HomeMy WebLinkAboutApplication and WC �`-�ays`r;vN
� � TOWN OF YARMOUTH BOARD E T Q�'( 2 S 2015
^�. .
, , APPLICATION FOR LICENSE/P �
�"� * Please complete form and attach all necessar}k.3�c ' by �� � CEPT.
Failure to do so will result in the return of your application packet.
ESTABLISHMENT NAME: S 1'�1 TAX :
LOCATIONADDRESS: � �r 120cr} a� TEL.#: cZ� �� �'�5-2332.
MAILINGADDRESS: wv� '7A�2�,o�t/ ✓!bl- oZc }
E-MAIL ADDRESS:
OWNER NAME: �, sZt! q n7 A i l;J
CORPORATION NAME (IF APPLICABLE): !'')%-S H to�A- C'O 2/�o/1TO nf
MANAGER'S NAME: '�2v a w'I M �a � r TEL.#: ��-4 - �10--6 0 2.�j
MAILING ADDRESS: Cott C�'O ciA 2ar � 2 > ti 7 el �.�-covi u
POOL CERTIFICATIONS: �l�-�- ������ C��• ��' ���" �T �����G
The pool supervisor must be certi6ed 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.
---j---- -- --_ _ - - - -_ _ _ _ _ 2.
Pool operators must list a minimum of two employees currently certified in 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. 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.
1. 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 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. 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-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 Tile at your place of business.
1. 2.
3. 4.
RESTAURANT SEATING: TOTAL#
_ ___ _ _ _ . __ _ _ _ O�'�IE�L3SESIVI��
. _-
__ __-- --
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQU[RED�FEE PERMIT# LICENSE REQUIRED FEE P RMIT#
B&B $55 CABIN $55 / MOTEL $I10 00
INN $55 CAMP $55 �SWIMMINGPOOL$t10ea. C�
_LODGE $55 _TRAILER PARK $105 _WHIRLPOOL $110ea.
FOOD SERVICE:
LICENSEREQUIRED FEE PERMIT# LICENSEREQUIRED FEE PERMIT# LICENSEREQUIRED FEE PERMIT#
0-IOOSEATS $125 LCONTINENTAL $35 �l6�O�FA NON-PROFtT $30
>100 SEATS $200 COMMON VIC. $60 WHOLESALE $80
—RESID.KITCHEN $80
RETAILSERVICE:
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 � $I 10
NAME CHANGE: $15 AMOUNT DUE _ $ 2SS.00
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM**•**
i
ADMINISTRATION I
Under Chapter 152,Section 25C,Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal I
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 'I
CERT. OF INSURANCE ATTACHED I
OR i
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED �I
Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK II
APPROPRIATELY IF PAID: '
YES NO �I
MOTELS AND OTHER LODGING ESTABLISHMENTS I
TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be il
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 I
elsewhere.Transient occupancy shall generally refer to continuous occupancy of not more than thir[y(30)days,and I
an aggregate of not more than ninery(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 OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected I
by the Health Department prior to opening. Contact the Health Deparhnent to schedule the inspection three(3) ',
days prior to opening. PLEASE NOTE: People are NOT allowed to sit in the pool azea 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 certified lab, and submitted to the Health Department three (3) days prior to opening, and quarterly
thereafter. I
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. �i
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
obtamed 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 I
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: i
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. !
OUTDOOR COOHING:
Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. I
-_ _ I
NOTICE: Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN I�I
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 I
TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. I
DATE: SIGNATURE: j
PRINT NAME & TITLE: I�
Rev. 10/O1/15
� The Commonwealth ofMassachusetts
Department of Industrial Accidents
' Office oflnvestigations
� 1 Congress Streef, Suite I00
Boston, MA 02II4-2017.
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Aunlicant Information Please Print Legiblv
Business/Organization Name: 1� n � �p�l q a� Ce��
Address: � � 020 U t ,�rf"
City/State/Zip: ��}'� �P�R^'�dd�N "��^ Phone#: S7�$� ��-� "2332-.
Are you an employer?Check the appropriate box: Business Type(required):
1.❑ I am a employer with employees(full and/ 5. ❑ Retail
or part-time).• 6. ❑RestauranUBaz/Eating Fstablishment
2. I am a�propnefor or partnershTp and fiave n� 7; � Office and/or Sales (incC ceal estate,auto,etcJ
employees working for me in any capaciTy.
[No workers' comp.insurance required] $• ❑Non-profit
3.❑ We aze a corporarion and its officers have exercised 9. ❑Entertainment
their right of exemption per c. 152, §1(4),and we have 10.0 Manufacturing
no employees. [No workers' comp. insurance required]* 11.❑ Health Care
4.❑ We aze a non-profit organization,staffed by volunteers,
with no employees. [No workers' comp. insurance req.] 12.� Other
*Any applicant that checks box#1 must also 5ll ou[the section below shovring their workers'comp�sation policy information.
••If the cotporafe officers have exempted themselves,but the corpo�on has otha employees,a workers'compensation policy is required md such an
organization should check box#1.
