUTOS NON-0WNED PROPERTYDAMAGE $ XXXXX���
AlIr05
$ �{�{�{�{��� I
uMe���`une oCCUR NOT APPLICABLE � EnCH oCCURRENCE S g�{J�J�J(gg ���'
IX��� QAIMS-MADE AGGREGATE y I�
DED REfENTION$ $ '�..
WORKERSCOMPEN8Al10N ��
A ANOEMPLOYeastuelurv N K'LRC47878123{AZ,CA,MA) 2/1/2014 2A/2015 X STAn1TE ER !
B ANYFROPRIETORIPARTNERIE)(ECUTNE y�N WLRC47$7$1J5(AOS) 2/1/2014 2/]/IO15 E.LEACHACCIDEPR $ I
A OFFICEwMEMeERexCLUDEO? � N/A SCFC47$7$i47(WI) 2/1/2014 2/1/2015 :
(Ma�WetaryinNH) E.LDISEASE-EAEMPLOVE $ ] OOOOOO '�
Hyes,tlescnEa un0er '�.
DESCRIPrI N OF OPERATIONS below E.L.DISEASE-POLICV LIMIT $ ''�,
i
DESCRN1qN OF OPERATONS/LOCATONS/VEHILLES (ACO�101,Atltlitlonal Remerke SMetlule,may b�atlaehatl H more tpac�G nWlretl) I
Policy it EIDO G2733037A includes policy grneral aggregare of S10M
�
CERTIFICATE HOLDER CANCELLATION See Attachment I
12160299 i
For Information Only SHOULD ANV OF THE ABOVE DESCRIBED POLIqE$BE CANCELLED BEFORE
TNE EXPIR4TION DATE THEREOF, NOTICE WILL BE DELNERED IN
ACCORDANCE WITH THE POLICY PROVISIONS. �
�UiHORQED REPRESENfAi1VE i
/�/�� �
_ R�A�•�� CF�L•!/[�"� v
OO 1988-2014 ACORD CORPORcATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are reglstered marks of ACORD
�
INSURED ���
BBU,Inc.on behalf � ��.
of itselT and U.S.subsidiaries ��
including(see attached addendum) �
255 Business Center Drive �
Horsham,PA 19044 USA
The fdlowing are Named Insureds under the GL and Auto policies: -�
Advantafirst Capital Financial Services,Inc
Allen Foods Inc
� � Amold Foods Company,Inc. '
-- Amold Produds,Inc
Arnold Saies Company Inc �
BHL Transport, Inc
Bimbo Bakeries USA,Inc
Bimbo Bakeries DisMbution Managemenl,LLC
Bimbo Bakeries Distribution Company,Ltd
Bimbo Foods Bakeries Distribotion,inc
Bimbo Foods,Inc
Bimbo Foods,LLC .
Butter Krust Baking Company Inc.
Carlisle Foods Inc
Earthgrains Vemon,LLC '.
Earingrains Baking Companies,Ina '�.
Earthgreins Bakery Group,Ina I
Earthgreins Distribution,LLC '��
EGR CalAomia Region Support Services,Inc. I
Enlenmann's Products,Inc ���.
Entenmann's Sales Company,Inc '�,
Freihofer Products,lnc �,
Freihofer Sales Company,Inc �'
Maspeth Holdings,LLC ;
Mid-Gult Bakery,LLC '�.
Orogrein Bakeries Manufacturirg,Inc �,
Orograin Bakeries Products,inc I
Orogrein Bakeries Sales,Inc j
Potomac Foods,LLC '
SB NY Inc '
Stroehmann Bakeries P.A.LLC i
Strcehmann Bakeries,Inc.
Strcehmann Bakeries,L.P. I
Stroehmann Line-Haul,LP. �
SLnehmann Sales LLC �i
Tia Rosa Bakery of Ohio,Inc '�,
Westfield Foods LLC '
i
The folbwing are Named Insureds under the WC policy: �
Allen Foods Inc
Amold Products,Inc �
Arnold Sales Co Inc
�
Bimbo Bakeries USA,Inc �
Bimbo Foods Bakeries Distribution,Inc
Earthgrains Baking Companies,Inc.
Orograin Bakeries ManuFacWring,Inc
Orograin Bakeries Sales,Inc
Orograin Bakeries Produc[s,Inc
Mid-Guli Bakery,LLC I
SVoehmann Line-Haul,L.P.
I
I
�
i
Standazd Attachment:BIMBAKUSNI i
Master ID: 1359436,Certificate ID: 12160299
