HomeMy WebLinkAboutApplication and WC � TO'VVN OF YA,itMOUTH BOAItn OF��Ab'FH�� � �� , ��'f,� / ° .
� APPLICATCON�OR LICENSE/PERM�'�}.�Ul6` n�0� S Lti.: i ,'u�9
v.,,
* Please eomplete fomi and attach all necessary doctiments by]'le e er I S 20 5.
' - Failure to do so will result i.a the return of youx application pac HEALTH DEPT.
ESTABLISHMENT NAM : �
LOCAT[ON ADDRESS: MA OZb�13 TEL.#: -8� -94
NIA.ILING ADDitESS: � $
�-MAIL A.DDR£SS: ✓
OWNER NAME:
. CORPORATION NAMB(IF APPLICABLE):
Iv1ANAGER'SNAME: TEL.#: - �02.- 99�
1vtAiLTNG A77DRESS•� G MPr 02b73 '
POOL CERTIk'IC.ATIONS:
The pool superviisor must be certfffed as a Pool Operatox,as required by State law. Please list ttae designated
, PooT Operator(s)and attach a copy of the certification to dus£oma.
i: N�tt z. -
Pool operators must list a minimum'of two employees currently certified in stazxdazd Pirst Aid and Community
Cardiopulmonary Resuscitation (CPR), baving one certified employee onp ises at all tiita�es. Please list tb.e
emp9oy�s below azid attach copies of their certifications to this form.The FYe�aMtb�Aepartment will not use past
years' reeords. You must provide aew copies and maintain a file at ypu�r place of business.
1. QL�/k 2.
3. 4.
F0017 PROTECTION MAIVAGBRS -CER7IFICATIONS:
All food service establishments are required to have at least one �utl-time employee who is eertifled as a Food
� Piocection Manager, as deSned in the State Sanitary Code for Food Se�vice Establishments, 105 CMR 590.000.
Please attach copxes of certification�to this applicarion. 7'he Health Department wfU not use pAst years'records.
Xon must provide new copiea and maivata'va a SIe at your establishmeut.
I..J �7SP h_,� 2. ��t�f.�1 'Y�X(71�11n�.�n
PERSON 1N CHARGE:
Each food establiskame�t baust have at least one Person In Chazge(PIC)oa site during hotus of operation.
i.V�l��)�v,��t�����__ � z. ��xd� �o-4t�;�..I P� �y
ALLERQEN CERTIFICATTONS:
A.1J£ood sezvxce establishments are required to have at Ieast one£ull-time employee who has Allergen eertification,
as'defined in the State Saaitary Code for Food Service Establishments, 105 CMR 590.009(G)(3)(a). Please attach
cQ�pies of cet'Cification to this ap�lication. The Iiea�th Departatent will not use past years'records. You must ���.6�
p�pov�de aew copiea and maintain a fde a�your establishmenw �5 � �O� �
t. � u r i�l�s 2. �
• HEIMLICH CEI2TIIF"ICATIOI�IS: '
All food service establasbments with 25 seats or more must have at least ome employee trained in the�Ieimlicb
Maneuver on the premises at all times. Please last yovr employees trained in anti-chokxug pcoeedures below and
attach copies o�eimployee c�rtifications to this form. The Health Departmeat will not use past years' records.
You must provide new copies and maintaan a£iile at yowr place of business. ,
1.�.��+' W1�11�Gc 2. '� i
3. �� 4. ,v �va,
RESTAURANT SE.A,TIIVG: TOT,AL#
:.:
' ADMYNTSTRATTON
Under Chapte�152,Section 25C,Subsection 6,the Town of Yarmouth is now required to hold issuance o�renewal
of,any license or permit to operate a biisiness if a persom oz company does not have a Ceati�cate of Worker's
Compensation Insurance. '�'� A'.f'�ACHED STATE WOTtKET2'S COMPENSATION IDiSUItA1vCE
AFFIDAVIT MUST BE COMPLETED AND SYGiVED,Olt
CERT. OF TNSLITtANCB ATTACI�£A
OR
WpRKBR'S COMP. AFFIDAVIT SIGNED AND ATTACFiED �
Town of Yazmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEA.SE CHECK
• APPFLOPRIA'I'ELY Ik'P.A�:
, XES ✓ . NO
,
• . MOTELS ANA O�'�iElt LODGING ESTABY.ISFII�IEN'1'S
TRANSIENT OCCUPANCY: For pu�wses of ihe limitatio�as of Motel or Hotel use,Transient occupancy shall be
lzmited to the temporary and short term occupancy,ordinarily avd customarily associated with motel and hotel use.
Transient occupants must have and be able to demonstrate that they naain.tain a principal place of residence
elsewhere.Transient occupancy shall genexaily eefer to continuous occupancy of not more thantltirty(30)days,aud
an aggregate of qot more than ninety(90)days within any six(6)ztaouth period. Use of a guest wtit 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 oz 830 CMR 64G,as amended, sha11 gemexaUq be considered Transient.