I am an employer that is prvviding workers'compensation insurance jor my employees. Below is the policy information.
Insurance Company Name:
Insurer's Address:
City/State/Zip:
Policy#or Self-ins.Lic. # Expiration Date:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failiue to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of crinunal penalties of a
�ne up to$�,Sb0.66 aricVor one=year impnsonmen�as w�IY�s civtY geu�ties irrthe fo:in af a 33'QP�VORif flRHER an�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
Investigations of the DIA for insurance coverage verification.
I do hereby certify,under the pcun d penalties ofperjury that the information provided abave is true and corred.
� 1 � �
Sienature� � �� Date: l o - .2 0 � l3-
, �
Phone#• �h F� �"�-S 2 33 z-
Officia[use only. Do not wr#e in this area,to be comp[eted by city or town o�ciaL
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.OtLer
Contact Person• Phone#•
www.mass.gov/dia
___ ._ _ __ _. - -. . _ _ _ _
BERKSHIRE HATHAWAY Worker's Comaensation and Emolover's �iabilitv Policv
INSURANCE NorGUARD Insurance Company - A Stock Company
G UARD COMPANIES Policy Number PAWC667358
Renewal of PAWC556715
NCCI No. [25844]
Policy Information Page •
[1]Named Insured and Mailing Address DOWnI G &O'NEIL INSURANCE AGENCY
PARI DEVANG CORP.
69 Main Street 973 Iyannough Road
West Yarmouth, MA 02673 P.O. Box 1990
Hyannis, MA 02601
Agency Code: MADOWLIO
Federal Employer's ID Insured is Corporation
Risk ID Number 48617
Additional Names of Insured
(N2) Days Inn Worldwide Inc.
�Z� Policy Period
From Au9us[ 11, 2015 to August 11, 2016, 12:01 AM, standard time at the insured's mailing address.
[3] Coverage
A. Workers.Eompensation Insurance - Part One of this policy applies to the Workers' Compensation
Law of tlie following states: Massachusetts
B. Employer's Liabi�ity Insurance - Part Two of this policy applies to work in each of the states listed
in item [3]A. The limits of our liability under Part Two are: 500,000 -
Bodily Injury by Accident- each accident $
Bodily Injury by Disease - each employee $500,000
Bodily Injury by Disease - policy limit $500,000
C. Other States Insurance - Part Three of this policy applies to all states, except any state listed in
item [3]A. and the states of North Dakota, Ohio, Washington, and Wyoming.
D. This policy includes these endorsements and schedules:
See Extension of Information Page - Schedule of Forms
[4] Premium
The Premium Basis and, therefore, the premium will be determined by our Manual of Rules,
Classifications, Rates, and Rating Plans. All required information is subject to verification and change by
audit. (Continued on another page)
Total Estimated Policy Premium $ $�0
Total Surcharges/Assessments $ 32.00
Total Estimated Cost $ 902.00
IMERNAL U5E xx Page - 1 - Information Page
MGA : PAWC667358 WC OOOOOlA
Da[e : 07/29/2015
MANOTE
•«�.:.... nrf�o� a_o. sox A-H. 16 S. River Street,Wilkes-Barre, PA 18703-0020 • www.guard.com
� _ ,
NOTICE NOTICE
� TO
TO "
�
'm I �
EMPLOYEES J,r EMPLOYEES
s�e
. monwealth of Massachusetts
The Com
DEPARTMENT OF INDUSTRIAL ACCIDENTS
1 Congress Street, Suite 100, Boston, Massachusetts 02114-2017
617-727-4900 - http://www.state.ma.us/dia
As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this will give you notice
that I(we) have provided for payment to our injured employees under the above-menrioned chapter by
insuring with:
� '.-- NorGUARD Insurance Company
NAME OF INSURANCE COMPANY
P.O. Box A-H, 16 5. River Street, Wilkes-Barre, PA 18703-0020
ADDRESS OF INSURANCE COMI'ANY
PAWC667358 08/11/2015 08/11/2016
POLICYNUMBER 973Iyannough Road P.o. eox 1990 EFFECTIVEDATES
DOW LING & O'NEIL INSURANCE � Hyannis, MA 02601 508-775-1620
NAME OF INSURANCE AGENT ADDRESS PHONE#
PARI DEVANG CORP. 69 Main Street W est Yarmouth, MA 02673
EMPLOYER ADDRESS ,
07/29/2015
,t EMPLOYER'S WORKERS' COMI'ENSATION OFFICER(IF ANI� DATE
MEDICAL TREATMENT
The above named insurer is required in cases of personal injuries arising out of and in the course of
employment to fumish adequate and reasonable hospital and medical services in accordance with the
provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the
injured employee. The employee may select his or her own physician. The reasonable cost of the ser-
vices provided by the treating physician will be paid by the insurer, if the treatment is necessary and
reasonably connected to the work related injury. In cases requiring hospital attention, employees are
hereby notified that the insurer has arranged for such attention at the
NAME OF HOSPTTAL ADDRESS
T(� RR P(�STED BY EMPLOYER