The URL can be used to link to this page

Home My WebLink AboutApplication and WC3 01 0 0 .o a a cn Uas� a a •ts s 'dGi.� cd p c 0 H � b ? o o [xw�sRa6s Ln > ° I CA a� 0 WZU pox C,)zo� wC,3=4-4 U GJ A ZI3I( 3 o a xz wz xoW a a ++ Wc¢q UUE-� 111 U0O Unw a a 1-4 -a � •CSS �1 ct U c C) O 2 ul . M N N 3 0 7102 >, � U y o° 0- 91. 00 -91.00 o-40. O � .sem •C� AnEn a o•� 00 C �cn0 �+C-•N�� H Co" ¢, ^� (3� U (,'44 U. +' O U`n .� orA a O U �+ C� U U Cm Mi LA � M W cn z 9 H DO 0 .o a a a cl a a W ---o c cd p c 0 H � b ? o o [xw�sRa6s Os� > ° I CA a� 0 WZU pox C,)zo� Q Q U GJ A ZI3I( ,�F a xz N N 3 0 7102 >, � U y o° 0- 91. 00 -91.00 o-40. O � .sem •C� AnEn a o•� 00 C �cn0 �+C-•N�� H Co" ¢, ^� (3� U (,'44 U. +' O U`n .� orA a O U �+ C� U U Cm Mi LA � M W cn z 9 H DO R'1 a a a cl a a W ---o W000 WM== Wkno WN= wM.o s RWW 4A tw�4Sv3 0 [xw�sRa6s Os� c4 �D C7 a0 lx Q W cGa a W 0 ��w a� 0 WZU pox C,)zo� Uz= �I�I3I ZI3I( ,�F a xz wz xoW a a R'1 Z a a a ws46s whV1p wM.o ho 00 wN� Q � tea' � Q Q C7� W cGc4�W ��o zwco uzd8 0 rCrrra�� a a a> z aQ � Oa a xz wz xoW Owz0 Wc¢q UUE-� 111 U0O Unw a a 1-4 -a R'1 Wv^iviiwii Wao k. s9E,5� ws46s w�kn Q Q W -4 WW U a a as C7� W cGc4�W ��o zwco uzd8 0 AZ�2 �I�lal olnl dz�N v�vl Oa a a a a R'1 r, 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 V111- NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or 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 (3 0) 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. 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 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., EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF TO COMMENCEMENT. RENOVATIONS M. DATE: SIGNATURE; PRINT NAME & TITLE: Rev. 10/12/16 PAINTING, NEW HEALTH PRIOR ' i . �- � The Commonwealth of Massachusetts � _ Department of Industrial Accidents ; Office of Investigations � ' 1 Congress Street, Suite 100 Boston,MA 02114-2017 ; � www.mass.gov/dia � Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legiblv � 4 Business/Organization Name: �'j"'�'�� ,� � 7��Z.I,�',�q-lV T _ ; Address:�9 �j'�- ►"Y(�t Pt �—� /'��---�:�� ; City/StatelZip: � a,�� G�26 a-3 Phone #: ��`bg" � �--�� -- �.� �- I 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 � 2.❑ I am 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.❑ Other *Any applicant that checks box#1 must also 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 orgazuzation should check box#1. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. i Insurance Company Name: � i ' 1•��'/�C� Insurer's Address: � 3 t"� � ( City/State/Zip: fY�f1 � � i Policy#ar Self-i.ns. Lis. _ _ (,��- ,��,��//� Exgiration'Jate: �Z- l� I Attach a copy of the workers' compensation policy declaration page(showing the policy number d ration date). ; Failure to secure coverage as required under Section 25A of MGL a 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 Office of ' Investigations of the DIA for insurance coverage verification. I do hereby certify,under the ains and penalties of perjury that the information provided above is true and correct. � Si ature: Date: � / � Phone#: