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HomeMy WebLinkAboutApplication and WC � ► TOWN OF YARMOUTH BOARD OF HEALTH � �� --- u � � APPLICATION FOR LICENSE/PERMIT -2017 � ` ` ,�, . ..�. �, ,. * Please complete form and attach all necessary documents by Dece er 1� �t�l`�.ZU 1� Failure to do so will result in the return of your application pa ket. ESTABLISHMENT NAME: �• TAX ID: LOCATION ADDRESS:___ �Ct � � , i�a L'�t'1 5� . �� , �� TEL.#: � �S-'7 7 1 �-d6��?'� MAIL1NG ADDRESS: ' E-MAIL ADDRESS: ��p p � 4 � ' . ��rrct, OWNER NAME: J.7 �U � , CORPORATION NAME (IF APPLICABLE): `� � C . MANAGER'S NAME: (�t 2'1C f��ct C� q� TEL.#: MAILING ADDRESS: �'� � . M u.i'Y1 St' - �t • �• POOL CERTIFICATIONS: 'p�d l �C pS� �O C� . � t �� S'lQ.{'J^M�''�' �I�d� Ib 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 copy of the certification to this form. d�,p,�n 1'Y� �*..�,�� �•tr� . � 1. 2. � •1 � Pool operators must list a minimum of two employees currently certified in standard First Aid and Community Cardiopulmonary Resuscitation (CPR), having 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 business. 1. 2. 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. 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. '�'l� �J�Q� Ct� 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. � 1�2�C, ��f"�Q G �'• 2. 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 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. l. �� �2'1C �h Ct lJ� G� ' 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 premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a �le at your place of business. i. I�-���c f31�aa a�- � 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE P, IT# B&B $55 CABIN $55 1 MOTEL $110 �-O3�p LODGE $55 TRAILER PARK $$OS �WHIRLPOOL OOL$1�1�0 aa. -6/p� — — � N� Lo�cr�i�C oP�r►i�cr� FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE P RMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 �CONTINENTAL $35 ��?_� NON-PROFIT $30 >100 SEATS $200 COMMON VIC. $60 WHOLESALE $80 —RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq ft. $50 >25,000 sq ft. $285 VENDING-FOOD $25 =<25,000 sq.ft. $I50 _FROZEN DESSERT $40 _TOBACCO $110 r � NAME CHANGE: $15 AMOUNT DUE _ $ ;�tii��- *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** 8���--���b�✓�3'"�� C�)�o4�sp-- 6�E-a�I-63 p,o�}F- V�S��--fifs 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 1NSURANCE 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 V 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 thirly(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 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.varmouth.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., PAINTING, NEW EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUI SITE PLAN. DATE: `1j� I '� SIGNATURE: , .�- , PRINT NAME & TITLE: �l��� �Y�Ct Qq►,,fi. Rev. 10/12/16 �coNo LoDG-E A Worker's Com�ensation and Em�lover's Liab6litv Policv V� BerkSi Ilre Hati 1aWa�/ NorGUARD Insurance Company - A Stock Co. ��♦� 7 Policy Number DIWC766848 �� Insurance Renewai of DIWC672964 �A � ���D Companies NCCI No. [25844], Policy Information'Page [1]Narned Insured and Mailing Address Agency Dipti, LLC DOWLING &O'NEIL INSURANCE AGENCY 59 East Main Street 973 Iyannough Road West Yarmoutf�, MA 02673 P.O. Sox 1490 Hyannis, MA 02601 � Agency Code: MADOWLIO Federa! Employer's ID Insured is Limited Liability Co. (LLC) , r �;�� ��. :���= Additional Names of Insured (N2) Econolodge ,���N � b�0� � [2] Policy Period , From November 24, 2016 to November 24, 2017, 12:01 AM, standard time at the insured's mailing address. [3] Coverage A. ' Workers' Compensation Insurance - Part One of this policy applies to the Workers'Compensation Law of the following states: Massachusetts B. Empioyer's Liability Insurance - Part Two of this policy applies to work in each of the states listed in item [3]A. The limits of our liability under Part Two are: Bodity Injury by Accldent- each accident $500,000 Bodily Injury by Disease - each employee $500,000 Bodily Injury by Disease - policy limit $500,000 C. Other States Insurance - Part Three of this policy applies to all states, except any state listed in item [3JA.'and the states of North Dakota, Ohio, Washington, and Wyoming. D. This policy includes these endorsements and schedules: See Extension of Information Page - Schedule of Forms [4] Premium The Premium Basis and, therefore, the premium wili be determined by our Manual of Rules, Classifications, Rates, and Rating Pians. All required information is subject to verification and change by audit. (Continued on another page) Total Estimated Policy Premium � 1,703 Total Surcharges/Assessments $ 73.00 Tota1 Estimated Cost 1 776.00 IrrreRNa�usE xx Page- 1 - Information Page MGA : DIWC766848 WC OOOOOlA Date : 10/29/2Qi6 MANOTE Issuing O�ce: P.O. Box A-H, 16 S. 