• ROOI.S .
� P.00L OPENTNG:All swimming,wading and whirlpools which have been closed for the season must be uaspected
by the Health Aepartment pzior to o ening. Co�xtact the Health Department to schedule the inspection three(3)
days pri�or to opening. �LE��: People are NO'['allowed to sit in the pool area u�il the�ool has bcen
inspected and operied.
pOOL'WATER TESTING: The wate;r must be tested for pseudomonas,total coliform and standard plate count
by a State certified lab, and submitted to the Hea.lth Deps�tment three (3) days pxaor to opening, and quaxtezly
thereafter.
POOL CLOSING: Every outdoox in gzound swimming pool must be drained or covered within seven(7)days of
closing.
� � . , FOOD SEItVICE
SEe4SO1VAL,FOOD SE12'VTCE OPENI�TG:
ualth nsPn�nr mP,en��Rche.�ei�i�lte he n eech'on three f31 davs�lvri Dep�ent�prior��ow{��N�g�Pt .41cntactthe_
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� The Commonwealth ofMassachuseds
Department oflndustrialAccidents
1 Congress Street,Suite 100
Boston,MA 02114-2017
www.mass.gov/dia
Workers'Compensation Insurance A�davit:General Businesses.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Leeiblv
Business/Organization Name:99 Restaurants&Pub-20050
Address: �4 Berry Avenue
City/State/Zip:Yarmouth Phone#:508-862-9990
Are you an employer?Check the appropriate box: Business Type(required):
1.❑✓ I am a employer with 5� employees(full and/ 5. ❑Retail
or part-time).* 6. Q RestauranUBarBating Es[ablishmen[
2.❑ I am a sole proprietor or partnership and have no �. �Office and/or Sales(incl.real estaze,auto,etc.)
employees working for me in any capaciry.
[No workers' comp.insurance required] 8� ❑Non-profit
3.❑ We are a corporation and its officers have exercised 9. ❑Enter[ainment
their right of exemption per c. 152,§1(4),and we have ]0.0 Manufacturing
no employees. [No workers'comp.insurance required]* �t.❑Health Care
4.❑ We aze a non-profit organizatioq staffed by volunteers,
with no employees. [No workers'comp.insurance req.) 12.❑Other
'Any applicant that checks box#1 must alw fill out the sec[ion below showing their workers'compensa[ion policy information.
••If[he corporate officers have ezempted themselves,but the corpolation has other employees,a workers'compensation policy is required and such an
organi>ation should check box#l.
1 am an employer thal is providing wo�kers'compensation insurance jor my employees. Below is the policy injormation.
Insurance Company Name:American Zurich Insurance Company
Insurer's Address:�001 Summit Blvd, Suite 1700
City/State/Zip: Atlanta, GA 30319
Policy#or Self-ins.Lic.#WC3878538-03 Expiration Date:08/01/2016
Attach a copy of the workers'compensation policy declaration page(showing the policy number aod expiration date).
Failure to secure coverage as required under Sec[ion 25A of MGL c. ]52 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[o$250.00 a day against the violator. Be advised that a copy of this statemen[may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
/do Nereby c �y under the pains nd penalties ojperjury that the injormation provided above is true and correct.
�' nature•�S�OI��__/t� �.�1.U/vll�-l� Date• I oZ I( c�5 I �O��
Phone#• �'O�� — ��6o�'`PS��
Offrcial use only. Do no[write in thrs atea,to be comp[eted by city or town ojficia[.
City or Town: PermiULicense#
Issuing Authority(circle one):
1.Board of Health 2.Building Departroent 3.City/1'own Clerk 4.Licensing Board 5.Selectmeds Office
6.Other
Contact Persoo: Phooe#:
www.mass.gov/dia
1NORKERS CONiPEkSAT10N M!D ENPLOYERS LIABk►.ITy
CON�AERCIAL INSURANCE INSURANCE POLlCY—INFOfB�[ATION PAGE
Senricing Office-
Irsunnce br tNs coverage part provided by: ATLANTA
Al�RICAN ZURICH INSURANCE C�ANY 1001 SUhID7IT BLVD
SUITE 1700
ATLANTA GA 30319
7. Policy Number WC 3878538-03 Renewal of Number WC 3878538-02
Named Insured and Mailing Address Produoer and Mailing Address
ABRH, LLC WIYLIS INSURANCE SERVICES OF
3038 SIDCO DRIVE TENNESSEE
NASHVILLE TN 37204 26 CENTURY BLVD.
NASHVILLE TN 37219
Producer Code 77093-000
Other workplaoes not shown above:
FEIN:
NCCI Company No. 17965 � New Qx Rer�ewrW � qewrrye of pria policy No.
This iniormation page,with policy povisions and endorsert�ents,H any, completes this policy.
