HomeMy WebLinkAboutApplication and WC� MaPc�WooD A�r'
j . � � � TOWN OF YARMOUTH BOARD OF HEALTH MQy��P�+�
' �
� APPLICATION FOR LICE11��/�E�1�liI�,�22�„6.� G,�-�LQ�
�"°� * Please complete form and attach all necessary documents by�,ecem�ier 15 2015.,
Failure to do so will result in the return.of your application pac ce . " �
ESTABLISHMENT NAME: �.A` TAX ID: � �
LOCATION ADDRESS: 5 :Ls TEL.#: �-`�S'7-�o vo
MAILING ADDRESS: or � �
E-MAIL ADDRESS:
OWNER NAME: �Hr� ` ,' b
CORPORATION NAME (IF APPLICABLE):
M�ANAGER'S NAME: TEL.#:
MAILING ADDRESS:
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.
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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 a11 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.��c�RCc� ��Z'z..�To (v ( �� F:cS�(a:�� 2. �it`�IS�A-� �ov�.Z �G�� 3- r:ss�A�c�
3. 4.
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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. \`C�� �� �A.�`�e.� �� 2. � L
PERSON 1N CHARGE:
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. ,
1. 1'`��i�-� J CY�� c� 2. �e�cr� �G�,v�C 0 v'� �
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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. Ybu must ;
provide new copies and maintain a file at your establishment.
i. ��c� P�����\ Z.���c�S��-��lln� '
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 i
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. 4
�
�.�,�� P�-�,G��. �-�� 2. � �=�
3.�� �_ �.e�n��e . 4.
RESTAURANT SEATING: TOTAL#
�
__ OFFICE USE ONLY �
LVtilsl ' -�--._------- .-
_.._ _ -._.__--^-_._...__.� _. . '
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �
___B&B $55 CABIN $55 MOTEL $110
—I� $55 C�P �SWIMMING POOL$110ea. '�S y i
_LODGE $55 _TRAILER PARK $105 �WHIRLPOOL $110ea.���3
FOOD SERVICE: '
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# i
0-100 SEATS $125 CONTINENTAL $35 NON-PROFIT $30
�>100 SEATS $200 �O� �COMMON VIC. $60 �7� =WHOLESALE $80 i
RETAIL SERVICE:
—RESID.KITCHEN $80 �
LICENSB REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
<50 sq.R. $50 >25,000 sq.ft. $285 VENDING-FOOD $25
�<25,000 sq.ft. $150 �f Z =pROZEN DESSERT $40 _TOBACCO $110
NAMECHANGE: $is AMOUNT DUE _ $ 630•OO
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*****
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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 i
;
OR I
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED '
Town of Yarmouth taxes and liens must be paid prio 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. i
Transient occupants must have and be able to demonstrate that they maintain a principal place of residence �k
elsewhere.Transient occupancy shall generally refer to continuous occupancy of not more than thirty(30)days,and j
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. '
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POOLS
POOL OPENING:All swimming,wading and whirlpools which ha�e 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 Vt'ATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate caunt
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
closin�r.
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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.yarmouth.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.
II �
, OUTSIDF. CAFES:
� Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health.
' OUTDOOR COOKING:
? Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibated. �I
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NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TQ�.TURN
! THE COMPLETED RENEWAI,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.
� � . ��
DATE: a� 7 SIGNATURE:
' PR1NT NAME & TITLE: �1 c��z�r l�YI ��.�.L�(.tci h t�, �i�'c�t-Gr
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` � Print Farm
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� NC�TICE NOTICE
TO } > TO
EMPLOYEES � EMPLOYEES
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The Commonvvealth of Massachusetts
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 Mussachusetts Generai Law, Chapter 152,Sections 21,22&.30,this�viil �;ive you notice
that [ (we)have provided for payment to our injured employees under the above-mentioned chapter by
� insurinb with:
