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Home My WebLink AboutApplication and WC�� .{S�nn � ._,. _ . ��/V`�✓ � � UL��V�t_./ 1 � � TOWN OF YARMOUTH BOARD OF HEA . .;,. ;� M�cqN j� � � � � APPLICATION FOR LICENSE 1 '�p ''�: Q�j 2� j�:�;� , „o �,;.. ;. �t ...� * Please complete form and attach a11 necessa oc y De e .T. ; Failure to do so will result in the retu your applicatao . � � ESTABLISHMENT NAME: ��1e'�'1 C�'�"1 h o 1 °�'M6)fi'�-. TA}� ID: (�� . LOCATION ADDRESS: G� �2oU1� �2� ct�.e�� l AR��r/i h TEL.#: '�'�-�- �n-' �� MAILING ADDRESS: ! OWNER NAME: v � �� °"'!' � CORPORATION NAME ( APPLICABLE): /�,e�u i �.Py�i,,,q„�n�/� � MANAGER'S NAME: %�v�� TEL.#: ��'�( S�1� 6p2� MAILING ADDRESS: y G� /2rav�- 2 a' t,.¢e��- �(/�/�-•Ko�✓fi�'' ' i POOL CERTIFICATIONS: ' The poal supervisor must be certi�ed as a Pool Operator,as required by State law. Please list the designated '; _Pool O�ei��o�s�_au�l a,t�ach a_s��f the cei-tification to this fon�. -- -- � 1. 2. � Pool operators must list a minimum of two employees currently certified in basic water safety,standard First Aid aud Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies ofemployee certificatians to this form. The Health Department witl not use past years' records. You must provide new copies and maintain a file at your place of business. ; i 1. 2. � 3. 4. ! � FOOD PROTECTION MANAGERS - CERTIFICATIONS: II All food service establislunents are requued to have at least one full-time employee who is certified as a Food Protection Manager, as defined 'ui the State Sanitary Code for Food Service Establislunents, 105 CMR 590.000. ; Please attach co�ies of certification to this application. The Health Department will not use past years' records. � You must provide new copies and maintain a fle at your establishment. i l. 2. � I PERSON IN CHARGE: � Eacli food establislunent must have at least one Person Iii Lharge (PIC) on site duruig hours of operation. � � � � � 1. 2. HEIMLICH CERTIFICATIONS: � All food seivice establishments with 25 seats or more must ha�e at least one employee trained in tlie Heunlich '� Maneuver on the premises at all times. Please list your employees trained in anti-chokmg 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 �le at vour place of business. '! 1. 2. ' 3. 4. � RESTAURANT SEATING: TOTAL # OFFICE USE ONLY ; LODGI\G: ; LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PER1bIIT� LICENSE REQUIRED FEE PER'�IIT� . _B&B S55 _CABIN S�5 �YIOTEL S» �"!�-G6 a- INN S55 CAMP S5� /S��I'�A�tING POnl. S8nea. /(— 0 LODGE S55 � ` �TRAILERPARK S10� I �'V�iIRI.POOL S80ea. �rr--o� I FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PER��ZIT� LICENSE REQL�IRED FEE PERMIT� ��! 0-100SEATS S85 �CONTINENTAL S3� I� (�dd7 _NON-PROFIT S30 >100 SEATS S160 COMMON VIC. S60 �'�'HOLESALE S80 RETAII.SER�'ICE: —RESID.KITCHEN S80 ' LICENSE REQUIRED FEE PER.NIIT tt LICENSE REQUIRED FEE PERv1IT# LICENSE REQUIRED FEE PER'VIIT?� _<50 sq.ft. 550 >25,000 sq.ft. S?25 VENDING-FOOD S25 _<25,000 sq.ft. S80 _FROZEN DESSERT S40 _TOBACCO S» \AVIE CHA`GE: sis AMOUNT DUE _ $ 250. 00 i ***'�*PLEASE TL�R:\OVER A\D COviPLETE OTHER SIDE OF FOR��1**"** �� . ,� �,,�.�- I i , �.. .�.�, ADMINISTRATION ' � Under Chapter 152, Section ZSC, 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 j Compensation Insurance. THE ATTACHED STATE WORKER'S COMP'ENSATION INSURANCE i AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR I CERT. OF INSURANCE ATTACHED I OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yannouth t�es and liens must be paid prior ta renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO 1VI()�i'ELS ANlI� t7►'1�fLR I.fJrD�ING�STA13L1S�IlV1�NT� ', TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy sha11 be I limited to the temporary and short term occupancy, ordinarily 