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Home My WebLink AboutApplication and WC ;__.._�iawa�a P� � TOWN OF YARMOUTH BOARD OF HEALTH � � � � APPLICATION FOR LICENSE/PERMIT -20 � � 1( 2, ; NOd � 0 2(�15 , * Please complete form and attach a11 nece��obuZine nts �?Decemb r I S 201 S. Failure to do so will result in the retutn of your application pack t_ : �; ESTABLISHMENTNAME: Thirwood Place TAXID• LOCATIONADDRESS: 237 North Main St . , So. Yarmouth TEL.#:508-398-8006 MAILINGADDRESS: 20 North Main St . So. Yarmouth, MA 02664 E-MAILADDRESS: mpurrier@thedavenportcompanies .com OWNER NAME: CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: Edward Goodwin TEL.#: 508-398-8006 MAILINGADDRESS: ZO North Main St. , So . Yarmouth MA 02664 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_. f��,�f�fr� _ _ _ 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 years' records. 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 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 tile at your establishment. l. QI�L'�-L� 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. �� 2. ALLERGEN CERTIFICATIONS: All food service establishments aze 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. /1-�GC.+`-� 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 Cle at your place of business. 1. ��t"�-c�`"�-v ' 2. 3. ' 4. RESTAURANT SEATING: TOTAL # OFFICE USE ONLY . __ _ — —�eBe;�r�;--- — -- -- --- --------- ----- -- LICENSE REQUIRED FEE PERMIT# LICENSE REQU[RED FEE PERMIT# L[CENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $1l0 —INN $55 CAMP $55 �SWIMMINGPOOL$IlOea. —oo LODGE $55 _TRAILERPARK $105 WHIRLPOOL $110ea .160.�00`Q FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 CONTINENTAL $35 NON-PROFIT $30 �>100SEATS $200 .I�IL_0(1 �COMMONVIC. $60 IG_010 _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 VEND[NG-FOOD $25 , �Q5,000 sq.ft. $I50 _�� —FROZEN DESSERT $40 _TOBACCO $t 10 , NAME CHANGE: $15 AMOUNT DUE _ $ (0.3 O. 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 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 X OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yazrnouth taaces and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES X NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations ofMotel or Hotel use,Transient occupancy shall be limited to the temporary and short term occupancy,ordinazily 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 ceRified 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.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 Permit until 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, 2015. 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 REQUIRE A SITE PLAN. DATE: 11-1-15 SIGNATU : "�'I PRINTNAME & TITLE: Mary Purrier, Asst . Control7 Rev. 10/O V I S � The Commonwealth ofMassachusetts ' Department of Industrial Accidents Office of Investigations I Congress Street, Suite 100 Boston,MA 02I14-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print LeLiblv Business/OrganizationName: Thirwood Placee Address: 237 North Main St . City/State/Zip: So .Yarmouth, MA 02664 Phone#: 508-398-8006 Are you an employer? Check the appropriate boz: Business Type(required): 1.[� I am a employer with employees(full and/ 5. ❑ Retail or part-time).* 6. ❑ RestaurantBaz/Eating Establishment - -- 2. I am a sole proprietor or parfnership and have no �, � 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 corpomtion and its officers have exercised 9. ❑Entertainment their right of exemprion per c. 152, §1(4), and we have 10.�Manufacturing no employees. [No workers' comp. insurance required]° 4.❑ We aze a non-profit organization,staffed by volunteers, I 1.❑ Health Care withnoemployees. [Noworkers' comp. insurancereq.] 12.