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Home My WebLink AboutApplication and WC, MAILTNG ADDRESS:�Z 9 �O u.�'Yt ��a✓e. �y/(��.-. Tl�O�A E-MAIL ADDRESS: f��J�cc�n�(,�l�c�So��,S'n� �on-, OWNER NAME: CORPORATION NAME(IF APPLICABLE): MANAGER'S NAME: G/l�Cl TEL.#: � � MAILING ADDRESS: Z e,. v 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 eopy of the certification to this form. 1. !�-�� q�lil� 2. � '� �" r<�r �t�SG� `�� Pool operators must list a minimum of two employees currently certified in standard First Aid and Community ; Cardiopulmonary Resuscitation (CPR), havmg one certified employee on premises at all 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 b iness. � 1. ��/!�l �<�L C��-- 2. �V/ �� 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, 105 CMR 590.000. i Please attach copies of certification to this application. The Health Department will not I Yau must provide new'copies and maintain a file at your establishment. 1. 2. Qv� ;� i ��f.�'i PERSON IN CHARGE: HEALTH DEPT. ; Each food establishment must have at least one Person In Charge(PIC)on site during hou�-��pe�,on� �`�`��_ I k , � ; ;�� 1. 2. t � ��,�_ 5 k a� � jt.�r--- i I ALLERGEN CERTTFICATIONS: All food service esta.blishments aze 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. 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 remises 11 i p at a t mes. Please list your employees trained in anti-chokin rocedures below and gP attach copies of employee certifications ta this form. The Health Department will not use past years' records. You must rovide new co ies and maintain a file at our lace of b ' P P Y P usmess. K,,�, ��.�-�5�(6t -oz 1. 2. �� r�s��2 wP Bc�tsP-(5-�co-t-oZ. 3. 4. � Qo�tF-tg-�tc5--az.. RESTAURANT SEATTNG: TOTAL# OFFICE USE ONLY LODGING: LI�ENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT B&B $55 CABIN $55 � MOT'EL $I10 ��T INN $55 CAMP $55 =SWIMMING POOL$110ea. 1?-pL2 _LODGE $55 TRAILERPARK $105 __j_WHIRLPOOL $110ea. �-1�C�� FOOD SERVICE: LICENSE RE UIRED FEE PERMIT# ICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEA�S $125 �CONTINENTAL $35 l��oZq NON-PROFIT $30 >100 SEATS $200 _COMMON VIC. $60 —WHOLESALE $80 � —uFcm xrr�NFu �An f WORKERS COMPENSATI01�AND EMPLOYERS LIABILITY INSURANCE POLICY IIVFORMATION PAGE Aala9V90 Mu�ua6 I��r�nce �o�p�ny �41'horc!Ave�ue, �url�r�gtor�, Mas��chus�t�s 0��03-0970 �� m�� NCCI NO 26158 POLICY NO. WMZ-800-8003831-2016A _ � PRIOR NO. WMZ-800=8003831-2015A Il'EM 1. The lnsured: SPM Resorts Inc DBA: The Ocean Club On Smuggler's Beach Mailing address: 329 South Shore Drivei FE►R!:****'8661 South Yarmouth,MA Q2664 � Legat Entity i'ype: Corporation � Other workplaces not shown above: . ;' 2. The policy period is from 04/01/2p9g ta 04/01/2017 12:01 a.m.standard time at the insured's maiting address. ------._— 3. A. VUorkers Compensati.on Insurance: Pa�rt One of the po►�cy applies to the Workers Compensation Law of the states listecl here: NIA ' i ; , ii B. Empioyers'Liability Insurance: Part Two of the policy appties to��rork in each sfate listed in item 3.A. , The limits of liability under Part Two are: Bodily Injury by Accident $ 1,000,000 each accident Bodily Injury by Disease $ 1,000;000 policy limit 8odily Injury by Disease $ 1,000,000 each employee C. Other States insurance: Coverage Replaced by Endorsement WC 20 03 06 B ' � D. This Policy includes these Endorsements and Schedules: SEE SCHEDULE � ' 4. The premium for this policy wiii be determined by our Manuals of Rules,Classifications, Rates and Ratin Ptans. ! All informafion required below is subject to verification and change by audif. I g ; CPassifications ' . Premium Basis � Rates Code Estimated Per$i00 'No• Total Annual Of Estimated Remuneration Remuneration Annual Premium INTRA 304730 � INTER 911387239 SEE CLASS CODE SCHEDU E ' Minimum Premium $309 Tofal Esfimated Annua!Premium $4,394 GOV GOV Deposif Premium STATE CLASS $1,i60 �A 90�2 State Assessments/Surcharges $4,264.00 x 5J500% $245 �.�:;=4 , , ,�' �„�"� � `'�"-�: � ,� - This policy, includirtg all endorsements,is hereby countersigned by � �� -t'�'��; ..� �' �'�'��`- ` �..�.-��. . . . Authorized Signature �2�29�2016 . . Date. SC;CVICe��(C@: ' �-`'ne Lakeshore Center HUB International New Engiand LLC ridgewater MA 02324 : 299 . Balf � ardval , . e Stree _ t Wilmingfon,MA 01887 WC,00 00 01 A(7-11) includes copyrighted materiai of the Nationa�c��n..n...,�..______.,. . � The Commonwealth of Massachusetts Department of Industrial Accidents O�ce of Investigations ' 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Aualicant Information Please Print Legiblv Business/Organization Name: �� l � � t.�l � Address: �d�q �aC.t-�1 c��(1Cj�G... �fr'1 �-fL---- CitylSta.te/Zip: S,�(��Q�,� �l�" Phone#: _�j O� — �v��-(��,LJ� � Are yon an employer?Check the appropriate bog: Business Type(required): 1.� I am a employer with �+� employees(full and/ 5. ❑ Retail or part-time).* 6. ❑ RestaurantBar/Eating Establishment 2.❑ I arn a sole proprietor or partnership and have no �, � Office and/or Sales(incl.real estate, auto,etc.) employees working for me in any capacity. [No workers'comp.insurance required] g•',�,Non-profit i 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 organization,staffed by volunteers, :with no employees. [No workers' comp. insurance req.] 12.❑ Othe�1/'Y)�S�1Q/�'^� _ "Any applicant that checks box#1 must also fill out the section below showing theu workers'compensation policy information. "'If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required aad such an organization should check box#1. I am an entployer that is providing worke�co»�pensation insurance for my employees Below is the policy information. Insurance Company Name: �/�'1 /�/L(f l//Q I i Insurer's Address: � � '�-� ' � p �t�' �� n �'1'I�4- � �03 c� is�.teiz� : Policy#or Self-ins.Lic.# �J Z. U� `"��'�C.l I�xpiration Date: L /� 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 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 forwazded to the Office of Investigations of the DIA for insurance coverage verification. ' I do hereb certi under the pains and penalties ofperjury that the information provided above is true and correct. ; Si ature K Date: �� Phone#: �U �J ��7 CJ "�' lf� ` �J� Official use only. Do not write in this area,to be completed by cily or town officiaL City or Town: Permit/License# Issuin�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 , 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 limita.tions of Motel or Hotel use,Transient occupancy sha11 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 nat 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. 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. OUTSIDE CAF�S: 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 retaal or food service esta.blishment 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