HomeMy WebLinkAboutApplication and WC . � TOWN OF YARMOUTH BOARD OF � ����.��A ��
APPLICATION FOR LICENSE/PER�IT�'�Z0�10 DEC O 1 1!1Q9
* .,-��{>Di0 t�7� � - �p i .
Please complete form and attach all neceS�ary documents by Dec �J
Failure to do so will result in the return of your application .
NAME OF ESTABLISHMENT:_/}(ZrJO(D�`Fl.FS Cb 1NG I?� 0 �(�-S� EL. # 50�'-39�i -o7q 1
LOCATIONADDRESS: 3r1 Ht1NT7N6TDN l�-�� 5. �f oaT�� F-i� oZlvfo�}
MAILING ADDRESS:
OWNERNAME:_ TAX ID (FEIN or SSNI:
CORPORATION NAME (IF APPLICABLE): B =YL�C:�S
MANAGER'SNAME: AtA►J G�J-fLi)Ict= TEL. #5o8-22I-Q ZS
MAILING ADDRESS:
POOL CERTIFICATIONS:
The pool supervisor must be certi5ed 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. _ NLF3 2.
Pool operators must list a minimum of two employees currently certi&ed in basic water safety,standard First Aid and
Community Cardiopulmonary Resuscitarion(CPR). Please list these employees below and attach copies of employee
certificarions 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.�(J 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
Protecrion Manager, as deSned in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000.
Please attach copies of certification tp this application. The He$lth Department will not use past years'records.
You must provide new copies and maintain a file at yoar establishment.
1. N�/-� 2.
PERSON IN CHARGE:
�ach Yood establishment must fiave atTeast one Person ln Charge (PIC) on site during hours oY operation.
�. ►��r� z.
HEIMLICH CERTIFICATIONS:
All food service establishwents 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-chokuig procedures below and
attach copies of employee certificarions 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.
�. N1� z.
3. 4.
RESTAURANT SEATING: TOTAL# IJ�A
OFFICE IISE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSB REQUIRED FEE PERMlT#
_B&B $55 _CABIN $55 _MOTEL $55
�INN $55 _CAMP $55 �SWL�4MITIGPOOL S80en.
_LODGE $55 _T1tAILERPARK $105 _WHIRLPOOL 380ea.
FOOD SERVICE:
LICENSE REQUIItED FEE PERM[T N LICENSE REQ[JIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT'#
_0-100 SEATS $85 _CONTINENTAL S35 NON-PROFIT 830
>IOO SEATS $160 _COMMON VIC. $60 1WHOLESALE $80 O�D O
RETAiI,5ERVICE: —RESID.K]TCHEN S80
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIl2ED FEE PERMIT#t LIC£NSE REQLJIRED FEE PERMIT ii
_<SOsq.ft. $50 _a25,000sq.ft. $225 _VENDING-FOOD $25
_QS,OOOsq.ft. S80 _FROZENDESSERT $40 TOBACCO S55
NnME caaivcE: sis AMOUNT DUE _ $ So.cn
.:«..pLEASE TURN OVER APiD COMPLETE OTHER SIDE OF FORM*""**
_ ( ' _
ADMIlVISTRATION . •
Under Chapter 152, Section 25C, Subsection 6,the Town of Yarrnouth is now required to hold issuance or renewat
of any license or pemut 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 ATTACkIED �
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth t�es 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, Transieirt 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 maurtain a principal place ofresidence e�Jsewhere.
Transient occupancy shall generally refer to continuous occupancy of not more than thirry (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. a 64G or 830 CMR 64G, as amended, shall generally be considered Transierrt.
POOLS
POOL OPENING: All swimming,wading and whirlpools which have been closed for the season must be ins
by the Health Department prior to opening. Contact the Health Department to schedule the inspection three(�
pnor to opening.PLEASE NOTE:People aze NOT allowed to sit m the pool area until the pool has been inspected
and opened.
POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and stai►►dard plate count
by a State certified lab, and submitted to the Health Department three (3) days prior to opemng, and quartetly
thereafter.
POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven('I)days of
closing.
FOOD SERVICE
CATERING POLICY:
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Departmait 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.
FROZEN DESSERTS:
Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health
Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Petmit until the
above terms have been met.
OUTSIDE CAFES:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval fromtheBoard ofHealth.
OUTDOOR COOHING:
Outdoor cookingzprepazatioq or di�lay of any food product by a retail or food service establishment is prohibitat.
NOTICE:Pemuts run annually&om January 1 to December 31. IT IS YOUR RESPONSIBILI7'I'TO RETIJRN
THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 15, 2009.
ALL RENOVATIONS TO ANY FOOD ESTABLISf�NT, 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 REQUIRE A SITE PLAN.
, .-
DATE: / 2 � SIGNATURE: �-�!��_ � / �
� PRINT NAME&TITLE: �//I././ �' _A�L6 �f—��./lLlcy' �o�' ,
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09l25/09
,.:
n; ' '� �� � DATE(MM/DD/YYV1')
ACORD,� C�i�T� .: . _ � ��_ . �€t;E ���o9�zoo9
eeooucex THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY
Aon fti5k SePviCeS Central, InC.
Phi 1 adel phi a PA Offi ce AND CONFERS NO R[GHTS UPON THE CERTIFICATE HOLDER.THIS
One Li be rty Pl ace CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE
1650 market Street COVERAGEAFFORDEDBYTHEPOLICIESBELOW.
suite 1000
vhiladel phia PA 19103 u5n INSURERSAFFORDING COVERAGE NAIC#
exorve. 866 283-7122 e,vc- 847 953-5390
msuaeo �rvsuaexw�. American Guarantee & �iability Ins Co 26247 �
Bimbo Foods aakeries, xnc. on behalf of msunexs: Zurich anerican ms co 16535 �
of its u5 subsidiaries and affiliates '�
including (see attached addendum) msuneac
255 Business Center orive �°
HorSham PA 19044 USA msux�cn�. i
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MSURER E: 0
, . ..� <.IY.G.a`� 132 *'.5k 4J_.: ' ' .;.".,.. -`.. .. ; .: r
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�THEPOLICIESOFINSURANCELISTEDBELOWHAVEBEEN[SSUEDTOTHEINSUREDNAMEDABOVEFORTHEPOLICYPERIODINDICATED. NOTWITHSTANDING �
ANY REQUIREMENT,TEAM OR CONDITION OF ANY WNTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY
PERTAIN,7'HE MSORANCE AFFORDED BY TF�POLICIES DESCRIBED HEREIN I$Sl1B1ECT TO ALL TH2 TERMS,EXCLUSION$AND CAND[TIONS OF SOCH POLICIES.
AGGREGATELIMITSSHOWNMAYHAVEBEENAEDUCHDBYPAIDCLAIMS. LIMITSSHOWN ARE AS REQUESTED
INSR POLICY EFFECTN POUCY EXPRtATTON
LTR w5 TYPEOFINSURANCE POWCYNIIMBER DATE(MM�DD\Yl') OATE(MM\DD\W) LIMRS
GENERAI,LIABILITY EACH OCQIRR6NCE
� COhN�RCGV.GENERAL L[ABILI]Y DAMAGE TO RENTED
PREA4SES(Eaoccurence)
CLAIMS MADE � OCCUR One pGmn
�
❑ PERSONAL ffi ADV INNRY �^
'i
GENERALAGGREGATE ^
GENL AGGREGA'IE LIA9S APPI.IES PER'. �
PRODUCTS-COMPIOPAGG M
O
❑ POLICY � IECT � L� O
AUTOMOBILE LIABILITY
CAbIDINEO SINGL2 L[A9S z
ANY AUCO (Qa sccidmt) �
ALL OWNED AUTOS W
BODILY INIURY �
3CHHDULED AUTOS (Per penon) �
'L
L
FpRED AUTOS d
BODILP INNBY U
NON ONNED AOTOS (Pee accldmtJ
PROPERTYDAMACE
(Pe�eccidmv)
CARAGE LIA6ILITV A11T0 ONLY-EA ACCmENT
B ANY AUTO
OTE�RTHAN EAACC
AUfOONLY�.
