HomeMy WebLinkAboutApplication and WC TOWN OF YARMOUTH BOARD OF HEALTH
APPLICATION FOR LICENSE/PERMIT-2017
*Please complete form and attach all necessary documerns by Decembe�16.2016.
Failure to do so will result in the return of your application packet.
ESTABLISHMENT NAME: � hk e '
LOCATION ADDRESS: 3�3 N�►�n S�- �,�' a'� l3 Yv�r�.al4.TEL#• ��S 775-SfSS
MAILING ADDRESS• 3 ai S' R � itJrs ezi u 7 3
E-MAIL ADDRESS: �►r�.�t�-l.rPsor�-CwD t Co� q n�il[ ceer•-
OWNER NAME: Ya s,�o.��N. 2QSE r�l-
CORPORATTON NAME(IF APPLICABLE):
MANAGER'S NAME: �.�, ��iS �at[C j�+t,.r,�' TEL.#: s�$ 775 SlSS
MAILING ADDRESS: Say..�.
POOL CERTIFICATIONS:
The pool snpervisor mast be certified as a Pool Operator,as required by State law. Please list the desigsated
Pool Operator(s)and attach a eopy of the certification w this form. = 0 �
1. /�d/+� �Gt vf s 2. �Ylrn �o��w.� D t"�'� m
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Fool operators must list a minimum of two empioyees currently certified in standard First Aid and Community = �, Il'!
Cardiopulmonary Resnscitation(CPR),having one certified employee on premises at all times. Plesse list the p � �
employees below and attach copies of their certifications to this fonn.TLe Health Departm�t w�!not�e past m � �.�
yesrs records. You must provide new eopies snd maintain s Sle at yonr place of busiaess. � --•
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1. �d/h �v+$ 2. il'�i, �o<�i�-n..
3. Ga ea;we fi:ct en 4.__�Q6 o b�br'n S
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FOOD PROTECTION MANAGERS-CERTIFICATIONS: '`��
All food s�rvice establishments are required to have at least one full-time employee who is certified as a Food -
Protecrion 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 ye�rs'records. ' ��'
You must provide Lew copies and maintain a file at yaur establishment.
1. 2. ��'�;��.� •!
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PERSON IN CHARGE: �� ''�
Each food establislunent must have at least one Person In Chazge(PIC)on site during hours of operation. �°t'��.� ;
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ALLERGEN CERTIFICATIONS:
All food service establishments are required to have at least one full-time employee who has Allergen certification,
as deSned in the State Sanitary Code for Food Service Establishments,145 CMR 590.009(Gx3)(a}. Piease attach
copies of certification io this appiicafion. The Health Department will not use past years'rccords. You mnst �
provide new copies and maintain a Sle at yonr establishment I
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HEIMLICH CERTIFICATIONS: �
F►II food service establishments with 25 seats or more raust have at least one employee trained in the Heimlich
Maneuver on the premises at a!1 times. Ple�ase list yols employees trained in anli-chokmg procedures below and
attach copies of employce certifications to this form. The Health Department will not use past years'records.
Yon must provide new eopies and maintain a file at your place of business.
1. 2.
3. 4.
RESTAURAN 1 SEATING: TOTAL# �o}�L-I S-172$-O'Z
��� f3W�1SP-lS-l�24-�-
OFFICE USE ONLY ��SR-IS-l�3o-oZ-
�°c�xsEc: (wr)�,atKP-15-1"7Ti'f--62.
REQUIRED FEE PE£.MIT# LICENSE REQUIRED FEE PERMIT# I.ICENSE REQUIRED FEE PERMIT# i
�B SSS CAB[N S55 �MO'fEL SI10 �
�.ODGE S55 =`IRAILER PARK $)OS z ��W�ING POOLSI�1(ka. .. ������ '
FOOD SBRVICE• j
LICENSE REQUlRED FEE PERMIT# LICENSE REQUIRBD FEE PERMIT# LICENSE REQUIRED FEE PERM[T� ;
a�S�TS �� _Oh1MON�V C $60 WIiOLESALE $80 i
—RESID.KITCHEN S80
RETAIL SERV ICE: �
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUlRED FE� PERMIT# �
_<50sq ft S50 >25,000 IL $285 VEATDING-FOpD S25
. <25,OOOsq.R. TI50 _FROZEN�ESSERT S40 TOBACCO $I10
NAME CHANGE: S15 AMOUNT DITE _ $ ��Di I�1, I
*'•**PLEASE TURN OYER AND COMPLETE 07'HER SIDE OF FORM;***• f
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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 COMPENSATTON 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 Mote]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 xhey 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 coilection 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 Depattment 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 pooi 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. '
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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. �
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CATERING POLICY: !
