HomeMy WebLinkAboutApplication and WC ' �`�
TOWN OF YARMOUTS BOARD OF AEALTH �
APPLICATION FOR LIG`ENSElPERNll'!'-2017
"Pleese c�mplete form�ci at#ach ell aecessary docuu�euts by�,i ' 6a,,1016. �
Faiiure to do s�witl nsult in tl�ratum of your applicat�on pac,cet �
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ESTARLISI IIv[ENT NAME: Y�L L.� 'C 1�c,.�. C�v`'O� TAX ID� ��
�tLOCATIONADDRES& 4iZ t�n ��nJ `�i W. �_ TEL.#: _,._-,-,-----,-•—
-�MAII.INGADDRE95: wnA t7'2- 7
E-MAII.ADDRESS: 'Rtt�..ftr`�+�ja�yl'Caa-t�L-a1`1�L`t ts. . �c�✓sf�
OWNER NAME• t:t-t- L''�._.�.�. _.
CQRPORA"1'ION NAME� APPLI ABT.�}:
MANAGER'�NAME� �°7C� � \��S—P�'� TEL#• ���l7� Ccc�sZ'�
MAIL,INOADDRFS3: �Mv��,
POOL C�R',fIFICATIONS:
The pooi snpervisor mnst be cerli6ed as a Pool Operator,as requir'ed by State Isw. Fiease list the desi,�nated t � A ,�
Pool Operator(s)and auach a copy of the certiflcsation te this form. j� Z ,�.�
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1. :�'�'C�--�_.. 'M.c��'Eu'�z�`� _ 2. --� o ,..
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Pool operators mvst tist a minimum of two employees cutrentiy ccrti6ed in standerd First Aid aad Comrnuaity �U N �.g
Cardiopulmonaiy itesuscitation(CPR),having one c.e�Sed employee on prcmises at all tunes. Please list tbe � o ��t
employees below and atta�ch cop�es of their certifications to this form.l'�e Health De�teat will npt uae past --{ .� ��
ye�'ncards. You mast provide new cogies sad e�iatain a file at yoer plarx o3'bustn�s.
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FOOD PROTECTTON MANA(3ERS-CERTIFIGATIONS: ;
All is�nents are required to have at least one fuil-time empl who is as a Food ;
Pro 'on as defined in tate Sanitary Cod ocl Serviee E ts> MR 590.000. f �.� T_�
Pl ies •erti�cati o pplicarion. e Aeat ert� wHl n et '�eorrds. � �
Xou a i d main ' a your estsbWs . ' .
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PER N II�T CHARGE: � �..Q �a
Eac ood estab' t must have at least o on In Ghargc(PIC)on siu diuing ho�us of operati ' �� �
1. 2. , ����
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ERGEN CER TtON , ����
service ts required ve at kest oae fuil ptoyee who has Allerge,n
as fined inthe S S 'tary far F 'ce Establis ,i MR 590.�09(Gx3xa). Ple,ase a h �
00 of ce�tificati to t ap ' n. lth Depprtm w�71 n n�e past yesr�s're,�ords_ Yon
pr ' e aew co a Ste at ur e�tablis�maa� j
1 2 i
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CH CER CATTO �
food sr.rvice blishme�ts with 25 or morc must at least cme loyee tisined in tLc He "ch
uv�on tt�c p�emises at all timeg. Pi list y�u o traiaed in procedurea and
atta�h copies of�pioyee aettificatsons to t�cxxm. "!'�e� �p tw�set a�e pasty s. 1
Yon mast provlde now copiea and maintx�n a tfle at your phoe of bus�'mea9. 1
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4.
RESTA
UFFICE USE ONLY
Y.ODGINCr:
LICENSE REQUIREp FEE PERMI'I'# LICENSE REQUII2Ep FEE PERMI'P# NSB RE(2i71RED FEE P RM(T�
Ba�a sss cnarr� sss �oa�. yiw �{ Bo�}L-l.�tOt2-OZ.
�rr S55 CqA�4' t55 �SW1MN[[NGPOOLS110ea. _ �DS9
�[.once sss T�rxnt[.�arcpnwc s�os �wK�.roo�. si�oo.. (►)�o►KP-IS-fOl3-02
�ooa sr.av,cE: (o�Do►KP-LS-Iol�-6Z.