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 elsewhere. Transient occupancy shall generally refer to continuous occupancy of not more than thirty (30) days, and an aggregate of not more than ninety(90) days within any six(6)month period. Use of a guest unit as a residence or dwellin unit shall not be considered transient. Occu anc that i g p y s 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. POOLS POOL OPENING:All swimming,wading and whirlpools which have 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 pnor to opening.PLEASE NOTE:People are NOT allowed to srt m the pool area 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. e PUU�:.CLOSING:Every outdoor in ground swimrning pool must be drained or covered within seven(7)days of � closing. FOOD SERVICE SEASONAL FOOD SERVICE OPENING: All food service establishments must be ins�ected by the Health Department prior to opening. Please contact the Health Department to schedule the inspection three (3) days prior to operung. CATERING POLICY: Anyone who caters within the Town of Yannouth 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 Heaith Department, or from the Town's website at www.yannouth.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. ' i OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth. _— ---_ __ _ OUTDOOR COOHING: " Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. i NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETiJRN '! THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 15, 2010. ' ALL RENOVATIONS TO ANY FOOD ESTABLIS�IlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. �DATE:_ Co �2��t�' SIGNATURE: � �� ' PRINT NAME&TITLE:_�T�,�c,�, y /,�'� � 10�06%10 ' I �% i ! � � The Commonwealth o ' f Massachusetts ' Departme�et of Industrial Accidents rr�r.a�e� 600 Washington Street, f�Floor Boston,Mas� 02111 , j Workers'Compens�tios Iroaranee Aft3davit:$uildiag/Plambiag/Ekctrical Coetractors . � � AnoHea�t Itiere��fin: Pka_re PRINT Ie�ibM. natnc: ��P 1�Ci 1J5 l�'1� � aaa�s: __��_ D v —Q?_�__- ----- ---- , city /'d� '�P,A2/ud fJ%�� state• /''�1� �P � Z'��3 phone# '��'-1� �(� 6 work site Iceation(fitll addressl: ❑ I am a homeowner perfornnng all work myseif. Pro�ect Type: �New Construction�]Remodel ❑ I am a sole proprietor and have no one working 1n any capacity. ❑Building Addition ❑ I am an emptoyer providing workers'compensation for my employees working on this job. : - ,-.� _.,R,—� ------__ _ ,. . _ , _ .. � como�uv iame: address: ci e N: tns co. # ❑ I acn a sole proprietor,geaeral costractor,or�omeowwer(circle ow�)and have hired the contractors listed betow who have the fo(lowing workers'compensation polices: comoaav nme: _ i address: i � i ciri• Dhoee!! ies ece ca � �e• addras- ciri: �� _ . _ i�svucsea. _ _ __ _ - __- -_ _ ��_� _ . _ __ _ - 1__. -.: _, � _ A�dei Mi�1�Y int ift�erw� � Failve 0�xe�re cr►aaae as requir+ed��dv SeeW�2SA�[MCL 132 a�lad b f�e��f v1�`al pe�aNln d a 6ne�b f1,3N�N aad/K °k Yb�'�mprMoa�eat�s wdl as dv�pceakie�le t6e[�et a 3TOr WORK ORDER asd�eee ef f18�.Os a day a�a�dt�e. 1 aedenh�d t6at a •, eepy a[ti6�tahmeel m�y be forwarded es tAe O�ke e[Iwe�aWa�•t t6e DU for e�vense verlAatlw. i !do Ber+eby certify reder Nie pa�ws awd penslt�es ojperfr�ry tAat�e i�for�nsfloe provided aboae 1s p�rre awd cormt Signatnre j Date Print name Phone* at5eiai osr only ' do aat w�rite is thb arca te 6e mvPieted bY dtY or bwa o@ieW _ I eify or towa• , ��N�� Boidina Depar�ent ❑eheck(f imme�ah rx�emc is reqdred ��Bt�^� QSeleetme�'s OI'dee centad penoa: p6e�e N• �flaltb Depart�t c�a xp mm� �OtAQ I i I i � 1 �� Workers' Comt�ensation and Emuloyer's Liabilitv Policv NorGUARD Insurance Company-A Stock Company ��'�R��E Policy Number PAWC122735 � ^ Renewal of NEW R c��P NCCI No.