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Home My WebLink AboutApplication and WC . .,�a��N Nasr .- a � .� � �' � TOWN OF YARMOUTH BOARD OF HEALTH �3 r;;�, � i,l`��,�, �� = APPLICATION FOR LICENS��Rl't��`T=��113 � e... * � �o�� ,��ad� � ,, Please complete form and attach all nece�� . �e�,t��t:D.etem er 1 S 2012. Failure to do so will result in the return o your applicahon pa . ` �_ �}�.~�I. ESTABLISHMENT NAME: �� I �Y`� ��-� �� ►'"�� TAX ID: � LOCATION ADDRESS: C�9� 1Zc� v� o�� TEL.#: SD g� � � �� MAILING ADDRESS:__ C'• cr ,2o u•� o?� OWNER NAME: V'�' I "/' Z-- ' CORPORATION NAM F APPLICABLE): j�•4� I i�.��j,9 .L�br' � MANAGER'S NAME: ��"c� �� r��r_ L TEL.#: '��-t� o- o2�j ' MAILING ADDRESS: � q �.v�/�- z , 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�f the certif cation�o ihis forn�.- 1. 2. f Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid � and Community Cardiopulmonary Resuscitation (CPR). Please list these employees 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 file at your place of business. � 1. 2. ! 3. 4. E I FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time em�loyee 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. l. 2. _ 1'��'f1P��I1Vs C�-fARC_'rL: - . _ _ _ Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 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 file at your place of business. ' l. 2. � 3. 4. � RESTAURANT SEATING: TOTAL# i OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# i B&B $55 _CABIN $55 I MOTEL $55 �-[3"60f _INN $55 CAMP $55 �SWIMMINGPOOL $80ea.�[�j—d�� _LODGE $55 _TRAILER PARK $105 �VHIRLPOOL $80ea. �_ FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _0-100 SEATS $85 �CONTINENTAL $35 �3�� _NON-PROFIT $30 >100 SEATS $160 _COMMON VIC. $60 _WHOLESALE $80 RETAIL SERVICE: —RESID.KITCHEN $80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $50 >25,000 sq.ft. $225 _VENDING-FOOD $25 <25,000 sq.ft. $80 _FROZEN DESSERT $40 _TOBACCO $95 NAME CHANGE: $is AMOUNT DUE _ $ 250 .00 — �D . c> *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** 1�� . � The Commonwealth of Massachusetts Department of Industrial Accidents " Office of Investigations ' ' 1 Congress Street,Suite 100 ; � Boston,MA-02114-2017 www.mass.gov/dia ' Workers' Compensation Insurance Affidavit: General Businesses A�plicant Information Please Print Legibly Business/Organiza.tion Name:��iq � � "�—e�/4 n�9 . Co�� Address: � 2' /�'i►�1 S� �c�v� � City/State/Zip: w�� '��`�`�� Phone#: ��— ��--� 23 3 �— Are yau_an employer?Che.ck t1ie.��r�� 'c�te b9x� . t- ,:_ , , -Busi�ess T�p��require_d�; �_, i • .r . - - . 1.�]'I am a employer with�employees(full and/ 5. �]Retail ' ' or part-time).* 6. ❑Restawant/Bar/Eating Establishment i 2.� I am a sole proprietor or partnership and have no �, �Office and/or Sales(incl.real estate,auto,etc.) ( employees working for me in any capacity. I [No workers' comp.insurance required] g• ❑Non-profit 3.�We are a corporation and its officers have exercised 9. ❑Entertairunent I their right of exemption per a 152, §1(4),and we have 10.❑Manufacturing � no employees. [No workers'comp. insurance required]* 11.0 Health Care 4.❑ We are 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 fill out the section below showing their workers'compensation policy information. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an i organization should check box#1. � I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. I Insurance Company Name: �o u�U �G � p ��J,C,Z I�S �►, G'Y � Insurer's Address: q�� 'y�+'��u tJ9 YI K�q�- � CiTy/State/Zip: (�" j'�'�r'1 � �S � f� dZ6`� � — ----�e�e3�#a�Sel��s.-�,ie�-#--_ -------_ - -----__�_____ ---- --�Y�Ztie�-IDa�:- - Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 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 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 pain and penalties of perjury that the information provided above is true and correct. Si ature: � c Date: 0 - 2� ' �Z Phone#: "� �L1�' �lo -�0 2 Lj Official 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.City/Town Clerk 4.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: _ Et�ww::nass.go r/3ia _ ! ,�� Workers' Com�ensation and Emoloyer's Liabilitv Policv NorGUARD Insurance Company - A Stock Company ��E Policy Number PAWC337898 j�(�� Renewal of PAWC229030 �� NCCI No.