i � Official use only. 73o not write in thds area,to be completed by city or town officiaL � City or Town: Permit/License# � Issuing Authority(circle one): I 1.Board of Health 2. Building Department 3. City/Tawn Clerk 4. Licensing Board 5.Selectmen's Office � 6. Other I f Contact Person: Phone#: www.mass.gov/dia anre�iurnioam^r� : ,a►corro� CERTIFICATE OF LIABILITY INSURANCE 2i24i1, THS CERTiFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFlCATE HOLDER. THIS CER7IFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLJqES BELOW. THIS CERTIFlCATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTAIIVE OR PRODUCER,AND THE CERTIFlCATE HOLDER. IMPORTANT: if the certificate holder is an ADD1710NAL INSURED,the policy(ies) must be endorsed. If SUBROGAl10N IS WAIVED,subject to the terms and conditions ofthe policy,certain policies may require an endorsement. A statemerrt on this certificate does not conier rights to the certificate holder in lieu of such endorsement(s). c NTACT PROOUCER NAME: Robert M. Zagami Insurance PH°NE 781 337-4033 FAX N ; ��81) 337-4103 � Agency Ao�Ess: bza ami@rmzinsurance.com 555 Bridge Street iNsur� S AFFORDING COVERAGE NAIC# � Weymouth, MA 02191 � iNsuReRn:Travelers INSURED IWSURER B: One Hope, Inc. , dba irisuR�xc: Heavenly Restaurant irisuR�x�: 194 Main Street iNsuReR e: , W. Yarmouth, MA 02673 irisuR�xF: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLIGIES OF INSURANCE IJSTED BELOW HAVE BEEN ISSUED TO THE INSlR2ED NAMED ABOVE FOR THE POLICY PERIOD IND�CATm. NOTIMTHSTANDING AN`�=REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WffH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. AOD SUBR POIJCY EPF POLICY EXP LIMTS �LTR TYFE OF INSURANCE POLICY NUNBER MIOD/Y NMIDDIYYYY EACH OCCURRENCE $ GENERALLIABILITY DAMAGETO RENTED a COMMERCIALGENERALLIABILITY " ��. CLAIMS�AADE �OOCUR MED D(P(Arry are persm) $ ' PERSOPIAL&ADVIWURY S GENERAL AGGREGATE S PRODUCfS-COMP/OP AGG S GEN'LAGGREGATE LIMIT APPLIES PER $ POLICY PR� �� COaB�,N�EeD�SINGLELIMIT $ AUTOMOBILE LIABWTY I BODILY INJURY(Per person) 5 i ANY AUTO BODILY INJURY(Per accident) $ . � ALLOWhED SCHEDULED ; AUTOS NON-0WNED PROPERfY DAMAGE g er accideM � HIREDAUTOS _AUTOS $ i 4 UNBRELLA LIAB OOCUR EACH OCCURRENCE S EXCESSLIAB CLAIMS-MAC� AGGREGATE $ S DED REfENTION$ 2�2q�1� 2/24/18 X WCSTATU- OTH- A WORKERS COMPENSATION jJB 2 JZ O O�.18 AND EMPLOYERS'LIABILITY Y/N E.L.EACH ACq DEM S �J OO OO O ANY PROPRIE'fOR/PARTNERIEXECUTIVE N/A OFFICERIMEMBER EXCLIDED? � E.L.DISEASE-EA EMFLOYE $ SOO OOO (MandaLory in NH) If Yes,describeunder E.L.DISEASE-POUCYLtMIT $ 5�0 �� DESCRIPTION OF OPERATIONS below � �ESCRIPTION OF OPERATIONS 1 LOCATIONS/VEHICLES (Ariach ACORD 101,Additional Rerterks Schedule,if more spece is reqd red) �2��D L5 ��=� ��$ �'�1� HEALTH DFPr CERTIFICATE HOLDER CANGELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILI BE DEUVERED IN WE3t Yarmouth Town Hall ACCORDANCE WITH THE POLICY PROVISIONS. F7@3t Yarmouth� Mpa pUIHORIZED REPRESENTATNE Robert M. Za ami O 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD Phone: Fax: E-Mail: Leejeyoung93@gmail.com