AGG
EXCE55 NMBRELLA L4IBILITY EACH OCCUARENCE
❑OCC[IA ❑ CLAIMS MAUE AGGREGA'fE
eDEDUCiBLE
RETENTION
B WC Ol 1 9 X wC S"fAN- OTH-
WORKERSCOMPENSATIONAND REt�O WI T
A EMPLOVExs'LUBILrrv WC938045400 O1/21/09 O1/21/10 E.L.EACH ACCIDEM E1,OOO,OOO
ANY PROPRIETOR/PAR]'NER I EXECUTIVE
OFF[CER/A�hBEREXCLUDEO? Ded ELDISEASB-EAHhPLOVEE E1�000�000
IEye;Eascnba�mdar SPEGAL PROVISIONS E L.DISEAS&PoWCY I.IM1QT E1�000�000
beiow
OTNCR
DESCIUPI[ON OF OPERAilONS/LOCATIONS/VEkflCLESIEXCLUS10N5 ADDED BY ENDORSEMEMISPECIAL PROVISIONS
��M'.� ?S
TF12 COIIIIIIOfIW2d�CFl Of Md55dCI1115ETT5 SHIXI[.DANYOFI'HEAHOVEDESCRIDEDPOL[CIESBECANCELLEDOEFORETNEE%PIRAiION
oepartment of Industrial ACCIdEfItS DATETHlREOF,THEISSUMGINSURERWLLLENDEAVOR]'OMAIL
office of investigations 30DAYSWRI'ITENNOflCETOTHECEftT1F1CATEHOLDERNAMEOTOTHHLEFf,
600 washin ton street, 7th Floor surFu�uasr000sosxnc���ossxooeucnr�oxorzune�urv
J OF ANY KIND I1PON THE A'SIIRER ITS AGENTS OR REPRESENTATIVES.
Boston MA 02111 USA
All'If30RIZEDREPRESENTATNE ..9 /.-Jf .�rp�f�9 �p e�
e�6' �LE J LbsaClaG
msunen
aimbo Foods eakeries, inc. on behalf of
of its us subsidiaries and affiliates
including (see attached addendum)
255 eusiness Center Drive
Horsham Pn 19044 USA
Named xnsureds
rhe following are Named xnsureds under the mentioned policies:
ALLEN FOODS INC.
ARNOLD POODS COMPANV, INC.
ARNOLD PRODUCTS, 2NC.
ARNOLD SALES GOMPANV, INC.
BHL TRANSPORT, INC.
BIM60 FOOD$ BAKERIES DISTRIBUTION, INC.
BIMBO FOODS BAKERIES, INC.
BIMBO FOODS, INC.
BIMBO FOODS, LLC
CARLISLE FOODS INC.
CHARLE$ FREIHOFER BAKING COMPANY� INC.
ENTENMANN'S PRODUCTS, INC.
ENTENMANN'S SALES COMPANY, INC.
ENTENMANN'S, INC.
FOOD SERVICES (ONTARIO), INC.
FREIHOFER PRODUCTS, INC.
FREIHOFER SALES COMPANY, INC.
MID-GULF BAKERV, LLC
OROWEAT BAKERS, LTD.
POTOMAC FOODS, LLC.
SB NY INC.
STROEHMANN BAKERIES P.A. LLC
STROEHMANN BAKERIES, INC.
STROEHMANN BAKERIES, L.C.
STROEHMANN LINE-HAUL, L.P.
STROEHMANN SALES LLC
WESTFIELD FOODS LLC
Certificate No: 570036765135
,�.co� CERTIFICATE OF LIABILITY INSURANCE DATE02/24/20 0 )
. ��.
rxouucex 1•�g CERITFICATE 1S ISSUED AS A MATT'ER OF INFORMATION ONLY
non Risk 5ervices Central, Inc.