Wesco Insurance Company
NAME OF INSURANCE COMAANY
800 Suparior Av�nue East 21 st Floor Cleveland OH 44114
ADDRESS OE 1NSURANCE COM['ANY
WWC3144084 6-1-15 i'0 6-1-i6
POLICY NUMBER EFFECTIVE DATES
USI lNSURANCE SERVICES 530 PRESTON AVE MERIDEN CT 800-303-7171
NAME OF [NSURANCE AGENT ADDRESS PHONE#
MAP�EWOOD AT MAYFLOWER PLACE SNF I.� BUCK ISLAND RD WEST YARMOUTH MASS
EMPLOYER ,�DDRESS
EM�LOY�R'S WORKER�' CCNwIA€P1�ATIC'�d C3��I�ER(IF ANl� DATE
������,�+ �.�,l�,�,_T�'�' ��
Tt�ee�v�natt��insur€r is req�ired in easds pf p�rsefnal ir�turi�arisi�g ottt of and in the cor�se Qf
empto�rr�ent to fi�rn�a�►ade�t�and rEaso���hc>spftal and n�eclic�l s�rvices in accardancd with�e
�uvisrons of th�Wc�rkErs' C�ns�tir�n Act. A cc�py of t!�Fi�st Rqjort of In�ury�ust be giv�n ta tl�
inj�+a��rnploy�e. The e�ployee�trtay s�i�ct hia er t�r awrt physici�n. The reason�ble cost ag the ser-
vices pcov�d�d by tlu treating physician w�ll be paid by th�insurer,if the trest�nent is r��ceas�ry arid
rcasc�riably eannccted to the work rclaE� injury. in c.ases t�quirin�hospital atEer�tion,�mployacs arE
h�reby notifted tMat the insu�haa arran�d fot s�c�a ettsc�tioa at the
NAME OF HOS!'[TAL ADDRE�S
TO BE POSTED BY EMPLOYER
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Wesco Insurance Company
A�tock tnsuriu�Ee Gompany
� WORKERS COMPEN�ATION ����1 B
AND EMPLOYERS LIA�Iti'fY
I INSURANC�POLICY INFORMATIOk PAfsE
i Ncci Code:26133
1. Intiurcd: Polic��Mus�ber: tV�VC3l�W09a
Maplewood�en�or Livin�LLC
c%Hunter Gre�ory Reaky Corp
( Gorham Island lndividual Pan�enhip
Wescport,CT 068ft0 lCorpocalion X LLC
Otixr�vori:places not shown above:
S�e Extension oClnformation Pa�c Pcdcral Tax!D: �
Producer: Risk(d:
AmTrust Nanh America.lnc. Rene�val of: W WC30429b5
c%PMC lnwtance A�cncy-Spc:cialty Pro6rams
209 Burlington Road
Bedford,MA 01730
? Thc policy period is from 6/1/3015 to G/1/2016 l2:OE a m at the intiurcM'ti mailing�ddretiti
3. A. Work�r�CoFnpensation Inswr�nce:Part One of the policy applies to�Ik Worken Comp�:nsation Laa of
the stales li�ted here:Connecticut.M8SS1CIlU5Ctl5
B. Employen Lia6iliry Inwrvncr.P�t Ttvo of thr policy applics to work in each stalr(isted in i�cm 3.A.
The limits of our liability under Part Ttivo arc:
State Bodily Injury by Accident Bodily Injury by Diceaa: Bodily lnjury by Discs�e
51.000,�0 each accident S1.00D,000 policy(imit S1.000.000 each employee
C. Other States lmurance:Pan lixee oF thc policy applies tp thc statcs,if any,lir•ted hrne:
AI!states except Nb,OEI.WA.WY and State(s)D��ignated in Item 3A.
D. This policy includcti th�e cndoru:ments and schrdules:Scc Gxtension of Information A��e
�. The premium for this policy witl bc drtermined by our Manuals of Ru)es,Classifications,Rates and Rating
Plans.All inforrnation cequired b�low is subject to veritication and change by audi�.
See Extcnsion of Information Parc
TOTAL ESTthiATED ANNUAL PREbl1Us�I 570,660
STATE ASSESSb1ENT 2�,678
TOTAL ESTIiMIAT�D COST ���3i
Minimum Prart►ium ��
ixsue Date:5:13?�013 Cwmt�si�d l�y:
Authorittd��excntative
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� Wesca tnsurance Company . WC 99 QO ai B
WORKERS COMPENSAi'!ON ANQ EMPE.OYERS UABILI'tY fNSUFtAlVCE PQLtCY (R1Ft?RMA'i'!ON PAGE
Insured:Mapfewoad Senic�r Living LLC Poficy Numbe�:WWC31q40g4
EXTENStON OF iNFORMATfON PAGE FCiR lTEM#9
!'1'EAA 1:NRMEp 1NSURED and WOR}Cpl.qCES
NAMED I�tSURED: Maplewood Senior Livirtg LLC
WORKPLACES: Location htum 7.
1 Gorham tsland
Westl�ort.CZ OGB�
NAMED lNSUREQ: Maplewaod at Orange
WORKPLACES: Lacadon Num 2.
245 tndisrs River Road
Clrange, CT 06477
NAMED INSUREp: Mapiewoad at Strawben}r liil!
WORKPLACES: �ocatian Atum 3.
73 Strawberry Hiil Ave
Norwalk, CT 06855
NAMEa t�ESUREE?: Maplewood at Darien
WORKPLACES: Locaqon Num 4.
599 Boston PosE Road
darien,CT 08820
NAMED tNSURED: Maplewood at tVewtown
WORKPLACES: Location Num 5.
766 Mt Pleasant Road
Newtown,CT 06470
NAMED INSURED: Maptewood aE Oanbury
Wt�RKPLACES: Locatian Num 8.
22 Hospitai Ave
Danbury,CT 06810
MAMEp INSUR�Q: Maplewood Norumbega Point ALF,LLC
WQRKPLACES: (.ocadon Num 8.
99 Norumbega Rd
Weston,MA�2493
NAMED ENSURED: Mapfewood Mayflower Place Al.F,i,LC
W�RICPLACE3: E.ocation Num 9.
579 Buck Island Road
West Yarmouth,MR 02673
NAMED iNSURED: Mapiewood Mayflower Piace�LLC
WORKPLACES: Location tdum 10.