IOSUfBd IS: LIMZTED LIABILITY COI�ANY 6 CORPOAATION
2. Policy Period:kom: 08-01-2015 to 08—01-2016 at 1201 A. M. Standard Time at insured's mailing address.
Insured's Identification number(s):
917057680\9830295A\025959\2877019
3. A. Wal�ers Compensalion Insurance: Part One of the policy applies to the Wwkers' Cort�pensatfon Larv of the
518105 IIS�Cd IIEfB:AL,AR�AZ,CA,CO,CT,FI.�GA,IA�I L,IN,RY,LA�MA,hID�ME,MI,MN,M0,MS�NC,NE,NH,
NJ,NM,NY�OR�OR,PA�RI�SC,TN,TX,IIT,VA�VT,WV
B. Employers Liability Insurance: Part Two of the policy applies to wak in each state listed in IOem 3.A.
The Limits ot Liability under Part Two are: Bodily InJury by Accident: i,000,o00 �ch accident
Bodily Injury by Disease: 1,000,o0o policy Ittnit
Badily Injury by Disease: i,000,o00 �ch�loyce
C. Otlier States Insur�ce: Part Thrce o1 the policy applies to the stabs,N any, listed here:
See 6�donener�t
D. ThIs Policy indudes these endasert�ents and scheduies:
See Sehsdule o7 Foma Nid Endaraemen�.
4. �xernium for tl�is policy wi I be mined by our Manuals of Ies, Classificetions, Rates and 'ng Plans. All
information required on the lollowing ClassHication Schedule is subject to ver'rfication and change by audit.
See f�a�Fa�fon Schedtre
TOTAL EST1N{ATED STANDARD PREMIUM $ tt i�;��I�,�u
PREMIUM DISCOUNT $ � � ��
D�ENSE CONSTANi $ �_ d prerrium ahe�l be m�le:
PREMIUM FOR ENDORSEMENT $ p,�„yiy � �y
TAXESANDSUflCHARGES $ � Semi-Nwwafry ❑ 7tisisaitree
TOTAL ESTIMATED ANNUAL PREMiUM $ v�Fxetl Rate
� Quvlerly Policy
MINIMUM PREMIUM $
DEPOSIT PREMIUM $
l�ent a Rotlucer Couneersigned by Re,vtlem licensetl qgeM pe�
WC 00 D001A U WC-031`A�07-94)
Page 1 011
COMMERCIAL GENERAL IJABILITY COVERAGE PARf DECLARATIONS
Policy Number: GLO 3878540-03
ZURICH AMERICAN INSURANCE COMPANY
Named Insured ABRH, LLC
Policy Period: Coverage begins 08-01-2015 at 12:01 A.M.; Coverageends 08-01-2016 at 12:01 A.M.
Producer Name: WILLIS INSURANCE SERVICES OF TN Producer No. 77093-000
Nem1. Business Description: HOLDING COMPANY
Hem 2 Limits of Insurance
GENERAL AC�C'.,REGATE LIMIT S 40, 000, 000
PRODUCTS-COMPLETED OPERATIONS AGCHEGATE LIMIT $ 2, 000, 000
EACH OCCURRENCE LIMIT $ 1, 000, 000
DAMAGE TO PREMISES
RENTED TO YOU LIMIT $ 1, 000, 000 My one premises
MEDICAL EXPENSE LIMIT N/A My one person
PERSONAL AND ADVERTISING INJURY LIMIT $ 1, 000, 000 Any one person or
organization
Hem 3. Retroactive Date (CG 00 02 ONLI�
This insurance dces not appy to'bodiy injury", "property damage"or"personal and advertising injury"offense
which occurs before the Retroactive Date, if any, shown here: NONE
(EMer Date or"None"if no Retroacave Dafe applies)
Item 4. Form of Business and Location Premises
Form of Business: LIMITED LIABILITY COMPANY
Location of All Premises You Own, Rent or Occupy:See Sd�edule of Loqtlons
Nem 5. Schedule of Forms and Endorsements
Form(s) and Endorsement(s) rrede a pert of this Policy at time of issue:
See Schedule of Fornis and Endorserrients
Nem 6. Premiums
Coverage Part Premium: �
Other Premium:
Total Premium: �
ur�-0-ivse cw�sioa�
PoYcy Number
GLO 3878540-03
ENDORSE6�ENT
ZURICH AMERICAN INSURANCE COMPANY
Named Insured ABRH, LLC Effective Date: 08—01-15
12:01 A.M., Standard Time
AgentName WILLIS INSURANCE SERVICES OF TN AgentNo. 77093-000
BROAD FORM NAMED INSURED
ABRH, LLC. , AND ANY SUBSIDIARY COMPANY AS NOW FORMED OR CONSTITUTED,
AND ANY OTHER COMPANY OVER WHICH THE NAMED INSURED HAS ACTIVE CONTROL
SO LONG AS THE NAMED INSURED OR ANY SUBSIDIARY COMPANY HAS AN
OWNERSHIP INTEREST OF MORE THAN 50$ OF SUCH COMPANY.
U1'aL-1114A CW(10/02)