Phi 1 adel pbi a PA Offi ce AND CONFERS NO RIGHTS UPON THE CER7'IEICATE HOLDER TffiS
One liberty Place CERTIFICATEDOESNOTAMEND,EXY'ENDORAL7'ERTHE
1650 Market Street COVERAGE AFFORDED BY THEPOLICIESBELOW.
suite 1000
ahiladelp hia Pn 19103 usn INS[1RERSAFFORDINGCOVERAGE NAIC#
exorve- 866 283-7122 Fns- g47 953-5390
rvsuxen wsu2eRn. ACE Amer'iCan Insurance Company 22667 ••
BBU, inc. on behalf of its wsuaana: indemnity insurance Co of North nmerica 43575 �
US Subsidiaries and affiliates
including (see attached addendum) �sue�xc: a°+
255 eusiness Center Drive �
Horsham PA 19044 USA �NStmEnn: r
m
7
RJSURERE: p
wvExnces x
THC POLIC�S OF INSIIRANCE LISTED BEIAW HAVE BEEN ISSUED TO THE INSURID NAMED ABOVE FOA THE P011CY PERIOD INDICATED. NOTWITHSTANDAIG
ANY REQUIREMEN'C,'1'ERM OR COND7770N OF ANY CONTAACT OR OTHCR DOCUFffiMI'WITH RESPECT TO�VHICH THIS CER77FICATE MAY BE[SS[JFD OR MAY
PERTAIN,THE INSURANCE AFFORDEII BY THE POLICIF.S DESCRIBED HOtEIN IS SUB.ICCT TO ALL THC 1'P.RMS,EXCWSWNS AND CONDITIONS OF SUCH POLICIES.
AGGREGATEI,IhIlTSSHOWNMAYHAVEBEENAEDOCEDBYPAmCI.AIMS. LIMITSSHOWN ARE AS REQUESTED
INSR D•
LTR INS 9'1TEOFINSUMNCE PoGCYNUMBER PoWCYEFFECTNE POWCYEXPIRATION ���
A'fE MM/DD DATE M/DD
A ������,�, HooG24939960 02/O1/2010 02/O1/2011 EACHoccUrt2eNCE $1,000,000
X COMMERCL4L GENERAL GAHIGTY DAMAGE TO RENTED El,000,000
CLAIMSh1ADE X� OCCOR � P��SE6(Eaoccurte�we)
MED EXP(�v om DersoN ^
PErssONnc&n�V�nmY S1,OOO,000 v`"i
m
GENEnncAGGaecA� 510,000,000 �
GENL AGGREGAiE Gtrlli APPLIES PEft: �
PRODUC'rs-CO�/OPAcc E2,O00,000 '"
❑ POLICY ❑ �� � �p� �
A AU'1'OMOBD.ELIABII.ITY i5n HO BS 88 03 A �2/�l/201� �2��1/2011 ��
COMBINED SINGLE Lltv�i O
X ,Wyp�O (ca��q $5,000,000 Z
d
ALL OWIJED AUiOS BODILY INNRY u
SCHEDOLED AUTOS ���� V � (Per perepo) �
X HIRED AUTOS HODILY INNRY �j
NONOWNEDAUTOS (� u t' (PR��)
MAR �7 V �` 1'" PROP9RNDAMAGE
L 1 1"1 r I ' (Per aaiamg
GARAGE L4IBILITY AUTO ONLY-EA ACCIDEM
ANYAUTO
0'I}IERTHAN EAACC
AU'IO ONLY:
AGG
EXCESS/IIMBRELW LIABILITY EACH OCCURRENCE
�OCCIIR � CLAlMS MADE AGGReGATH
_ DEDUSTI&LE
. __-_ _ __ __ .. . _
AETEN]'ION . . . _. ._ _ . __. _"_.. _
A WORKERSCOMPE9SATIONAND WLRC46131524 02 Ol 1 X µ'C STAN- OTH-
A EMPLOvexs'Luenl'rr NN / /2010 02/Ol/2011 E.L.EACHACCID�r S1,OOO,OOO
uavPROPu�ETOR/Pna'rn�R/E�cvrlve � SCFC46131836 02/O1/2010 02/O1/2011
OFFlCER/MEAIDEREXCLUDED? El.DISEA$E-EAEMPIAYEE S1�OOO�OOO
(Mandatory io NN)
If descnbewderSPEC1ALPROVI510NSbelow
E.GDISEASE-POGCYLIIMT $1,000,000
O]NER
DESCRIP'IION OF OPERATIONS/LOCA]'IONS/VEHICLES/EXCLUSIONS AODED BY ENDORS6h]ENT/SPECIAL PROVISIONS
nny qdditional xnsured status granted to Certificate Holder is limited to the specific terms and conditions
contained in the contract and/or agreement currently in effect between insured and Certificate Holder as of the
date this certificate is issued.
