HomeMy WebLinkAboutApplication and WC �' TOWN OF YARMOUTH BOARD OF HEALTH �p�`���
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� APPLICATION FOR LICENS�EII' � �? ' ���� �k� � 21��3
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` * Please complete form and attach all nec s�ary , � � � �j em 13.
Failure to do so will result in the r�t�''rn h�t� . •
ESTABLISHMENT NAME: Q.. ti Po�.T 11d. G � -
LOCATION ADDRESS: 33�o Ac�'�'� 6 D YOR.rt�,o�'r� Po Q.T' TEL.#: $��3`2• �i�
MAILING ADDRESS: S4tu►E
E-MAIL ADDRESS:___-W��tfcE.u�{at S �.�. Hs�T M4�L. �•O�
OWNER NAME:--. -___�__ US1G.t�1�. '7iK.f�+AS w�S
CORPORATION NAME (IF APPLICABLE): �yl.V E M p 2 i,�ti1 'R.+�V E Q A 6� CerrQ,?,
MANAGER'S NAME: IG tJ IL TEL.#: C � 2
MAILING ADDRESS: 33c� Qo v T� G P "t rv�0 t1114 ae Q.T
POOL CERTIFICATIONS:
The pool�up"� ' or must be certified as a Pool Operator,as required by State law. Please list the designated Pool
Operator(s) and attac o y of the certification to this form.
__ 1. . . A 2. �
Pool operators must list a minimum of two emplo urrently certified in basic water safety, standard First Aid and
Community Cardiopulmonary Resuscitation(CPR),havi certified employee on premises at all times. Please list
the employees below and attach copies of their certifications to � ' rm. The Health Department will not use past
years' records. You must provide new copies and maintain a file a lace 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, TOS 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. UtV�-'Io� 2U 1t•O�3 K��, 2.
PERSON IN CHARGE:
Each food establishment must have at least one Person Iri Charge (PIC) on site during hours of operation.
1. V tK.'R3�. Z.�1�-4 vt,S 1�'S _ 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.
l. 2.
HEIMLICH FICATIONS:
All food service esta. ' ents with 25 seats or more must have at least one em�loyee trained in the Heimlich
Maneuver on the premises at . Please list your employees trained in anti-cholcing procedures below and attach
copies of employee certifications to tlu . The Health DepaY-tment will not use past years'records. You must
provide new copies and maintain a file at you of business.
1. 2. Np'
3. 4. �
RESTAURANT SEATING: TOTAL# NA
OFFICE USE ONLY
LODGING: '
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUFRED FEE PERMIT#
BBcB $55 CABIN $55 MO'TEL $55
INN $55 CAMP $55 SWIMMING POOL $80ea
_LODGE $55 =TRAILER PARK $105 _WHIRLPOOL $80ea.
FOOD SERVICE:
LICENSE REQUIRED FEE P$x�T LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
�0-100 SEATS $85 �l�F-6�/ _CONTINENTAL $35 NON-PROFIT $30
>100 SEATS $160 COMMON VIC. $60 WHOLESALE $80
—RESID.KITCHEN $80
RETAIL SERVICEc
LICENSE REQUIRED FEE PERMIT# LIC�NSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
<50 sq.ft. $50 >25,000 sq.ft. ' $225 VENDING-�'OUD $25
�<25,000 sq.ft. $80 =��5 =FROZEN DESSERT $40 ,�TOBACCO $95 �
NAME CHANGE: $IS AMOUNT DUE _ $ Z(o0.0("j
*****PLEASE TURN OVER AND COMPLETE OTHER SID�OF FORM*****
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" � � ' Issued by The Stock Insurance Company PoGcy Num6er—�`�'���
S 2021461 ����� �
• SELECTIVE INSURANCE COMPANY OF SOUTH CARQLINA
3426 TORINGDON WAY, CHARLOT`I`E, NC 28277 ���r�
COMl��IERCIAL P4LICY COMIIZON DE�LARATION
Named Insured and Address Poticy Period
BLUE MARLIN BEVERAGE CORP � From: JULY 9, 2013
330 ROUTE 6A �' To: JULY 9, 2014
YARNIOUTH PORT, MA 02b75-1818
12:01 A.M. Standard Time At
Location of Designafed Premis�„° i'
Named lnsured is: Producer Number:
CORPORA7ION 00-20045-00000
Producer:
WM. F. BORHEK INS AGY INC
MASSACHUSETTS
Sehedule of Coverage
BUSINESSOWNERS COVERAGE
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PREMIUM INCLUDES TERRORISM COVERAGE $84. 00 > >
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� �n�eturn:#'nr paymenf oftlie premium, ;and subject to�tl the#esms of tlirs Pe►I�e.Y� vve'agree w�h :
y ouu to provide the�nsurat�ce ent�icated�t�e sctied�le sbav� I�suraneg�s pravi�ed only#'or f4tose;
� coveragcs fsr vqtiieh a spec�c IEmd�s sbossn an:#he atfa�[�ed eoi�erage i�ee�ra#ion(s� :>
_. : . :. ,
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_ PAYMENT METHOD Tota!Policy Premium 54,300.00
— D�B - 10 �
� ('This premium may be subjeet to adjustment)
�
� Date Issued: JUNE 12, 2013 ,
_ f
C Issuing Uflice: NQRTHEAST REGION
� Autharized Representative
IL-7025(11/89) ;
f�k+rtn�nte. �+nnv ,
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The Cotnmonwealth ofMassachusetts
Department of Industrial Accidents
' Office of Investigations
' 1 Cortgress Street,Suite 100
Boston,MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Apulicant Information Please Print Legiblv
Business/Organization Name: yiOQ C,/til � Go�iQ��
tliu.a�� SiD2G
Address: 3?o R•cd f� �e/�
City/State/Zip:�ti6�21�+Ovj14PQ� /N�, pL67s Phone#: Sa8 ��6L• 2ga''o
Are you an employer?Check the appropriate boz: Business Type(required):
1.� I am a employer with_� employees(full and/ 5. �'Retail
_ er pa.�?-tir�e):* _ _ E. ❑Restau�nt/�a�l�ating Est�blishr�ent
2.❑ I am a sole proprietor or partnership and have no �. � Office and/or Sa1es(incl.real estate,auto,etc.)