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[bti8SZ] 'oN I��N saiueduao �/�� �ti899L�MIU aaqwnN l���od a�u ea n s I a��n �``�j�� o� ��o�S �r - �(uedwo� a�ueansuI a2lv119aoN /CpM�I��pH c'�.III,�S�.la9��� ���od ���qe�� �aa o� w3 pue uo�;esua wo� s,aa�ao/y� r ,, .. . � .t. .� �. ... �. � � . � � � . � .� � � � . � � � . F � �... . . . . �. . . � " . R Workers'Compensation and Emoloyer's liability Policv �� NorGUARD Insurance Company -A Stock Ca ��V� BerkShlre HathaWa�/ Policy NumberDIWC766848 �'G U A R D I n s u ra n c e Renewa l of DIWC672964 �A Companies NCCI No. [258441 Sole Proprietors, Partners, Officers and Others Endorsement Po18cy Effective D�ate 11/24/2016 , IsSU�d TO Dipti, LLC An election was made by or on behalf of each person described in the Schedule to be subject to the Workers' Compensation Law of the state named in the Schedule. The premium basis for the poficy includes the remuneration of such persons. _ Schedule Persons State Others: David Patel INTERNAL USE XX MGA : DIWC766848 WCC00310 Date : 10/29/2016 MANOTE R.O. Box A-H • 16 S. River Street• Wilkes-Barre, PA 18703-0020 •www.guard.com � WORKERS COMPEiVSAT10N AND EMPLOYERS LIABILITYINSURANCE POUCY WC 00 04 22 B � (Ed.1-15) TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT DISCLOSURE ENDORSEMENT This endorsement addresses the requirements of the TeRorism Risk Insurance Act of 2002 as amended and extended by the Terrorism Risk lnsurance Program Reauthorization Ad of 2015. It serves to notify you of certainJimitations under the Act,and that your insurance carrier is charging premium forJosses that may occur in the event of an Act of Terrorism. Your policy provic3es coverage for workers compensation I�sses caused by Acts of Temorism, including workers compensation benefit obligations dictated by state law. Coverage for such losses is stiA subject to all3erms, definitions,exclusions,and conditions in your policy,and any applicable federal and/or state'laws, rules, or regulations. Definitions The definitions provided in this endorsement are based on and have the same meaning as the definitions in the Act. tf words or phrases not defined in this endorsement are defined in the Act,the definitions in the Act wiH apply. pAcY'means the Te�rorism Risk Insurance Act of 2002,which took effect on November 26,2002,and any amendme�tsfhereto,induding any amendments resulting from the Terrorism Risk Insurance Program Reau#horization Act of 2015. "Act of TerrorismA means any act that is certified by the Secretary of the Treasury,in consultation with the Secretary of Homeland Security,and the Attomey General of the United States as meeting all of the following requirements a. 'The act is an act of terrorism. b. The act is viotent or dangerous to human life, property or infrastructure. c. The acf resulted in damage within the United States, or outside of the United States in the case of the premises of >United States missions or certain air carriers or vessels. d. The act has been committed by an individual or individuals as part of an efFort to coerce the civilian population of � the United States or#o influence the policy or affect the conduct of the United States Government by coercion. "Insured Loss"means any loss resulting from an act of terrorism(and,except for Pennsylvania,including an act of war, in the case of workers compensation)that is covered by primary or excess property and casuafty insurance issuecf by an insurer if the loss occurs in the United States or at the premises of United States missions or to certain � air carriers or vessels. , "Insuret D�ductible'means,for the period beginning on January 1,2015,and ending on December 