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the
required Temporary Food Service Applicati�n 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 Deparhnent, ,
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 Departrnent. Failure to do so wiil result m the suspension or revocarion of your Frozen
Dessert Permit undl 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.
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OUTAOOR COOKING: !
Outdoor cooking,preparation,or display of a*►y food product by a retail or food service estabIishment is prohibited. �
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NOTICE:Pemuts run annually from January 1 to December 31. IT IS YOUR RESPONSIBILTTY TO RETURN
THE COMPLETED RENEWAL APPLICAI'ION(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 SIT PLAN.
DATE: //-34�I k� SIGNATUIZE: �.� � ��-- �
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PR1NT NAME&TITLE: /(�0 I►�(S f� I�v i� Q flPrQ��Qk S /hG T. �
Rev.10/12/I6
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, `�y The Commonwealth ofMassachusetts
Department of Industrial Accidents
D�ce of Invesiigations
I Congress Street,Suite 100
Bosdon,MA 021I4-2017
www mass.gov/dia
Workers' Compensation Insurance Affidavit: General Busrnesses
Analicant Information Please Print Le�iblv
Business/Organization Nam�: �k�,v,A -�'� 1��Sdr-f-
Address: 3�3 /�(�cih ,��- �-�, a�
City/State/Zip: W ar�au{'� /`�/} 0�6 7 3 Phone#: SO 8 775- SlSS' ^
Are you an employer?Check the appropriate boa: Business Type(reqnired):
1.[✓]�I am a employer with,�_employees(full andl 5. ❑ Retail
or part-time).* 6. ❑ RestaurantlBar/Eating Esta.blishment
2.❑ I am a sole proprietor or partnership and have no �, �Office and/or Sales(incl.reaI estate,auto,etc.)
employees working for me in any capacity.
[No workers' comp.insw�ance required] g• ❑ Non-profit
3.❑ We are a corporatior_and its officers have exercised 9. ❑Entertainment
their right of exemption per c. 152,§1(4),and we have 10.0 Manufacturing
no employees.[No workers'comp. insurance reyuiredJ* 11.Q Hea1th Care
4.❑ We are a non-profit organization,staffed by volunteers, �{
with no employees. [No workers' comp.insurance req.] 12•[]'Other__ (Td�� �
'Any applicant that checks box#I must also fill out the section below showing theu workers'compensarion policy information.
*•If the corporate ofl'icers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an
organization should chedc box#l.
I am an employer that is providing workers'compensation insurance for my employees Below is the policy information.
Insurance Company Name:_ G r T"d�� CQS�CQ I�'L1 �i, G rG�rLe `d. `
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Insurer's Address: I �-�ar f�6�� P�u �.,C ;
City/State/Zip:_ �l-6yT �D✓'c� i �� d(pl� �
Polic #or Self-ins.Lic.# d� G�E G L,�7 (�p� / �
y Expiration Date: I a ,v2� / ��7
A t t a c h a c o p y o f t he wor kers'compensa t ion pa licy declaration page(showing the policy number and egpiration 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the O�ce of
Investigations of the DIA for insurance covera.ge veri$cation.
I do hereby cerhfy,under the pains and penalties ofperjury that the information provided above is true and correct. j
Signature• �,K� /�- � _ �� 30 / lo
Date
Phone#: V��g 7 7.� S l S s
Official use on[y. Do not write in this area,to be compteted by city or town officiaL
City or Town• Permit/License#
Issning Authority(circle one):
1.Board of Healt6 2.Building Department 3.City/Town Cterk 4.Licensing Board 5.Selectmen's Office
6.Other
Contact Person• Phone#:
www.mass.gov/dia
�— .,.."r--a �a, � �'.. ..�. a..s U U l.�
..-.� $ ,: �� � , .
� �����t)�€ PAGE
��� ������4��5 C�OMRENSAT70N AND ENIPl.OYERS LiABILlTY POlICY
�;,��e = --== :.��:�fiZ,'�`Y 3NSURANCE COMPANY
�� -, =< -�=s� �'Z.,�ZA, HARTFORD, CONNECTICi7T 06155 .