employees working for me in any capacity.
[No workers' comp.insurance required] g• ❑ Non-profit
3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment
their right of exemption per c. 152, §1(4),and we have 10.❑ Manufacturing
no employees. [No workers' comp.insurance required]* 11.❑ Health Care
4.❑ We are a non-profit arganization,staffed by volunteers,
with no employees. [No workers' comp.insurance req.] 12.�'Other
*Any applicant that checks box#1 must also fill out the secfion below showing their workers'compensation policy information.
**If the corporate officers have exempted themselves,but the corporadon has other employees,a workers'compensation policy is required and such an
organization should check box#1. ._ _
I am an employer that is providing workers'compensation insurance for my employees Below is the policy information.
Insurance Company Name: N1A. IQ�]�1(. M�+Ci�. I�G G�-P
Insurer's Address: �O �O X $',� �Z,'t.— �{'Z LZ-
City/State/Zip: Q Q•A�11U rQ.� , NGA. (�1 ji"��
Policy#or Self-ins.Lic. # O 14-oo S 6�►3 O �j� �/Q•� Expira.tion Date: � �� O �
Attach a copy of the workers' compensation policy declaration page(showing the policy number and ezp' ation date).
_ _���`iiu`e to-s�ure-coverage as requirec�under�ctidn 23�e�i�IG�,e: i 52�an leact t�d�e-itn�osi�icrrr�af`�rim'rn����F-�� , - ---
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 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 far insurance coverage verification.
I do hereby certify,under p ins andpe Ities ofperjury thal the information provided above is true and correct.
Si ature: Date: l�L.•g•��
Phone#: �g 36Z' ��Uj�
Official use only. Do not write in this area,to be completed by city or town officiaL
City or Town: yL��2./y�p�}-�}.} Permit/License#
� ' cle one):
.Board of Health 2. uilding Department 3. City/Town Clerk 4.Licensing Board 5.Selectmen's Office
6, er
Contact Person: Phone#: Sb e-,3 q8 ar3 / X/2-Y/
wwwmass.gov/dia
. E S T I M A T E D B I L L I N G
MA Retail Merchants WC Group Inc. Print Date: 11/11/2Q13
PO Box 859222-9222 Certificate #: 014Q05033088114
Braintree, MP, 01285 Division: 00000
Cert. Period: 1/01/2014- 1/01/2015
I
Agent #: 641 `
�
Wm F Borhek Insurance Agenc�, Inc.
311 Plymouth Street
Yarmouthport Village Store Halifax, MA Q2338
Blue Marlin Beverage Corp (781) 293-6331
330 Raute 6A
Yarmouthport, MA 02675
Rating 8tate: MA
_ �
Code Classification " � " Payroll Rate Premium
8017 STORE: RETAIL NOC 100,000 1.15 1,150
8810 CLERICAL OFFICE EMPLOYEES NOC 20,000 .09 18
_._ I
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Serviced by: Cove Risk Services, LLC Phn# (800) 790-8877
PO Box 859222-9222 AJACRSON
Braintree, MA 02185
Page 1
. '• ' .
CoVe����
ser,.��es.u..c
November 2013
Re: 20I4 R�newal c�f Workers' Compensation Coverage �
- Massachusetts Reta.il Workers' Compensation Group,Inc. - - __ _
Dear Participant
Thank you for the opportunity to provide your warkers' compensation coverage again this year.A copy of
your 2014 estimated billing is enclosed. A copy of your policy will be sent under sepazate cover in early
January 2014. The Group is applying a 15%rate deviation for 2014.
Our website is www.coverisk.com to access important workers' compensation information such as:
report claims and fraud online and to download the claims forms you need.Also go to the website to get -
tips on how to make your business safer and much more.
Should you have any questions,please contact our policy services department at
800-790-8877 or email us. Thank you for your continued participation.
Sincerely, '
�
Poticy Services _ _ _ �
_ _ _ _ _ �_� ___. __ , ___- _ - _.
Ann Jackson, ext 2081 ajacksonnu,coverisl�com -
Anne Sheridan, ext 2II0 asheridan(a�coveriskcom
a
i
� 1
�
35 Braintree tf�Office Park
Suite 206
82Nttree.MA 02184 '
800-790-8877
www.coverisk.com
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