HomeMy WebLinkAboutApplication and WC TOWN OF YARMOUTH BOARD OF HEALTH
, AP'PLICATION FOR LICENSE/PERMIT-2017
*Please complete form and attach all necessary dacuments by December 16 2016.
Failure to do so will result in the return of your applicahon pac��et.
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ESTABLISHIvIENT NAME: vs
� LOCATIONADDRESS: 3� AIFPTvivE GANE . Sov-rH Y�4RMo�THTEL.#: SO$>39N- 9Sel
' MAILING ADDRESS: -S AME� �
E-MAILADDRESS:�ph=11,'�@�'l-�en verv:ew�eSo�-F. �or-�
OWNERNAME: fZo�E2v��w 'LLesori.r MFOMEowiv�/1,S RSSoC14T1CN
CORPORATION NAME(IF APPLICABLE):
MANAGER'S NAME: JEFF P��ti�Ps T'EL.#:,��8-39�1� 9801
MAILINGADDRESS: - s�ar�-
POOL CERTTFICATIONS:
The pool supervisor mnst be certified as a Poal Operator,as required by State law. Please list the designated
Pool Operator(s)and attach a eopy of the certification to this form.
1. �oN�v �4►�NESE 2. MA?T i�lESTE2
Pool operators must list a minimum of two employees currenfly certified in standard First Aid and Community
Cardiopulmonary Resuscitation(CPR),having one cerlified employee an premises at all ti�es. Pl�se list the
employ�s below and at�ch cmpies of thcir cerhfications to this fonn.Tk Heaith w�eet nse paat .
-�m�ra��ecords. Yea�aaat_�xi�r�copies and maiatain a fik at�ec�laee���_ -�-- __ -- _- _ :
1. �EFF PH��c.�ps 2. �oNN S?IG.vEs�
3. 1M�-rRa orro 4. LvG4S DEV�s►.✓
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FOOD PROTECTION MANAGERS-CERTIFICATIONS: rn � ���a
All food service establishments aze required to have at least one futl time employee who is ceatified as a Food �
n
Protection Manager,as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.00Q. -I -+ � '
Please attach co pies of certification to tlus a pplic�tian. The Health Departmeet will not nse pflet years'reoords. � � i
You must provide new copies and mainhin a file at yonr�tablishmen� � N �;9.
� � 3���
1. �,�� 2. . � � ��
PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation.
���
1. N�+�- 2. s ,
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 Foud Service Establishments,l OS CMR 590.009(G}(3xa). Please attach � �. :
copies of certification to this application. The Health Department will not use past years'records. Yom m�st �
provide new copies and maintain a Sle at your establishment. '�
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1. N�A 2. ,a„��.,��
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HEIIuILdCH CERTIFICATIONS: �, -�
All food service establishments with 25 seat4 or more must have at least one employee trainod in the Heimlich ���'"`
� Manativer en t�pr�iees at afl.tiffies. Please list Yc�ar ea�Ploy�t�ai�d is�tischoktng prt�cedures belaw�3
attach copies of employes certifications to this form. The Heslth Department will not use past years'records.
You must provide ne�v copies And maiatain�file at your plaee of business.
1. N/�4 2.
3. 4.
RESTAURANT SEATING: TOTAL#
i.oncnvs:
OFFICE USE ONLY
LICENSE REQU[RED FEE PERMIT# LICENSE REQI7IRED FEE PERMIT# L CENSE REQUIRED FBE RM T# �
�s sss cAsn�r sss �a�o�r. suo ?-Jo 4oN-1.- �$-6(6�2
—nax sss cn►,� sss swn,.u,atr�a rooi,si so�. �30{{SP-t$-6161-C�
�.onc� �55 1RAILEttPARK 5705 �WEflItLPOOL suo�. � —15-6�7l--OZ�;
FooD s�v��
LICENSE REQ�J�� FEE PERMIT# LICENS&REQUIRED FEE PERMIT# LICENSE UIRED FEE PERMPP#
0-200 SEA�'S t125 _CONfIIVENPAL S35 I�1+6-PRO S30
>I00 SEATS 5200 _COMMON VIC. S60 T�TOLESALE S�
— —xEsro.icrrc�v sso
RETAII.SERVICE:
LiCENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMiT# L CENSE REQTJIRED FEE RMI #
,<25,WOsq.R Si 0 �ROZ�EN�ESSERT S40 �TOEBACC�O_� 5110 ����6t�3��
�c�cE: s,s �o�rrr nuE = s �'3 �"�S; °n
**�•*PLEASE TURN OVSR AND COMPLETE OTHER SIDE OF FORM••+•*
T
ADNIINISTRATION
Under Chapter 152,Section 25C,Subsection 6,the Town of Yacmouth is now required to hoid 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 jnsurance. TNE ATTACHED STA'i'� WORKER'S COMPENSATION INSURANCE
AFFIDAVTT MUST BE COMPLETED AND SIGNED,OR
CERT.OF INSURANCE ATTACHED�
OR
WORKER'S COMP.AFFIDAVTI'SIGNED AND ATTACHED
Town of Yazmouth ta�ces and tiens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES� NO
MOTELS AND OTHER LODGING FSTABLISHMENTS
TRANSIENT OCCUPANCY: Foz pnrposes of the limitations of Motel or Hotel use,Tiansient occupancy shall be
limited to the temporary and short tetm occupancy,ordinarily and customarily associated with motel and hotel use.
