HomeMy WebLinkAboutApplication and WC °'-" T�WN C)F'YARMOCITH BOARll OR liF,AIaTH ,�j
� APPI.ICATION�tJII2 T.It'FNSFJPERMTT-2417 k' �`�-�
� ` ' �
*Ptease aomplete f'orm and atiach a11 necessary d ncumenCs by December 16.20t 6. � ""�" `'"" `
Fail�ue to do so witi resuli in the return c�f vour applic�cion packet.
�;_�
ESTr�IiI.[SFtMENT NAME:1/-t� UtVCt ��`�`_
M�Te FL 1�vn� TA T • .2'7 - o '�S - sd9�f-
LC)CrIT'ION AL)F�RESS:__1�o S c--"A vi e w /-1 LE- S•�a r+�re�rit,. T'EL.#: So� - �_q_�,��c�62
I��fAILI'�C;AL)L7RESS: t'7v. S c'-a vi P� �}vP. S- �a trn c kf� M A �a 6G t+-
E-MAi:T.AIIDRESS:---__�.�.��rmes � Cc,oe co�_ �e� .
ow�t�,rz vn�t�: p. 2a,r�+ • LL �__ y �
COf2PORATION NAME QF APPi,ICABLB): P e m�,y w;1� e�r�Q era-t;e,-, c..�c _ � -�-� 177
h4ANAt;ER'S NAME:__��'"�4 G�r ri�N L�!�rYA . TL'L#�• sd,�'� 3 9'cY . 3 0 6 � (�
�L�ILINGAI��RESS: l'7t� SPavi��.J Av� • S�%u+t. Yg,rt-lau-f1.� /'1A • �126�t�}- Z �p PTI
��....� 0 �a �
POOL C�RTI�ICATIONS; � � �
The�oal sapervisor mnst be certified as a Paol Operator,as reqnired by State i�w. Please iist the d�sigt�ated -i c7i �'
Poc�l Operator(s}and attach a eopy of the eerkification 2o this farm.
� /��t,� �etl.�,� ��'o.,.� �jnvta�i g��Yp�»5�:� � `J�ACe�'Ivt►n� I'QF1NA .
Poni nperators mnst list a minimum of Ya�o employees currently certified in standard First Aid and Comrnunity
Cardiopulmonary Resuscitarion(CPR),having nne certified en�pla}�ee on premises at ali times. Piease list the -�
employees betovt�and attach copies of their certifications tc�this form,The Health Department wiIl not nse past � �w ��
years records. 'Y�u must provide new capies and maentain a file at your p(ace of busines�. 'L''' �,'
� ,;` r n
1. `7�l+��1 ✓/i rd ��1 r'►/� 2 S s+ i2a 7(`.rA U R � ,��aYR , E,��0 �``��r
3._ '��R t E'�'�'e � ��G�orvF 4_ ,��r^�� `�
vL U
Foon�Ra�r�;c�na��Nt�����Rs-c��r1�ICATTQ�r�s:
Al(fc�od service esCablishments ate required tu hac�e at IeasC one fu11-tinte etnplQyee who is certi�ed as a I�crod
Protecrian Manager,as defined in 2h�Stata Sanitary Code for Pac�d Service Establishments, 105 C:MR 590A04.
Please att:�ch copies af certificatian Co this ap�lication. The Health De�artment witl not nse past years'reeords.
�'e�u must pravide new capies and maintain a file at your estAblishment.
i.� 2.
PERSC�N IN CHARGF:
rach#opc3 establishrnent must have at teast vne Perse�n tn C°harge�PIC)on site during hours of vpeca#ic�n.
L 'z
��I,LE�RGfiN CERTI�'IGAT[UNS:
A1I food ser�=ice establishments are rec�uired tcs have at least otie full-time empioye�who has�lllergen certification,
as delined in the SCa�e Sanitary Cnde fnr Faod Secviee Establishm�nts,I05 CMIt 590.b09(G){3�{a}. Please attaeh
copies caf certification to this applicaTion. The Health Department will not use past years'records. You must
proti�ide new copies and maintain��le at yoar establishmen�.