579 BucEc tsiand Road
West Ya�mouth,MA 02673
NRMED tNSURED: Maplewood et Stony Hill LLC
WORKPLACES; tocation Num 11,
46 Stony Hiil Rd
Bethel,CT Q680i
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� Client#:836501 MAPLESEN
DATE(MMIDD/YYY1n
ACORDTM CERTIFICATE OF LIABILITY INSURANCE sro3rzo,s
i THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
I CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
f BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CON371TUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED
� REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOIOER.
I NYIPORTAKT:If the certificate holder is an ADDlT10NAl INSURED,the poHcy(ies)rtwst be endorsed.H SUBROGATtON IS WAIVED,subject to
� the terms a�d condkions of the policy,certaln polictes may requlre an endorsement A statement on dds certFflcate does not confer nghts to the
oertificate holder in lieu of such en�rsement(s).
PRODUCER
USI Insurance Services LLC �+E �,g�g7q�123 �N,; 203 634-5701
530 Preston Avenue e
aoott�ss:
Meriden,CT 06450
855 8740123 iNsu� s�asox�c covEw4c� Neuc r
wsu�A:wesco t�sura�ce Company 25011
INSURED MSURER B:
Maplewood Mayflower Place SNF L�C
INSURER C:
566-579 Buck island Road
West Yarmouth,MA 02673 iNBURER D:
INSURER E:
qJSURER F:
COYERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS iS TQ CERTfFY THAT THE PQLlCIES QF INSURANCE L18TED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
iNDICATED. NQTWITH6TANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
GERTIFICATE MAY BE lSSUEQ OR MAY PERTAIN, THE INSURANCE AFFORDED BY TFlE POIICIES DESCRIBED HEREiN IS SUBJECT TO ALL 7HE TERMS,
EXCLUSIONS AND CONDITIONS OF SUGH POLICIE3. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
� TYPE OF MfSURANCE yyyp POIICY NUMBER EFF E7Q+ ��Rg
��-t��� EACH OCCURRENCE S
COMMERCIAL GENERAL LIABILITY PREMI 5 Ee�nce S
CLAIMS-MADE �OCCUR MED EXP wie $
PERSONAL 8 ADV INJURY S
GENERALAGGREGATE S
GEN1 AC,GREGATE LIMIT APPUES PER PRODUCTS-COMPlOP AGG $
POLICY PRa lOC $
�������Ry CO�INED SINGLE LIMIT
Ee ecadent
ANY AUTO BODILY INJURY(Per person) $
ALL OWNED SCHEDULED BODILY INJURY(Per eccident) ;
AUTOS AUTOS
NON-OWNED PROPERTY DAMAGE �
HIRED AUTOS p{�pg per acd
a
U1�RELlA LIAB pCCUR EACH OCCURRENCE S
�C��� CLAIMS-MADE AGGREGATE S
DED REtENTION$ S
A "���E"�`nON VYWC3744094 01/2015 06/01/201 X wcsrnru- o�+
Atq E�LOYERS'11ABILRY
ANY PROPRtETOWF�ARTNEWEXECUTIVE Y�a E.L.EACH ACCIDENT $'I OOO OOO
OFFICERIMEMBER EXCLUDED? � N/A
(Mendatory in NH) E.L DISEA3E-EA EMPIOYEE ;� �OOO
If yes,desaibe under
OESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $�OOO�OOO
DESCRIP110N OF OPERATION9!LOCATIONE!VEMICLEB(/1Hach ACORD 101.Additlond RemsAcs 8chsdule.iF mws apeee is requfred)
**Supplemental Name**
Maplewaod Senior Living,LLC
Map�wood A!Danbury,LLC$Maplewood At
Danbury ALSA,LLC
Maplewood At Newtown,LLC
(See Attached Descriptions)
GER'TIFlCATE HO�DER CANCELLATION
Town of Yarnwuth 3����TME A80V6 DESGRIBEQ POLIC�S BE CANCELI.BO BEFORE
THE EXR�ATION DATE THEREOF, NOTICE WILL BE DELNERED IN
Building Depatfir�ent ACCQRDANCE NRTH THE POLICY PROVI,RI�N.S.
1146 Route 28
South Yartnouth MA 02664 AI)TFIORQED REPRESENTATIVE
�1968 2010 ACORD CORPORATMDN.All rfghts reserved.
ACORD 25{2010/05) � pf 2 The A�ORD n�ne and logo are reglstered marks of ACORD
#S15233429/M15232788 EXBCH
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DESCRIPTIONS (Continued from Page 1)
Maplewood at prange AL3A LLC
Maplewood at Orange,LLC
Maplewood at Strawberry Hfll,LLC
Maplewood Senior Living LLC
Maplewood At Darien,LLC
� Maplewood at Stony Hill LLC
� Maplewood Norumbega Point ALF LLC
Maplewood Mayflower Place ALF LLC
Maplewood at Mayflower Piace SNF LLC
SAGITTA 25.3(2010l05) 2 of 2
#515233429/M15232788