1.ICENS£REO�U[RF;D �FE PE[tAA1T� LICENSE RBQUIRLD F88 PERMIT� L1G£Nb'�R�RED FE6 PEAkl1?N
a1DOSEA 5125 _G�ONl7NEN!'AL f33 NQN-PlfNFII 530
�toosenTs rioo _co�auv�c, �o �L�sn�.s s'o C�)�ONS�-l$IbIS-�Z
—RESID.K17�IEN S80
R6TAQ.9ERVECE-
4lCE.'NS�REQI3IltED PEE PFRMIT S LdCENSE R$Qtl�FEfi PEKM�S# I.iCQ'1$E!t£QIISREfl FEE PFRMCC 1l
«sq ft�. f50 �25 000 R 5285 VEND[I�-FOOti SZS �
`45,U�sq.ft. S[50 �'RgZEN�SERT S40 �COBACCO Si10
NAMECHANGE: St5 AMUUNTDIIE = S ��D.�Ca �
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••��•PLSAS&TURN OVER AND COl►al.e7'E OTfiLR SID8 OF FORM:••+r�� � ��
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ADM[1VI5TRA'CIOIY
Utx�r Cha�ater 152,Secdoa 25C,SubaecGon 6,tl�e Town of Ymmouth is now required to h�otd iesuenoe or nenewal �
of a�+license or permit to operate a iwsuwess i�a persom or compauy does mot have CertiiScate of Wo�er's �
Compensaaion Insuranve. THE ATTA(.'HED 3TATE WORKER'S COMP ATI�N INSURANCE
Ak�'IDA.VI1'M�ST BE COMPLETED AND SIGIVED,OR
CERT.OF INSL11tANG�A'�fA�HED ,
DR �WORKER'S CUMP.A.F�IDAViT SIGNED AND ATTAG`H�D
Towa of Yarmouth taxes and liec�.s must be paid pirior to rerAewal or issuance of your pennits. PLEASE CHFCK '
APPROPRIATELY IF PAID:
YES N(? ;
M�'I'ELS AND OTHES IADGING ESTABLISffi1+�'lYTS {
TRANSIE�YT OCCUPANCY: For purpc►ses oftt�limitabc�as of Motel or Hatel uae,Ti�ern ocxa�pancy st�ati be
limitcd w ttte tcmporacy a�shoct Yeim oocupazwy,ordinatily aad custamariiy associated with�t+el and hotcl t�e.
Transiem owupaats mnst have and be able to demonstrate that they maimain a principal place of resideace �
elsewl�ra�e.Tcansient occupancy shatt generelly refer to continuous occupancy of�at more�thirty(30)days,and
su aggregate of not�than ninety(90)days witi�in ar►y six(6)a�nmh period. Use ofa�unit as a a�denca or
dwelling unit shalt not be considered transient. Occupa�.y that is subject to t6e�llecti�of Rnom Oacupancy
Excise,as defined in M.G.L e.64G or 830 CM�t 64C�,as amended,sball generally be con.gidex+cd Trae�sie�
POOLS
POOL O�'ENINC:Ail sv+�i,mming,wadin$aad whirlpools wl�h have been closed for the season must be iaspaeted j
by the Health D�parinnentpn or to o�en�ng. Comact the Heaith�p artmenx to eched�ile H►e' n three(3)
dnya priar to openiu�,PLEASE NOTE:Peopie are NOT sllowod to sit in the pool area un�pool has'been ,
inspeciad and apeaed.
POOL WATER TLSITI�TG: Tl�e water mu�be teated for pseudomonas,total colifvim e�d s�ard plate count
by�� certised lab,�na subminea w rhe xeakh nepertmenc three(3)aays pdior co openiag,end qumterly
POOL CLOSING:Every outdoor in gro�md swimming pool must be drais�ad ot covered within seven(�days of �
closing.
FO(?D SERVICE ,
SEASQ11TAi,F()0�,1 SERyICE OPENII�TG:
A!i food serviee estabfishmonts must be ins�pected by the Health Departrnent prior to apteiag. Ple�e contad the
I3eaith D�artment to schedule the inspectwn three(3)days prior to opemng. �
CAT'ERING POLICY:
Anyonc who caters witl�in the Town of Yar,mouth must notify the Yarmauth Hea1t�Deparlment by filing tb�e (
reclu!red Te�pc�ra�Food Service Ap�lication form 72 hoius prior to the catered event. 'i'hese forms can be
obtamed at the�calth Department,or imm the Town's website at www.varmouth.maus under Hesidi DepemneQt,
Dvwn[oa�dabl�e�orazLs. �
FR07.EN DESSERTS• �
Frnun desa�ts must be tested by a State ce�tified lab paior to openiug and mo�ly therGafter,with sample resulis '
submitted to tbe Heatth Dep�t Failuie to da so wiil resu(t im tbe suspenaion�nevocffiion of yom Frozen E
Dessert Permit tmh'1 the above berms have been met
OUTSIDE CAF�`.6:
Outside ca£as(i.e.,outdoar seating with wai#ex/waitress service),must have prior appinvat froux tlta�of Health.
OUTDOOR COOI�TG:
Outdoor eooking,�on,or display of aay food product by a retsil or food s�+ice establishment i�proiibi�ed.
Np�'ICE:Pernats run annually 6vm January 1 to Deeember 31.TT I3 YOiIR RF.SP+piYS1BILITy Tp gENR3K '
THE C�MPLETED RENEq►qI,AppLICATION(S),AND REQUIRED FEE(S}BY DECEI►�IDER 16,2016. �
ALL REN�VATIONS TO AIYY FOOD ESTABLLSHMENT, MOTEL OR POOL (i.a, PAINTING, NEW
EQUIPMENT,ETC.),MUST BE REP{)RTED TO A.PPROVED BY THE BQARD OF HE,ALTH PRIOR
TO COMIvfEN• . RENOVATIOIVS MA S] P
DATE: S[GNAT[JRE:
PRINT E&7TTLE: � - .