I. �.
I�IE[MLICH GERT'TFICATIVNS:
All f'ood service establishments with 2S seats or more must have at least one em�loyez trained in r1�e 1[eimlich
1�9aneuver on tf��premises at atl times. Please list your employees trained in anti-chok�ing procedures below anc}
attach copies of employee iertificatians tc�this f�mi. TBc Health Department wili not use past years'records.
You must provide new copies and araintain a file at your place af business.
�. L.
3. q.
RI.STA[�'kANT SEA"t�[NG: TOTAL#
OFFICE USE t�NLY
LQD(;ING:
i iCENSE REQ[)[RN;D FEE FERMIT'# L[CEN56 RCQUIRED FEE YERMIT� I CENSE I�CQUIRE[) P�F P �C'
B&B $55 CABtAI $5S �MOTEL $t!0 �`..'•�O�
INid $55 —C`AMP $55 -- --. SWIMMING PO<}L$I l�ea
��t ��7
___L(JllG[ �53 _......___ ��____TRAILERPARK 3105 _.___..__.___ .__WHIRi,PC)CtL $it@ea
F04D SERViCE:
L1t.ENSE TtE�tRRi:D FEE PERMI'1'# i.IGENSE Ft£Q't�t(Z�in TLE ':k34TT a� L[CEN9E REC�UIRED fiEE PERh4iT#
0-100 tif A '$ �125 1CO1VI`INI N"f`AL A34 �j�.0(7j �NCrN-1�ROCI'i' �30
�'I00 SF,A"1'S 5204 ___ ��_ `C0�4�tUN VIC. SfiO WFIOI.�,SAE.f S$0
RETAIL 5ERVICE: _ ___ _��;Sib.KITCNF,N $80 -__
t_iCENSE REQIJIRED F'EE PERM[T# L1CkNSE REQt,[RI;I7 �F;E PERMI"I'i€ LtCENSE REQL'IRED 'FEE PERMIT N
*:50 s .ft. .$5t1 `-25.000 sq.ft. $2R5 VFh�TNG-FOC)1.) S_5
. ?
�<25,0_ sq.ft. $IS() --- - - �FRU"LENDESSERT S94 �—_....__ —T(}BACCt) SIlO __...._.._..��
__...___
svantF.cEt4Nc�;: sis AMULiNfi DIIE _ $ 2SS.OO
'`*`*`PLEASE'T1TItN QV�R ANp Cp7vipLETE QT4iER 51DF OF FORM•'�"*
AI3PVIIIVIS"TRATIUN
t.3nder Chapter I 52,Scctian?�(�,Subsectic�n 6,#he Town of Yanmoutt�is now required to iYr�ld issuanca or renewai
of�n�y= license or permit to operate a business if a petsan or coznpany daes not have a Cerii�eate af Warker's
Compensation Insurance. THE ATT�1GEiED STA'CE WOKKER'S CUMPENSATIUN INSURANCE
A�PInAVIT MCi5T BE CQMPIIETC�.b ANI}SIGNE+D,C)R �
CE12T.OF I'VSURANCE A"!""I`r1CHf:I�
OR _.__v_..
WORKER'S COMP.A}�F`It3AVIT SIC'iNED AND ATTr'�CHfiD
"l awn of'Yarcnauth taYes and lierrs mvst he paid prior ta renewal or issuance of'y�aur permits. PLEASE CHECK
t1PPR(�PRIATELY IF'PAII):
YES V NO
MOTEI,S AND t)THF,R LODGING ESTABLISNMEN'I'S
TRANSIENT OCCUPANCl`: Foz purpc7ses crf the lirnitadons of Motel ar Hatel use,Transient occupaney shail be
li�yited to the temparary�id siiortternl ncaupancy,ordinarily�ancl custoinarily associated��ith motel and hotel use_
Transient accupants inust l��ve and be at�le ta dernonstrate that they maintain a principa] place of residence
elsewhere.Tz�sient occupancp shal l generally r�fer to continuous oocupaney of not mare than thirty(30}days,an�i
an a�gregate qf npt m�ore Yhan��.inety(90)days within at�y six{G}rnondi period. Use of a guest unit as a residence ar
dwelling unit shall nc�t be cousidered transienC. t7ccupancy�that is subje�t to the eQllectian of Room Occupancy
I;xcise,as detTnett in�4.Cr.I,.c.6=tCi or$3O CMR 5��,as anaez3dcd�sha11 generally be considereci Transient.