Transiern occup�nts must have and be abie to demonsirate thax they maint�in a principal place of residence �
-- elsewhere.Transieat oc.cepaeey shal��ene�lly�fer tocontiauoe�.s c�eeupaney ef�t more tt�an thirtY(3�}�an� �
an aggregate of not mare than ninety(90)days within any six(6�month period. Use of a guest unit as a residence or
dwelling unit sha�l not be considered traosient. 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 considere�Transient.
POOLS
POOL OPENING:AIl swimming,wading and whirlpools which have been ciosed for the seasom m»st be inspected
by ti�e Health Department pnor to opemng. Contact the Health Dcpartmern to schednle We iaspection three(3) ;
daya prior to opening.PLEASE NOTE:People ace NOT allowed to srt in the pool area until t�►e pool has been j
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 drainad or covered within seven('7)days of
closing. '
FOOD SERVICE
SEASONAL FOOD SERVICE OPENIIVG: '
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 opemng.
CATERING POLICY-
Anyone who caters withiu the Town of Yarmouth must notify the Yarmouth Health Departtnent by filing tbe
reqwred Tempor�y Food Service AppIication form 72 hours prior to the catered event These fornis can be
obtamed at the Health Department,or from the Town's website at www;varmoutb.maus.under Health Departanent,
Downloadabte Forms.
FROZEN 13ESSERTS:
Frozen desserts must be tested by a State certified lab prior to opening and monthly thereaiier,with sample results
submitted to the Heatth Department. Failure to do so will result m the suspension or revocation of your Frozen
Dessert Permit�mtil the above tetms have been met.
OUTSIDE CAF�S:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior apprnval from tbe Boatci of Heaith :
� OTJTDOOR COOKING:
; Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prolubited.
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' NOTICE:Permits nm annually from January 1 to Dacember 31.1T IS YOUR RESPONSIBILITY TO RETURN
, THE COMPLE�'ED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 16,2016. �
� ALL RENOVATIONS TO ANY FOOD ESTABLISHIKENT, MOTEL OR POOL (i.e., PAIIdTING, NEW I
! EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY Tf�BOARD OF HEALTH PRIOR I,
,
TQ CO�NCEMENT. RENOVATIONS MAY REQiJ�RE
DATE: �Z�Z�ZT_SIGNATURE: ' :
PRINT NAME 8c T1TLE: �.1 G�F P�SFI LL!Pf G���'7ZAL /VV�N"}�.E/Z
rs�•.ta�vi6 ' '
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� The Contneonwealth of Massacl�usdts ,
Depar[ment of Industrial Accidents ,
O,�'ice of Investigatio�ts
� 1 Congress Street,Suite 100
Boston,MA Q2114-2017.
www nras�.gov/aFia
Workers' Compensation Insurance Affidavit: General Bnsinesses
Anaticant Iaformation Please Print Legiblv
Business/Organization Name: � fvL�2v►e✓ 12�o2T Co,�Dor��n���� T�2�s i
AddTBSs: 3� /t�v?fv�� LAn�� S o�T}} �,�cr-.o..�y M�► o Z 6 LN
� �
City/State/Zip: S�a.n-►� �Arzr�w�r+� � o z e by Phone#: �D� ' .3 R`�— 1� 1
Are yon an employer?Check the apprnpriate boz: Bnsiness Type(reqnired):
l� I am a employer with 10-15 employees(full and/ 5. ❑Retail �
_ _ - or�_��*- -- -- _-- -- _ _____ _6 Q��tamant�B�r/Ea�uig Esta�sMttetrt _
2.❑ I am a sole proprietor or partnership and have no 7. �p���a/or Sales(incl.real estate,auto,etc.)
emplayees working for me in any capacity.
[No workers'comp.insuraz►ce required] 8. ❑Non-profrt ,
3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment
their right of exemption per a 152,§1(4),and we have 10.Q Manufacturing
no employees.jNo worke.rs'comp.insurance requiredj* 11.�Health Care I
4.❑ We are a non-profit organization,staffed b3'voluntcers, �
with no employces.[No workers'comp.insurance req.] 12.�.Other T�n�Es HR Q� �E".So�c.�
•Any appGc�t tf�chedcs box#t must also fiIi out tf�section 6elow sfiowing their workas'oompen�on Policy information-
s•If the corporate officeis have ex�pted themselves,but the c�prpo�tion has other employxs,a wo�s'compeosalioa Poli�Y is required end swch an
organizatian should chedc box#L
I am a�e e»r,ployer that is pmvi�ing workers'o��on nr�rerunce for»�e�rrpfoyee�. Belo�n is fhe poliry i�forn�ioir.