[25844] � Policy Infonnation Page [i] 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 Federal Empioyer's ID I�lsured is Corporation ' Risk ID Number 48617 Additional Names of Insured (N2) AMERICAN HOST MOTEL [2� Policy Period From August il, 2010 to August 11, 2011, 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 foliowing 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 appiies to ail 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 Manuai of Rules, Classifications, Rates, and Rating Plans. All required information is subject to veri�cation and change I by audit. (Continued on another page) Total Estimated Policy Premium $ 867 Total Surcharges/Assessments � 38 Total Estimated Cost � 905 . INTERNAL USE ao Page - 1 - Information Page MGA : PAWC122735 WC OOOOOlA Date :09/28/2010 MANOTE 16 South River Street•P.O. Box A-H•Wilkes-Barre, PA 18703-0020•www.guard.com � .��.� , I � , 1 � � i ,. x IY�TICE U '� IITQTICE TU � � T� EMPLOYEES r EM�'LQYEES . .- ,� �` � The Commontiveal�th of NYassachusetts DEP.ARTIVIENT �F INDUS�RIAL ACCIDENTS 600 Washington Street, Boston, Massachusetts 02111 617-?27-49.00 As required by ,l?assachusetts General Law, Chapter 152, Sections 2I, 22 & 30, this will give you notice that I (we) have provided for payment to our injuzed employees under the above mentioned chapter bp insuring with: NorGUARD Insurance Company NAME OF l'i�iSURANCE COI�ANY P.O. Box A-H 16 South River Street Wilkes-Barre PA 18703-0020 ADDRESS OF INSURA,1�iCE COI2PANY PAWC122735 08/11/2010 08/11/2011 POLICY�'UtiiBER EFFECTNE DATES DOWLING&O'NEIL INS AGY 973 Iyannough Road P.O. Box 1990 508-775-1620 NP,i1r1E OF P11SUR.ANCE AGE�tT ADDRESS PHONE ' PARI DEVANG CORP. 69 Main Street _ E�'IPLOYER ADDRESS � 09/28/2010 E,I�IPLOYER`S WORKERS COMPENSATIO\' OFFICER (IF A:�`� DATE MEDICA�, TREATNIENT ' The above named insurer is required in cases of personal injurits arisin�r out of and in the course of • employrnent to furnish adeqtiate and reasonabie hospital and mtdicai services ia accordance with the provisions of ihe Workers Compensation Act. A copy �f the First Report of Injury must be given to the injured employee. The employee�may seiect his or her own physician. The reasonabie cost of the ser- vices provided by the treating physzcian will be paid by the insurer, if the treatment is necessary and reasonably connected to the work related iajury. In cases requiring hospital attention, empioyees are hereby notified that the insurer has arranged for such attention at the ' Nr'at� OF HOSPIT.AL e�,DDRESS TO BE P�ST�]D �-3Y �Il��''L��R ; r 1 i , ` �� YA� �� :`�o T _4WN OF YARMOUTH 0 �" —y �, I 1-�G ROU'TE 28 SOliTH�AR:410UTH 1IASSACHL''SETTS 02664-4451 �MATTACHECS '�r,.,p,�,�,�r�' Telephone (;i08j 398-2231, E�t. 12�1 -- Fax (508j 760-3472 — _ _._____ __----. ___.---__---------- __--__------- S��A---R`�-�---�F_____H_Ev-A L T H November 3, 2010 Devang PateUPari Devang Corp. d/b�a Elmerican Host Motel 69 Route 28 West Yarmouth,MA 02673 Re: 2011 license application Dear Mr. Patel, . O�� Thank you for submitting the 2011 application for your establi em's licenses issued through the Heatth Department. However,we are unable to complete the processing of your pool and whirlpool pernuts at this ti�ne bec�use there were no copies o , . .. , , _ ;. �q submitted with your applicarion.� Please�n�ote that the �ealth DePartmem caru�ot use past year's records, as we aze unable to verify if those staffmembers are still under your employme�t. As soon as our office receives copies of the above noted certifications for your establishment's employees, we will be able to issue your 2011 licenses to you. If you have any questions on the above, please feel free to contact the Heahh Department at \ (508)398-2231, ext. 1241. Thank you for your anticipated cooperation. ; Sincerely, . i� Mary Alice Florio \�, Principal Department Assistant � /maf �c: file