POOLS
POOI�OPENL�'VG:All sw�icnming,wading and whirtp�ols which hav�been clased far the seasnn rnust be inspected
by the He�lth I)epartment pric�r tU npening. Cantact the I3ealth De�artment tn se6eduIe tbe inspection three(�)
�3ays prior tn opening.PI_EASE:N(}TE:People are NOT allowed to�it in the paol area until the pool has been
i,ispected and opened.
POOL WATER T�STING: The water must be tested f'ar pseudomonas,tc�tal cotiform and standard plate count
bv a State certitied Iab, and subinitted to$ie Health lleparEment ihree (3)days prior to o�ening,and quarterly
thereafter.
I'OC)I.E;'L(1SC�tG.Every outdoor in ground swirr�nnin�p�al must be drained or covered witt�in seven(7)days of'
ciosirig.
F()QI}S�;KVIC'E;
SFIA�ONAL.�OOD SERVICE QPENING;
All food service establisfunesits mast be iuspected by the f�ealkh I�epartmenf prior ro opening. P'lease contact the
E Tealth De��artment fa sehedule the inspectian three(3}davs pric�r to«pening.
CA1"ERING POLICY: �
Az�yone�vha caiers within the Tawn c�f�'annouth must notify the Yasmouth Heatth Department by iiling i1�e
reyun•ed"rempe>rarv Food Service App(ication forni 72 hc�urs prior to tlae catered event. These forms can be
�htained at the E lea�th DeparYn�ent,vr frc�ni the 7'c�wri's wet�sit�at www.�armt�uth.ma.us under Health Departme:nt,
D��wnioadable Forms.
FROZEN DI:SS�R'I'S:
Frozen desserts m�st be tested bv a State cEtti�ed lab pric�r tn c�pes�ing and ruonclily the�eafter,witl�sam�ale resnits
submitted tu thc Health L?epartn�ent. l�aiiure tc�da sn wil(result in the suspension or revacation of your Frozen
Dessert Permit untiI the abave terms have been n�et,
� nUTSIDE C�FE�:
Outside ca�"es(i.�.,outdoor seating with waiteriwaitress ser��ice),nzust have p�or appmvat�am the Board af Health.
OU'CDOOR COOKING:
�utdonr caoking,preparation,c�r display of any f'o�i pro�uct by a r�tail or fcic�rl serviee establishment is prahibited.
N[ITICE;Perrnits run annually from January 1 to December 31. IT TS YOUR RESP0IVSIBILITY T4}RLTURN
TI3E C:OMPLETED RENEWAL APPLICA`TIt�N(S}AND REQIJIRED FBE(�)BY llECEMBER l6,�016. '�
� ALL IZFNOVATT{)NS TC3 ANY E�4QD ESTABLISHMENT, M(7TEI, OFt PQE7L (i.e., PAINTlNG, NEW ���
��: EC7(tIPM�NI,E'TG.),MUS7��t3F�,12i�T�C)RT"EL7'["C)AND APPRC)VEI)BY 7`[��IE BC}ARb OF I-IEALTH PRIOR ��
"1(J COi�3MENCEM�;N"I'. RENOVATI{7NS MAY REC�UI�rl 5I'CE PLAN.