It1SW�II(;6COII1p8i1�+N8II1C: AME2ICAN �7'ATES 1/VSvR/�NLC COMPAN�y
Insurer's Address: 3 SO E�4 s T 1� �� S�
C1Ly/StB�/Zlp: � 'V D I AN�PD L/f � �D i A N �� Z�O
Policy#or Self-ins.Lic.# � 1 W C y �O� � � 2�? _ F�tpiration Date: �`� ��
Attach a oopy of the worlcers'compe�sxtion policy declnntion page(showing the poli�y anmber and ezpiration dute�.
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fne up to$I,SOf}00 and�br one-y�ar i�tpriso�e�as well as civii�enai�es in the form of a STOP WOR�dRDE�t and a fne
of up to$250.00 a day against the violator. Be advised that a copy of#his statement may be forwarded to�e Oi�ice of
Investigations of the DIA for insurance coverage verification.
I do kenby cera'f}+,under t/�e �ir +��1,� naNi�s ofF�.l�'Y��ie iiejorn�atlon prov�ded abovre Ts true and corred
; 1� z�
Phone#• ..5� � ' �3 9�!- `I p'O 1 �'x f �o Z
Of,flcial u�only. �o not wr�te in this area,to be complded by c�ty or mwn official
City or Town• Permitllaeense#
IssQin�Aethority(circle one}:
1.Board of Heatth 2.Baitding De�rtment 3.Cityrl'own Cterk 4.Licensing Board 5 Seiectmen's Ot�ce '
6.4ther
Coatact Peraon• ���•
Irv�vw.ma�s.�v/dia
"••REPRINTED FROM THE ARCHIVE.THE ORIGINAL TRANSACTION MAY INCLUDE ADDITIONAL FORMS ""`
�Liberty Muttlal. AMERICAN STATES INSURANCE COMPANY - CARRIER N0. 11495 PAGE 1
I N S U R A N C E SEATTLE, WASHINGTON
STANDARD WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
' 1. NAMED RIVERVIEW RESORT CONDOMINIUM INFORMATION PAGE
INSURED TRUST
' MAIDLING RIVERVIEW RESORT CONDOMINIUMS POLICY NUMBER 01-WC-410775-2 0
, ADDRESS 3 7 NE PTUNE LN RENEWAL OF Q 1-WC-410 7 7 5-10
SOUTH YARMOUTH, MA 02664
FEDERALID NUMBER:
i
!
FORM OFBUSINESS: ASSOCIATION AGENT THE ARMSTRONG COMPANY INS
OTHER WORKPLACES,IF ANY, ARE SHOWN ON ATfACHED SCNEDULE. ANDE CONSULTANTS
2. POLICY FROM 0 4-01-16 ro 0 4-01-17 12:01 AM ADDRESS 2�8 0 SKYPARK DR #4 4 0
PERIOD STANDARD TIME AT YOUR MAILING ADDRESS SHOWN ABOVE TORRANC E, CA 9 0 5 0 5
04-59726 (310) 530-0099
� - - __ ___ _.___ ._ ___ _ � - _
_. _ -_ - --- _ _ _ — --___—__
, - -
THIS POLICY IS SUBJECT TO FINAL AUDIT.
THE ANNUAL DEPOSIT PREMIUM DUE IS: $5, 443 . 00
; DUE ON EFFECTIVE DATE: $453 . 62
; PREMIUM WILL BE BILLED MONTHLY.
,
3. COVERAGE
i 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 3A.
THE IIMITS OF OUR LIABILITY UNDER PART TWO ARE: BODILY INJURY BY ACCIDENT 1,000,000 EACH ACCIDENT
BODILY INJURY BY DISEASE 1,000,000 EACH EMPLOYEE
BODILY INJURY BY DISEASE 1,000,000 POLICY LIMIT
C. ALL OTHER STATES INSURANCE PART THREE OF THE POLICY APPLIES TO THE STATES IF ANY LISTED HERE:
; ALL STATES EXCEPT HAWAII, MAINE, NORTH DAKOTA, OHIO, RHODE ISLAND, WASHINGTON, WEST VIRGINIA,
� WYOMING, AND STATES LISTED IN ITEM 3A ABOVE.
i4. PREMHE PREMIUM FOR THIS POLICY WILL BE DETERMINED BY OUFi MANUALS OF RULES,CLASSIFICATIONS,RATES AND RATING PLANS. ALL INFORMATION
REQUIRED BELOW IS SUBJECT TO VERIFICATION AND CHANGE BY AUDIT.
MINIMUM PREMIUM: $ $309 MA TOTAL ESTIMATED PREMIUM: $ 5,443.00
INCLUDES $84.00 TERRORISM
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ENDORSEMENTS ATTACHED:
SEE THE FOLLOWING PAGE FOR LIST OF ENDORSEMENTS.
COUNTERSIGNATURE
BY
(DATE) (AUTHORIZEDREPRESENTATNE)
WC 00 00 01 A (0588)
COMPANY USE ONLY
WC000001 G1
NORTHEAST 25 (ROCHCO) INSURED COPY PREPARED 04-07-16
AFP-META2-07-PRINT001-0876-0007-I