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Home My WebLink AboutApplication and WC, � , � ��a---_�, E .� TOWN OF YARMOUTH BOARD OF HEALTH �'� '"- `` °' ' � � � � � APPLICATION FOR LICENSE �a ; RMIT -201'J '` �� Q E� 2 � 2 0�6 � �� "� * Please complete form and attach all necess�documents b� ��' r 16 2016. '�� Failure to do so will result in the return of your application pac et. �"-r�','�` r`�'� �T._ .j ESTABLISHMENT NAME: TAX ID� -' LOCATION ADDRESS:_ _�� v)ti1 Al 1„/,o�cd- 1i�•/Idl/�`� TEL.#_,S� "7�f��/,S d('/ MAILING ADDRESS:�`,rr• .�.� ' E-MAIL ADDRESS: . �/ ' OWNER NAME: 1�'(� .C'V�/� CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: C�� '��' 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. '__- �- �l t�►� �,J�'___t_1-� v�'�� - — - 2. 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. l. � _1G`�(��alf� �i��t � 2. �� 1�� "" 3•--„��l-�-l�t I//'�I JV S 4. v. 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. ��L E"+� G'f�9�J5'� 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. ��/��Z /YI�1/N/�'�" _ 2. )f'1`�j�- ( ��,�,� '� - _ __ _ - _ 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. � 1. � r.,/�,,�� ` 2. __... , -r-r— , 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. 1. �� °� l✓°�� %S� 2. G�l� �°1/�N��j� 3• ��} ��/��, 4. � —� RESTAURANT SEATING: TOTAL# OFFICE USE ONLY . LODGING: — — __ — — -- -- LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $SS / MOTEL $110 IT1N $55 CAMP $55 �SWIMMING POOL$I l0ea��SS"oS� _LODGE $55 _TRAILER PARK $105 �WHIRLPOOL $110ea. ' FOOD SERVICE: LICENSE REQUIRED FEE P RMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �0-100 SEATS $125 �I�((� CONTINENTAL $35 NON-PROFIT $30 >100 SEATS $200 �COMMON VIC. $60 7— 7(0 _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. $285 VENDING-FOOD $25 <25,000 sq.ft. $150 _FROZEN DESSERT $40 _TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE _ $ �3�. OU *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** BoN�-I�f-b��5-o3 Cw�O��aP-t�-o��t-o3 C5�?7o�h5P� V�4�p?l.rt--�3 wP BoN�SP-t�{-0773-�03 Ce� t�o�4sP-t�lr-oZb�-03 C3o+F F-l�'-0"�5g-b3 T 7 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 �� OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior 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 ar Hotel use,Transient occupancy shall be 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 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. 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 prior to opening. PLEASE NOTE: People are NOT allowed to sit in 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. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. . FOOD SERVICE 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. FROLEN 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. OUTSIDE 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 prohibited. NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 16, 2016. 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 TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: I��(� SIGNATURE: �--� ----_ PRINT NAME & TITLE: T��F�L'( SL�� /N(°� Rev. 10/12/16 r - i � The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ` ' I Congress Stseet, Suite I00 Boston, MA 02II4-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Iaformation Please Print Le�iblv Business/Organization Name:��,pP �f �'IO'�{P( Address:__�� /"l �� L✓�j�' �G��/"1�� ,�� d��jT City/State/Zip: Phone #: `rJ�'� —7�$`�,5��/ Are you an employer? Check the appropriate box: Business Type(required): 1.[�I am a employer with�_employees(full and/ 5. ❑ Retail '��or part-time).* 6. [,�RestaurantBar/Eating Establishment __�� atrt � ► ' • 1 , - — --—-- - - ----- _ _--- - __ 7. 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 organizaxion, staffed by volunteers, �'� f� / with no employees. [No workers' comp. insurance req.] 12.