�OtherRPt; rPmanr rnmm,m; r� •Any applicant that checks box#1 must also fill out the sectioa below showing their workecs'compensation policy infoxmation. **If the coiporate officexs have exempted themselves,but the corporation has other employees,a workets'compensation policy is requ'ved and such an organization should check box#I. � I am an emplayer that is providing wotkers'compensation insurance for my emp[oyees. Be[ow is the policy informdtion. InswanceCompanyName: Zurich American Ins . Co. Insurer'sAddress: see attached City/State/Zip: Policy#or Self-ins. Lic. # WC 819 6 03 5 Expiration Date: 3-1-16 Attach a copy of the workers' compensarion policy declaraflon page(showing the policy nnmber and ezpiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposirion of criminal penalties of a fine ug to$i,5@��00 andlor otre-yearimprisonment��s iveil ascivil penalties ix the f�t�tt-of�STE3P-�V�F�K ORDSR aud a ftne of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify,under the p ' s and penalties ofperjury that the information provided above is true and corred Si ature. Date: 11-1-15 Phone#• 508-39 -2293 Offacial use only. Do not write in this area,to be completed by city or town officiaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2. Building Department 3. CitylTown Clerk 4.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: www.mass.gov/dia �� DAVEREA-01 KSCH162054 facoRo' CERTIFICATE OF LIABILITY INSURANCE DATE�MMIDDf/YYY� �/ 215/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFER$NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BYTHEPOLICIES . BELOW. THIS CERTiFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S�,AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOIDER. � IMPORTANT: If the certiFlcate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the tertns and conditions of the policy,certaln policies may require an endorsement A statement on this certificate dces not confer rights to the . certifiwte holder in lieu of such endorsement(s). PRODUCER �Tp�T Krickett Schaefer NFME: . The Atltlis Group LLC PNONE (610)279$550 �a�c No:(610)279-8578 2500 Renaissance Blvd. E��4.€xtl Sutte t00 noonEss:�chaefer theaddis roup.com . King Of Prussia,PA 19406 INSUREfySIp�ORDIN6COVEFAOE NAIC% wsunea n:Zurich American Insurance Co. 16535 INSURm W SURER e: Thirwood Place L.P. elo DavenpoR Realty Trust M15URER C: Mr.Stephen Aschettino MSURER 0: 20 North Main SL INSUREftE: South Yarmouth,MA 02664 INSURER P: 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 POLICV PERIOD INDICATED. NOTVNTHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CON7RACTOROTHERDOCUMENTNATHRESPECTTOWHICHTHIS CERT7FICATE MAY BE ISSl1ED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREINISSUBJECTTOALLTHETERMS, �� EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMRS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TypEOFINSURANCE POfJCYNUMBER M NIDYE� MMIW/YWPY LIMITS LTR A X COMMERCIALGENERALLIFBILITV EACHOCCURRENCE E 'I�OOO�OO CIAIMS-MADE �OCCUR GL06196291 03I01I2015 03I01I2016 pREMISES Eaoccurtenee E $��00 MED EXP(My arie persan) E 1,00 PERSONALBADVINJURY E ��OOO�OOO GEN'LAGGREGATELIMITAPPLIESPER: GENERALAGGREGATE E Z�OOO�OOO � X POLICV��Ea �LOC PRODUCTS-COMP/OPAGG E ' X oTHER:Prod Compl Ops Indu s � auron+oei�euaeiun CAMBINED iN LEIJMI a 1,000,00 Ee eccitleM A X ANYAUTO BAP8196256 03I0712015 03I0112016 �DI�YINJURV(Pe�pereon) E ALLOWNE� SCHEDULED BpDILYINJUftV(PeracGde� E AUTOS NON-0NMED PROPERTYDAMA E . X HIREOAUTOS X q�pS Pera�tlent § �( COMPE100 �( COLL 550� s UMBREILALln6 ��R EACHOCCURRENCE E EXCESS LIAB CLAIMS-MADE AGGREGATE E DED RETENTIONS s WORKERS COMPENSATION �( � ANOEMPLOYERS'LL181LJTV STATUTE ER� � A ANYPROPRIETOR/PARTNEWEXECUTIVE �� N/A CB796035 OEIO112015 03I01/YO'IB E.L.EACHACCIDEM $ 'I�OOO�OO OFFICER/MEMBER EXCLUOEOi � (ManCatorylnNX) E.L.DISEASE-EAEMPLOVE f 1,000,00 Hyea,tlascnbe untler DESCRIP�IONOFOPERATIONSbNow E.L.DISEASE-POLICVLIMIT f ��OOO�OO DESCRIPTION OF OPERATION3/IACATONS/VEHICLES (ACORD 101,Ntltlitlonal Ramarin Schatlule,may Ce afficMtl tl rtare ape<e Ia�equintl� � CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRA710N DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTXORQEO REPRESENTFIIVE Town of Yarmouth �T i/1J � Route 28 `��— South Yarmouth MA 02664 rT �� 01988-2014 ACORD CORPORATION. All rights reserved. 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