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Rev.lNl?ll6
���"1 HOLLTRE-03 DKULICK
,a►CORv" CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYV)
�� 11/8/2016
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to
the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate dces not confer rights to the
certificate holder in Ifeu of such endorsement(s).
PRODUCER LiCense#1780862 CONTACT
NAME:
HUB International New England PHONE 978 657-5100 FAx
299 Ballardvale Street A/C No e�:� ) _ A�c,No):(978)988-0038
Wilmington,MA 01887 A DRIESS:
INSURER(S)AFFOROING COVERAGE NAIC#
�NsuReRn:Granite State Insurance Company 23809
INSURED
INSURER 8:
Holly Tree Condo(WC) INSURER C:
Attn: Brian M.O'Hearn
412 Main Street INSURER D:
West Yarmouth,MA 02673 INSURER E: _
INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH 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.
INSR �7ypE OF INSURANCE ADDL S B POLICY EFF POLICY EXP LIMITS
LTR. INSD WVD POLICY NUMBER MMIDDIYYVY , MMIDDNYYY
I COMMERCIAL GENERAL LIABIUTY EACH OCCURRENCE $
__l CLAIMS-MADE '� OCCUR X II PREMISES Eaoccurrence $
1 . _ � �� j . i MED EXP(Any one person) $
'� � PERSONAL&ADV INJURV $
---.._..--------- !I
I
GEN'L AGGREGATE LIMIT APPLIES PER: ! �' �GENERAL AGGREGATE $
� POLICY��E� ��i LOC I � I I PRODUCTS-COMP/OP AGG $
� OTHER: I I $
AUTOMOBILE 1IA81LITY � COMBINED SINGIE LIMIT $
Ea accident
ANY AUTO �, . � I, BODILY INJURV(Per person) $
AUTOS NED �AUTOSULED I BODILY INJURY(Per accident) $
HIRED AUTOS ���NON-0WNED PROPERTY DAMAGE $
� 'AUTOS Per acciden�__
r—
$
� UMBRELLA LIAB i OCCUR � EACH OCCURRENCE $
EXCESS LIAB I CLAIMS-MADE AGGREGATE $
r � DED 'RETENTION$ � $
�WORKERS COMPENSATION PER OTH-
'AND EMPLOYERS'LIABILITY � STATUTE ER
A ANYPROPRIETOR/PARTNER/EXECUTIVE Y�N WC003603399 �$/��/2��6 �8�0��2�77 E.�.EACHACCIDENT $ 5�����0
OFFICER/MEMBER EXCLUOED? � N I A
�(Mandatory in NH) j E.L.DISEASE-EA EMPLOYEE $ 5��,00�
DESCRIPTION OF OPERATIONS below I I I E.L.DISEASE-POLICY LIMIT $ $OO,OOO
I I
�
I
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additfonal Remarks 5chodule,may be altached if more space Is requfred)
No.of Days;10
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Town of Yarmouth THE EXPIRATION DATE THEREOF, NOTICE WIL� BE DELIVERED IN
1146 Route 28 ACCORDANCE WITH THE POLICY PROVISIONS.
South Yarmouth,MA 02664-0000
AUTHORIZED REPRESENTATIVE
����1��� '.
O 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
� 7'he Commonwealth ofMassachusetts
Department of Industrial Accidents
Office of Investigations
I Congress Street, Suite I00
Boston,MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legiblv
Business/Organization Name:_ HOLLY TREE CONDOMINIUM TRUST
Address: �+12 Route 28
City/State/Zip: West Yarmouth, MA 02673 phone#: 508-771-6677
Are you an employer?Check the appropriate bog: Business Type(required):
l.� I am a employer with 20 emptoyees(full and/ 5. ❑ Retail
or part-time).* 6. ❑ RestaurantTBar/Eating Establishment
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.insurance required] 8• ❑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 organization,staffed by volunteers,
with no employees. [No workers' comp.insurance req.] 12.� Other Homeowners Assn.
•Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy informaLion.
**If the corporate officeis have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an
organization shou(d check box#t.
I am an employer th at is provdding workers'campensation insurance for my employees Below is the po[icy in,f'ormation.
Insurance Company Name: HUB International New England, LLC Granite State Insurance Co.
Insurer's Address: 299 Ballardvale Street 2595 Interstate Dr. Ste 103
City/State/Zip: Wilmingtnn� �, 01887-000 Harrisburg, PA 17110
Policy#or Self-ins.Lic.# WC 003-60-3399 Expiration Date: 8�1/17
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 Iead 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 af 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 coverage verification.
I do hereb ' ,u er t a' s,and penalties of perjury that the informaiion provide above is true and correct.
Si ature: Date: �
Phone#:
Official use only. Do not write in this area,to be completed by city or town offuiaL
City or Town: PermitlLieense#
Issuing Authority(eircle one):
1.Board of Health 2. Buitding Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office
6.Other
Contact Person: Phone#:
www.mass.gov/dia