[25844] Policy Information Page [1] Named Insured and Mailing Address Agency PARI DEVANG CORP. DOWLING & O'NEIL INS AGY 69 Main Street 973 Iyannough Road West Yarmouth, MA 02673 P.O. Box 1990 Hyannis, MA 02601 Agency Code: MADOWLIO Federai Empioyer's ID 20-8890836 Insured is Corporation Risk ID Number 48617 Additional Names of Insured (N2) AMERICAN HOST MOTEL [2] Policy Period From August il, 2012 to August 11, 2013, 12:01 AM, standard time at the insured's mailing address. [3] Coverage A. Workers' Compensation Insurance - Part One of this policy applies to the Workers' Compensation Law of the following states: Massachusetts B. Employer's Liability 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: Bodily Injury by Accident - each accident $500,000 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 Infarmation 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 $ 809 Total Surcharges/Assessments $ 21 Total Estimated Cost $ 830 INTERNAL USE xx Page - 1 - MGA :PAWC337898 Information Page Date :08/03/2012 WC OOOOOlA MANOTE 16 South River Street• P.O. Box A-H• Wilkes-Barre, PA 18703-0020• www.guard.com i I �� Workers' Comoensation and Emplover's Liability Policy �� NorGUARD Insurance Company - A Stock Company [�,�j(,��/��E Policy Number PAWC337898 �(��Q Renewal of PAWC229030 1 i I NCCI No.[25844] Policy Information Page Extension of Information Page Schedule of Forms * WC 000403 - EXPERIENCE RATING MODIFICATION FACTOR * WC 000414 - NOTIFICATION OF CHANGE IN OWNERSHIP ENDT * WC 200601A - MA CANCELLATION ENDORSEMENT * WC 200301 - MA LIMITS OF LIABILITY ENDORSEMENT * WC 200302A - MA ASSESSMENT CHARGE * WC 200401 - MA PENDING PREMIUM CHANGE ENDORSEMENT * WC 200405 - MA PREMIUM DUE DATE ENDORSEMENT * WC 200101 - MA TERR. RISK INS. PROG REAUTHORIZATION WC OOOOOlA - INFORMATION PAGE WC 0000006 - STANDARD POLICY ' * As part of GUARD's ongoing commitment to environmental responsibility throughout our operations, we have chosen not to reprint those forms (marked with an asterisk) that have not changed and were previously sent to you. You can obtain a new copy of any of these forms by accessing your account information at GUARD's Po/icyholder Service Center(a selection available via our website at www.4uard.com). Please be aware that you will be asked to enter your policy number, policy inception date, and federal ID number in order to log on to this secure portion of our site. Alternatively, you can contact us via phone at 1-800-673-2a65; our Customer Service Representatives will either be able to help you locate a document yourself or can send a copy to you. As always, we thank you for selecting GUARD as your insurer. We look forward to serving you! INTERNAL USE XX Page - 2 - MGA : PAWC337898 Information Page Date :08/03/2012 WC OOOOOlA MANOTE 16 South River Street• P.O. Box A-H . Wilkes-Barre, PA 18703-0020•www,guard.com ' l � �� Workers' Comoensation and Emplover's Liabilitv Policy NorGUARD Insurance Company - A Stock Company [N��/�,��E Policy Number PAWC337898 �� j� Renewal of PAWC229030 �'� NCCI No.[25844] Policy Information Page [4J Premium (cont.) Massachusetts Classification Code Premium Basis: Rate per Estimated Total Estimated $100 Annual Annual Remuneration Premium Remuneration Effective: OS/11/2012-08/11/2013 HOTEL- ALL OTHER EMPLOYEES 9052 35,400.00 1.49 527 Increased Limits Emp Liability 500000/500000/500000 9807 1.000% 5 Amt to Bal Inc Lim 9848 45 Merit Modification 9885 .950% -29 Tot Est Premium 08/11/2012-08/11/2013 548 Minimum Premium $231 Tot Est Standard Premium for Massachusetts 548 Polic Totals Total Estimated Standard Premium for Massachusetts �— 548 Expense Constant 250 Total Terrorism MA 9740 0.03 35,400 11 Minimum Premium MA $2g1 Total Estimated Annual Premium 809 MA State Assessment 08/11/2012-08/i l/2013 4.2000% 21 Total Estimated Cost for PAWC337898 830 ' INTERNAL USE XX Page - 3 - � MGA :PAWC337898 Information Page Date :08/03/2012 WC OOOOOlA MANOTE 16 South River Street• P.O. Box A-H• Wilkes-Barre, PA 18703-0o20• www.guard.com ! � ,�� Workers' Comnensation and Emnloyer's Liability Policv NorGUARD Insurance Company - A Stock Company ((v��/��}�E Policy Number PAWC337898 �� Renewal of PAWC229030 NCCI No.[25844] Policy Information Page Policy Payment Terms Payment Option: Direct Bill Installment Plan (prepared 08/03/2012) Down Payment received 08/03/2012 - $830.00 Since your expiring coverage was with GUARD, please be aware that any audit premium for that policy must be paid by the date shown on the Final Audit Billing Statement to keep your current coverage in force. If a check is returned due to insufficient funds, a fee of$20 will be assessed. Payments received after the due date may be subject to a $10 Late Fee. INTERNAL USE XX Page - 4 - MGA :PAWC337898 Date :08/03/2012 MANOTE 16 South River Street• P.O. Box A-H • Wilkes-Barre, PA 18703-0020• www.guard.com