31,2020, an amount equal to 20%of our direct earned premiums,during the immediately preceding calendar year. Limitatian of Li�bility The'Act limits our liability to you under this policy,If aggregate Insured Losses exceed$100,000,000,000 in a calendar year and if we have met our Insurer Deductible,we are not liable for the payment of any portion of the amount of Insured losses#hat exceeds$100,000,000,000;and for aggregate Insured Losses up to$100,000,000,000,we will pay only a pro rata share of such Insured Losses as determined by the Secretary of the T�easury. Policyholder Disclosure Notice 1. Insured Losses would be;partially reimbursed by the United States Govemment. If the aggregate industry lnsured Losses exceed: a. $104,080,000,with respect#o such Insured Losses occumng in calendar year 2015,the United States Government would pay 85°�of our Insured Losses that exceed our Insurer Deductible. b. $120,OOQ,OE)0,with respect to sueh Insured Losses occurring in calendar year 2016,the United States Govemment would pay 84°�6 of our Insured Losses that exceed our Insurer Deductible. c. �140,OUO,t300,with respect ta such Insured Losses occumng in calendar year 2017,the United States Govemment would pay 83°�of our Insured Losses that exceed our Insurer Deductible. d. $16Q.�0,040,with respect to such Insured Losses occurring in calendar year 2018,the United States GoVetnment would pay 82%of our Insured Losses that exceed our Insurer Deductible. e. $1$O,�OO,QOO,with respect to such Insured Losses occurring in calendar year 2019,the United States Government wouk!pay 81°k of our lnsured Losses that exceed our Insurer Deductible. f. $200,QOO,Q00,with respect to such Insured Losses occurring in calendar year 2020,the United States Govemment would pay 80%of our Insured Losses that exceed our Insurer Deductible. �CopyrlgM 2015 Nafronal Council on Compensation Insurance,Inc.All Rights Reserved. �, . .� : NOTICE NOTICE TO . � , ; T4 � d EMPLOYEES � EMPLOYEES . . � . . . � . . 0�4 . . . . . . . . . . � ' � . . . . �e The Commonwealth of Massachusetts DEPARTMENT �F INDUSTRIAL ACCIDENTS 1 Congress Street, Suite 100, �oston; lVla.�sachusetts 02114-2017 617-727-4900 - http://www.state.ma.us/dia As required by Massachusetts General Law, Chapter 152, Sections 21, 22& 30, this will give you notice that I(we)have provided for payment to our injured employees under the above-mentioned chapter by insuring with: NorGUARD Insurance-Company NAME OF INSURANCE COMPANY PA. Box A-H, 16 S. River Street,Wiikes-Barre, PA 18703-002G i �DxEss oF nvsux�v.vcE co�rn� - DIWC766848 11/24/2016 il/24/2017 P4LICY NUMBER 973 Iyannough Road P.o. Box 1990 EFFECTIVE DATES DOW LING&O`NEIL INSURANGE� Hyannis, MA 02601 508-775-1620 1VAME OF INSLTR.ANCE AGENT ADDRESS PHONE# Dipti, I.LC 59 East Main Street West Yarmouth, MA 02673 EMPLOYER ADDRESS 10/29/2016 EMPLOYER'S WORKERS' COMPENSATION OFFICER(IF ANI'} DATE MEDICAL TREATMENT The above named insureris required in cases of personal injuries arising out of and in the course of' employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the ser- vices provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably connected to the work related injury. In cases requiring hospital attention,employees are hereby notified that the insurer has arranged for such attention at the NAME OF HOSPTTAL ADDRESS TO BE POSTED BY EMPLOYER ► .. . . . . . . . � . . � . . � . . � . � . � . ' k WC 00 04 22 B WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY (Ed, 1-15) 2. Notwithstanding item 1 above,the United States Government will not make any payment under the Act for any portion of Insured Losses that exceed$400,000,000,000. 3. The premium charge for the coverage your policy provides for insured Losses is included in the amount shown in ` Item'4 of the information Page or in the Schedule below. Schedule State Rate Premium MA 0.030 $23.00 This endorsement changes the policy to which it is attached and is effective on the date issued unless othervvise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective , Policy No. DIW C766848 Endorsement No. Insu�ed Premium Insurance Company Countersigned by WC 00-04 22 B (Ed. 1-15) ` �CopyrrigM 2015 National Council on Compensation Insurance,lnc.All Rights Reserved.