� n,�rr: C�� �°�I a,r� ��c�N�z�����;: �- GZy---
�'iZIN`1'NA.MF..&TITI,E: �C� _ �eZ.0v+1ti• _
� Rev.l�i12di6
� The Cnmmvnwealth nfMassa�husetts�
Departrrte�nt of Industrial Accidents
Cl.ffce r�1'Investigations
1 �'ongress Street, Suite 1Ot1
.8osto�,MA fI2I14-2lI.X 7
wwrv.mass.gt�Y�ldiu
Wa►rkers' Compensation Ins+�rance Affidavit. General Businesses
A licant Inforrnation �P}ease Print Le ibl
Bu�iness/Or;anizatian Name: �e �u ►ve:=s �o T�2 T r��v
�ddress: 17�, S �Atrie�J �VQ. �o�x-t� �/��r•�au+�,, MA d� G6 �,
Cit}�/State/Zip: 5du+ti y'a2r�aLN�. ma c�z66r� Phane#. so� - 3923 - 3�G2
Are yoa an employer?Check the apprapriate bo�c: Busin+e.ss Type{r�uired):
l.❑ I am a ernptoyer�ith S emptoyees(futt attcil �. ❑R�tail
or part-time).* �. ❑ RestaurantlBar/Eating Establishment
2.❑ I am d sc�le prc�prietor or par€nership and have nc� 7. ❑ C7�ce andfar Sales{incl.reaI estate,auto,etc.)
employees working for rne in an}�capacity�.
[Nv v�arkers' cornp. insurance required] �' [�N°n`pFofi�
3.❑ We are a cc�rporation and its officers t�ave exercised 9. [�Entiertainment
their right af exemption per c. I 52,§I{4},and we have 14.[�Manutacturing
no em�loyees. [No warkcrs'comp. insuranc�required}�` I 1 [�Health Care
�.� We are a non-prafi�c�rganization,sta#�'ed by voli�nteers,
with no emplc�yees. [�Io workers' cam�. in�urance req.] I2.(�Other
�`Ai�v ap�tican!that chrcks box#1 must alsa�t)out the secEion belaw showing thexr wc�rkers'compensation palicy information.
""3f the cor�wrete officers have exempted thems�lr�es,hut the r.orpc�ratian has other employees,a workers'campensatian p�licy is required and svch an
or��nizafion should chec�C bax#l.
I am an emplr�}�er thal is pr�vr'ding w�rkers'rurrr��asation itesurance„fvr►nyp employees. Belaw xs the policy infar°matir�n.
Insurance Company�Name: �ot,J t,-�r�� d p rve i t 1'�S .
Insurer's Address: 9�7 3 Z 1�A l�o u �.i-� r2��a� , p•d-r3�x, i 9`'i �
C;itylStatet�ip; {�l y H t�N r�J /� /-► O � 6 � J
Poticy#c�r Self ins.Lic.# �S�Z U r3 � .2 E 2 9 c',t�2 -G-t 6. Expiratian I7�at�e: c�`7 - �^ 6• -2 o i 7
Atfach a copy of the workers'compensation policy deciaration prage(showing the palicy nnmber and eapiratian date}.
Fail�are to seGure coverage as required under Section 2SA ofMGL c. 1 S2 can lead f�a the impositian afcriminal penalties of a
line up to$1,504.00 and/or one-year imprison�nen�,as well as civil penalties in the fr�rm of a STC}P W4RK ORDER and a fne
of u�to�'?50.00 a day=against the violator. Be advised that a copy Qf this statement may be forwarded to the t�ffice of
tnvestigatians of the DIA for insurance coverage verificatidn.
I rlo{rere8y certi;fy,er�der the pains ar�d penult�es of perjury that the informt�tion pravided abo�*e is irue und earrect.