�i�Ci Company Number: 14397 THE
campany code: 3 ��ARTFORD
�
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suffiX
� LARS RENEWAI
� PQLICY NUMBER: 42 WSG LJ'/666 06
� Pnevious Policy Number. 02 WEG LJ76b6
� HOUSING CODF: 75
h 1. Named Insured and Mailing Address: Y�MOUTH�RESORT CONDOMINIUM TRUST
N (No.,Street,Town, State,Zip Code) . �- �
0
N '
0 343 ROIITE 28 '
M FEIN Number. WSST YARMOUTH, MA 02673 !
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State Identification Number(s):
� UIN:
= The Named Insured is: CORPORATION ;
— Business of Named Insured: BUILDIlJG OWNER - B[JILDING �
_ Other workplaces not shown above: 3 43 ROUTE 2 8 I
� WEST YARMOUTH MA 02673
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— 2. Policy Pe�iod: From 12/21/16 To 12/21/17
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= 12:01 a.m., Standard time at the insured's mailing address. �
=
= Producer's Name: SMITH INSURANCE INC/PAC
"�' PO BO% 33015
� SAN ANTODiIO, T% 78265
= Producer's Code: a25471
�
'— issaing Office: T� ��'F'o� I��
�
3600 WISEMAN BLVD. ;
� SAN ANTOIVIO T% 78251 i
= t877) 287-1316 �
(
= Total Estimated Annuaf Premium: $6,401 +
� Deposit Premium: !
'—` Policy Minimum Premium: $242 MA `
� �1�di#Period: �T� Installme�t Term: �
— ��e�licy is not binding unless countersigned by our authorized representative. :
Countersigned by ��`"� C�Z�`''��' 11/0 5/16 '
Authorized Representative Date �
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�orm WC 00 00 01 A (1) Pnnted in U.S.A. Page 1 {Continued on`next page) �
Process Date: 11/0'5t16 Policy Expiration Date: 12121l17 i
/�DT/�TLT�T " i
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JRMATION PAGE (Continued) Policy N�nber. 02 wE� r.�'�666
3.A Workers Compensation Insurance: Part one of the po6cy applies ta the Workers Compensation law c
states tisted here:l�
'� g, Emplayers Liability Insurance: Part Two of the poHcy applies to work in each sEate listed in Item 3A.
The limits of our IiabiGiy under Part Two are: -
godily in jury by Acciderrt $10 0,0 0 0 each acciderrt
Bodily injury by Disease $500,000 palicy Nmit�
Bodily injury by Disease $100,000 each employee
C. Other States Insurance: Part Three of the policy applies to the states, if any,listed here:
ALL STATES E%CEPT ND, OH, WA, WY, US TERRITORIES, AND
STATES DESIC�TATED IN ITEM 3.A. OF THE INFORMATION PAGE.
D. This policy includes these endorserrients and schedule:
WC 00 04 22B WC 20 03 d3D WC 99 03 OOD WC QO 04 14 WC 20 03 O1 ,
WC 20 03 02A WC 20 04 O1 WC ZO 04 OS .WC 20 06 41A '
4. The premium for this policy wilf be determihed by our Manuals of Rules,Class�cations, Rates and Rating ;
Pfans A(1 irrfoRnation required below is sub,ject to verification and change 6y audit. !
- � Premium Basis
Class�cations Totaf Estimated Rates Per Estimated
Code Number arx! Annual $100 of Annual
pescription Remuneration Remuneratipn Premium
9052 346,404 1.80 'o,��� �
xo�: �L o�z �r,o�s �
SAT.FSPERSONS, DRIVERS '
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MA RATE DEVIATION PREMIUM CREDIT (.Q5) i9037) -312 f
�T�, pg� �g�g�T Tp gXpg2IIIJCE ffi?DIFICATION 5.923
MA - MERIT RATIl�TG CREDIT (9885) .950
PgE1�UM ADJUSTED BY APPLICATION OF EBPERIENCE 1KODIFICATIQN 5.627
TOTAL ESTIMATED ANNUAL STANDARD PREMIUM 5,627 ;
E%PIItTSE CONSTANT (Q 9 0 Q) 3 3 8 ;
MASSACHUSETTS DIA ASSESSNR�NT 5.600 PERCENT 332
TERRORISM (9740) 346,400 .03fl 104
TOTAL ESTIMATED ANNUAL PREMIUM ' 6,401 ,
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Total Estimated Annual Premium: $6,401
Deposit Premium:
Policy Minimum Premium: $242 MA
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InterstateJlntrastate lderrtfication Number. / 000487396
NAICS: . .
Labor Corrtractors Policy Number: SiC: 6512
UIN: =
NO. OF EP�P: 0 0 0 010
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Form WC 00 00 01 A (7) Printed in U.SA. Page 2
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