❑ Other 7 *Any applicant that checks box#1 must aiso 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 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: � � ��-lG.t � l,/� ��'JI/�— �G°li'� l�!j'�f Insurer's Address: _�C��'�/�� _ Cj Z.2� City/State/Zip: ��;�` !N�r��-� �� Policy#or Self-ins. Lic. # Expiration Date: Attach a copy of the workers' compensation policy declaration page(showing the policy number and ezpiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a _ �ne up-fio��f'i.DG��n�-y�r im�gis�ine�t�as wei��s�ivii p�naiti�s in the f�m-�f a S�flF�vZflRI��R�?E�2-ard 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 cer 'y,under the pains and pena[ties ofperjury that the information provided above is true and correct. Si ature: Date: Phone#: Official use only. Do not write in this area,to be comp[eted 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#: www.mass.gov/dia INFORMATION PAGE RENEWAL AGREEMENT Insurer: PRODUCER: Agent# 137 MA Retail Merchants WC Group Inc. Boynton Insuarance Agency Inc. PO Box 859222-9222 72 River Park St Braintree, MA 02185 Needham, MA 02194 {Carrier Code: 34355) Carrier Palicy #: 014005033479116 Carrier Prior Policy #: 014005033479115 1. The Insured: Dockside Hotel Group Inc Mailing Address: 476 Main Street West Yarmouth, MA 02673 Fein: 043541364 Other workplaces not shown above: Type of Business: Corporation SEE SCHEDULE OF OPERATIONS � Risk ID: 2. The policy period is from 12:41 a.m. on 1/01/2016 to 12:01 a.m_ on 1/O1J2017 at the insured's mailing address. 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident $ 1,000,000 each accident Bodily Injury by Disease $ 1,000,000 policy limit Bodily Injury by Disease $ 1,000,00o each employee C. Other States Insurance: D. This policy includes these endorsements and schedules: WCOOOOOOC{O1/15) WC000310(04/84) WC000406(08/84) WC000414 (07/90) WC000422B(O1/15) WC200301(04f84) WC200302 (05/86} WC200303B(07/99) WC200306B(06/13) WC200405(06/O1) WC200601A(07/08) 4. The premium for this policy will be determined by our Manuals of Rules, classifications, Rates and Rating Plans. All information reguired below is subject to verification and change by audit. Classifications Code Premium Basis Rate Per Estimated No. Total Estimated $1Qo of Annual Anrival Remuneration Remuneration Premium SEE SCHEDULE OF OPERATIONS Total Estimated Annual Premium $ 14,596.00 Minimum Premium $ 309.00 Expense Constant _00 Deposit Premium .0 SCHEDULE OF OPERATiONS FOR: PAGE: 1 Dockside Hotel Group Inc Carrier Policy #: 014Q05033479116 476 Main Street Fein: 043541364 West Yarmouth, MA 02673 DIV #: OOOOQ E/L Number: OOOOOQ0001 OTHER WORKPLACES : The Point LLC Fein: 043418497 Cape Point Hotel 476 Main Street, Route 28 Eff date: Ol/O1/16 West Yarmouth, MA 02673 NAICS: 721110 DIV #: Q0001 E/L Number: 0000000001 The Marine Mot Lodge LLC Fein: 043418500 Mariner Mot odge 5'73 Main Str t, Route 28 Eff date: O1/Q1/16 West Yarmou , MA 02673 NAICS: 72I110 DIV #: OOQQ2 Mailing• E/L Number: 0000000001 573 Main Street West Yarmouth, MA Q2673 Cape Town & Country Motor-Lodge LLC Fein: 043418499 Town 'N Country Motor Lodge 452 Main Street, Route 28 Eff date: O1j01/16 West Yarmouth, MA 02673 NAICS: 721110 DIV #: 00003 Mailing- E/L Number: 0000000001 476 Main Street, Route 28 West Yarmauth, MP, 02673 WC 00 00 02 B December 13 2016 Cape Point Hotel 476 Main Street, Route 28 ( West Yarmouth, MA 02673 Re: Workers' Compensation Reinstatement n Name of Trust: MA Retail Merchants WC Group Inc. Certificate Number: 014005033479116 Dear : Enclosed is Notice of Reinstatement for your Workers' Compensation caverage. Paymerit has been. received and coverage continues without lapse. If'`you�have any-questions.please feel free to contact our office at 1-800-790-8877. Sincerely, �� _ Kelley Doyle Director, New England Se1f-Insured Grpups .._. Boynton Insuarance Agency Inc. 72 River Park St � Needham,' MA 02194