�i�nature: ✓" + �� Dat�' 1 � / f q � -?�/ G ,
i'hone#: 5"� 8 . 3 g S- ��6 2
Officiat use unly. Do not wrrte ir�ihis area,to he corrrpleted by�clty ar town offxciu�
City or Town: Permit/L'rrense#
Iss+�iag Authority(circle c�ne):
1. Baard of Health 2. Building llepartment 3.CiEy/Town Clerk 4.Licensin�Board 5.Selectmen'�Offiee
5. Other
C4tttact Fersnn: Phane#:
ti+'ww,mass.g�wfdia
__ . _ _ _ _ _ .
The �unes nnotor � nn The Dunes Guest Registration Form
170 Seaview Ave
s. Yarmoutr,, MA o2664 M o t o r� ` Reservation # : 6585137
Phone: +1 5083983062 � Folio Name : Guest Folio
Fax : +� 5083942143
Email : thedunesC�capecod.net — —
Website: http://www.thedunesmotorinn.com/ —
N(�T'I�E N � �� � NO►TI�E
Reservations cancelled within 5 days of due arrival are subject to s ni u
�� a d J. �
1 �,../
Disclaimer: Reservatlons booke�d''�t�hrou h ou[r�thirci party � , ce nts as specified the ve e 7F������-�!��'1
revi�o�k��rm io �r�e��et�on your deposi � � �M������L Lt a'��
L 11:.�1.�1.7 �.�
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O,�M Sv�
The Commonwealth of Massachusetts
DEPARTMENT OF INDUSTRIAL ACCIDENTS
1 Cc�ngress Street, Suite 100, Boston, Massachusetts Q2114 — 2017
617-727--4900 — http://www.state.ma.us/dia
f�s rc:yuired by Massaihusetts Ge;neral Law,Chapter 152,Sectians 21, 22&30, lhis will give y��u notic�: t�a<a�
[� f wu} have provicied Cor paymcnt to our injured employe:es undcr the abovc; m�;nt�ionecl ch�apte�-I��y
� insuring wlth:
ACE GROUP _..e..__
� � N.�TF OF INST 1RANCE�'OMPANY
P .Q. BOX 1450
MIDDLEBORO MA 02344-1450 _
ADDRESS(�r INSURANC'F COMPANY
�6S62UB-2E29042-6-16) 07-06-16 TO 07-06-17
��(�I.iC"Y N1?MBLR FFFFCTI4'E D�T�:�
C�OWLING & 0 NEI� INS 973 IYANNOUGH RD
HYANNIS MA 02601
"= NAME�F;1'v'SURANCF AGENT ADDRESS I'EI(�N1� �*
- PENNY WISE OPERATIONS LLC 170 SEAVIEW AVENUE
SOUTH YARMQUTN
MA 02664
.,�.. A.,____..
� E�.Iv1�'I,C)Yl�R ADDRFSS
�,r. _ �..�._.__..._ .�.�_�.....
<� E:?I`v1f'� �'�YF;IZ'S WORKERS CUMPENSAI'ION C3FFI.C�L-'R (IF ANY) I>`r�i'��
_ MEDICAL TREATMENT
:� "C'he al�c��-c:� riamcd insurcr is requircci in cases oi� personal injuries arising c�ut of� and in Eh� c:c����s�:; ,al
_ �:n�l�l����rnenl to furnish adequate and reasc'�nable hc�spita( and mcdicat services in ��cc7rdanc,c tivitl� tla�.�
- ��r��3��i��cu,s «f the Workers' Compensation �ct. A copy ��f tt��. First Rc;p��rt c�f Injury n�tist (�c gia�e►�� t�� tl�c,
�—�
ir��u���:�i e;tt�pl«ye��. The employee may select his or her c�wn pbylic;ian. Th� rc.asanable; c:ost of t11�� sef�vic.G��
._�,
�,�-r�vi�lcel hy ttie trealing physician will be paid by thF; insurc�-. if the treatme��t is ncrc:�,ss<�ry <�n�� rc�asc»,T�►_�rl�r
`� ��c�r�r��„�t�,� t(� t ` �c�- ('c; atc �n ury. n cases requ�ring cxsE�� <� << c.n u�n, �inp ��y�c:s arc; e.r� 7�� nc�til��c�<i
""—`Booked on : S�un`May 22, 16 04:�3 M By,: ms�h6 <
Print�d�d��kiti;����1��'-fo�i��r��ed tor such attc�nt�c�:�,��"
��w��ed:sy
.���`1:1�F:t���='�lt�7SPCTAL AL�DItESS .�.._..�..�._.,