CERTIFICATE HOLDER CANCELLATION �..,
TOWfI of Yarmouth Board O'F H2d�Lh SHOULDANYOFiHEABOVEOESCRIBEDPOUCIESBECANCELLEDBEFORETHEEXPIAATION
1146 Route ZS pATE'IHEREOF,THE ISSUING MSURER WILL ENDEAVOR'IO MA1L
Yarmouth MA 02664 USA 30DAYSWRITTENNOTICETOTE[ECERTIF]CATEHOLDERNAMEDTOTHELEPf',
BUT FAQ.URE i0 DO SO SIIAI.I.IMPOSE NOOBLIGATION OR LLIBILITY
OF ANV qND UPON'IHE INSURER ITS AGENTS OR REPRESEN'IA]'IVES.
AUTNORIZEDREPRESEMATIVE �� ����� � ` p��
c,ssscK�
ACORD 25(2009/Ol) �198Sd009 ACORD CORPORATTON.All rights reserve —
The ACORD oame and logo are registered marke of ACORD �
INSURED
asu, inc. on behalf of its
us subsidiaries and affiliates
including (see nttached addendum)
255 Business Center Drive
HofSham PA 19044 USA
Named xnsureds
rhe following are Named Insureds under the mentioned policies:
ADVANTAFIRST CAPITAL FINANCIAL SERVICES, INC.
ALLEN FOODS INC.
ARNOLD FO005 COMPANY, INC.
ARNOLD PRODURS� INC.
ARNOLD SALES COMPANV, INC.
BHL TRANSPORT� INC.
BIMBO BAKERIES USA, INC.
BIM60 BAKERIES DISTRIBUTION MANAGEMENT, LLC.
__ .. _ __ . .. . . . . ___._ . . . _
BIMBO BAKERIES DISTRIBUTION COMPANY, LTD.
BIM60 FOODS BAKERIES DISTRIBUTION, INC.
BIMBO FOODS BAKERIES, INC.
BIMBO FOODS, INC.
BIMBO FOODS, LLC
BIMBO HUNGRIA COMPANY
CARLISLE FOODS INC.
GHARLES FREIHOFER BAKING COMPANY, INC.
ENTENMANN'S PRODUCTS, INC.
ENTENMANN'S SALES COMPANY, ING.
ENTENMANN'S� INC.
FOOD SERVICES (ONTARIO), INC.
FREIHOFER PRODUCTS, INC.
FREIHOFER SALES COMPANV, INC.
MID-GULF BAKERY, LLC �
OROGRAIN BAKERIES MANUFACTURING, INC. � �
OROGRAIN BAKERIES PRODUCTS, INC.
OROGRAIN BAKERIES SALES, INC.
OROWEAT BAKERS, LTD.
POTOMAC FOODS� LLC.
5B NV INC.
STROEHMANN BAKERIES P.A. LLG
$TROEHMANN BAKERIES, INC.
STROEHMANN BAKERIES, L.C.
STROEHMANN LINE-HAUL, L P. .
STROEHMANN SALES LLC
TIA ROSA BAKERY OF OHIO, INC.
WESTFIELD FOODS LLG .
Certificate No: 570037828527