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Home My WebLink AboutApplication and WC � � TOWN OF YARMOUTH BOARD OF HEALTH - _ � ; � s��u v�'l�D �� ' � APPLICATION FOR LICENSE/PERI��'F��2(��C � � ;� �e �� , � � � � � � I��R 21 ?0�6 * Please complete form and attach all necessary do'u�um�nt ;�b� ec�h�e 1 S 201 S. Failure to do so will result in the return of y�i�;ap�ication packe �lEALTH DEPT. ESTABLISHMENT NAME: `-/��( lLL�l1�-' TAX ID: �� ' LOCATION ADDRESS: ,�� f�I��/ $�'T �- �.�/L�'�� TEL.#: �SG� 77S''2� 3� MAILING ADDRESS:�� r✓ �T• w� �R2/�IDd7h� !�'!� D2GT3 E-MAIL ADDRESS:�� /,� ,q�z/�y'� c l��!?.,ox� �t,/c� OWNER NAME: --�'��/ �,�v�r-� CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: �,la�� '��— TEL.#: �F�, ��• �3d� MAILING ADDRESS: 7 �'��do �T G✓, 7`�s�0�� m� � POOL CERTIFICATIONS: �'�o�, z`-'``�L v"`'��`� '"'� `J`'�-`� 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. -- 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 cerhfications 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. 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. . _.� __ _ _ _ _- �, _ __ . �. �. ALLERGEN CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who has Allergen certification, as defned 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. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on th�premises at all times. Please list youx 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 file at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# - . _ _ _ _ ------ - � - - - — -- LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE P IT#� _B&B $55 CABIN $55 MOTEL $110 �-03� _INN $55 CAMP $55 �SWIMMING POOL$110ea. � —Q _LODGE $55 _TRAILER PARK $105 WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# L[CENSE 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: LICENSB REQUIRED FEE PERM[T# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 =<25,000 sq.ft. $150 =FROZEN DESSERT $40 TOBACCO $110 NAME CHANGE: $i s AMOUNT DUE _ $ 2-�•�a *****PLEASE TURN OVER AND COMPLETE+�`T�R SIDE OF RC3��** ��.. � '�� 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 pri 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 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(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 contaet th�� 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 15, 2015. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW I� EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR I, TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: SIGNATURE: PRINT NAME&TITLE: Rev. 10/O1/15 i , � The Commonwealth ofMassachusetts Department of Industrial Accidents Office of Investigations Vt ess Street Suite I00 1 Con � � _ Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses . Applicant Information Please Print Le�iblv Business/Organization Name: y�rt/K'�""� t�i�.�-�a �d��-- Address: ��S' /'7�� T City/State/Zip: Tit�. �,92�/1�� Phone#: ��' �� 3 Ar�e yo an employer? Check the appropriate boz: Business Type(required): 1.L� I am a employer with 3 employees(full and/ 5. ❑Retail _ or part-fime).* 6. ❑RestaurantJBar/Eating Esta.blishment -- 2. I am a sole proprietor or partnership an ave no � -- - ---- � 7. ❑ Office and/or Sa1es(incl.real esta.te,auto, etc.) employees working for me in any capacity. [No workers' comp. insurance requixed] 8• ❑Non-profit 3.❑ We are a corporation and its o�cers 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.❑ ealth Caze�r�� 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 organization should checkbox#1. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: � Z I� 07��'L GNS'- �� Insurer's Address: �� f}y/C� �11�� D ��x 4�0 7I� City/State/Zip: v �G � D J��3 -- O - Z� Policy#or Self-ins. Lic. # � A� Lv G ~ �4 '� ��23� 2-,� " E�p�ratio Date: -7 i� %�' 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 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 WURK URDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this sta.tement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify,un, the pains nd penalties ofperjury that the information provided above is t{ue and correct. f � ,'`��Y�_ / '' � Si ature: � / �%-'� Date: -� / / Phone : � _�._..y� '- � ^ Z Of i aal use only. Do not write in this area,to be completed by city or town offtciaG City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2. Building Department 3. City/Town Clerk 4.Licensing Board 5.Selectmen's Office 6.Other �5 - ��F�- ��:._ � �N�e�� Contact Person: Phone#: www.mass.gov/dia , �"""" WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WFORMATION PAGE A.I.M. Mutuai Insurance Company 54 Third Avenue, Burlington, Massachusetts 01803-0970 (800)876-2765 NCCI NO 26158 POLICY NO. AWC-400-7023125-2015A � PRIOR NO. AWC-400-7023125-2014A ITEM i 1. The Insured: John Barker � DBA: Yankee Village Motel . ` Mailing address: 275 Main Street FEIN:'*-*** ; West Yarmouth,MA 02673 Legal Entity Type: Sole Proprietor ; Other workplaces not shown above: _._._�...-...__.__..�......__.�.._.____,.._ �q 2. The policy period is from 07/18/2015 to 07/18/2016 12:01 a. .standard time at the insured's mailing addrsss. li 3. A. Workers Compe�sation Insuranc__ _eLPart One of the polic lies to the Workers Compensation Law of the � states listed here: MA B. Employers'Liability Insu�ance: Part Two of the policy applies to work in each state listed in item 3.A. The limits of liability under Part Two are: Bodily Injury by Accident $ 100,000 each accident Bodily injury by Disease $ 500,000 policy limit Bodily Injury by Disease $ 100,000 each employee C. Other States Insurance: Coverage Replaced by Endorsement WC 20 03 06 B D. This Poliey includes these Endorsements and Schedules: SEE SCHEDULE 4. The premium for this policy wiil be determined by our Manuals of Rules,Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Classifications Premium Basis Rates Code Estlmated Per$100 Estimated No. Total Annual Of Annuai Remuneration Remuneration Premium INTRA 87394 INTER SE CLASS CODE SCHEDU E Minimum Premium $234 Total Estimated Annual Premium $620 GOV GOV Deposit Premium $640 STATE CLASS MA 9052 State Assessments/Surcharges $343.00 x 5.8000% $20 .�...,.� This policy,including all endorsements,is hereby countersigned by � L�k� O6/26/2015 Authorized Signature Date Service Office: Benson Young&Downs Ins Agency inc 54 Third Avenue P O Box 158 Burlington MA 01803 .� H�rwic�h�<part,MA 02646 �. �,,w•��:. � ti��:;�.�.�.3•' WC 00 00 01 A(7-i 1) __._.__.._.___-_---- Indudes copyrighted material of the Nationai Councif on CompensaUon Insurance, used with its permission. , A,� �. _ ��fu�� A.I.M. Mutual Insurance Company Massachusetts Employers Insurance Company New Hampshire Employers Insurance Company INSURANCE Ct3MPANlES Associated Empioyers Insurance Company RENEWAL PROPOSAL WORKERS'COMPENSATION TEL.# (800)876-2765 PIEASE MAKE REMITTANCE TO Date 06/02/2015 , A.I.M.Mutual Insurance Co' P.O.Box 4070 � Burlington,MA 01803-0970 Yankee Village Motel IMPORTANT: COVERAGE WILL NOT BECOME John Barker EFFECTIVE UNTIL YOUR POLICY EFFECTIVE 275 Main Street DATE. West Yarmouth,MA 02673 • P�EASE PAY THE TOTAL AMOUNT DUE SHOWN BELOW NO LATER THAN: � iNsuReo � June 28,2015 j Benson Young&Downs ins Rgency Inc payment of the deposit premium will constitute � P O Box 158 the empioyer's acceptance of and agreement to � Harwich Port,MA 02646 the terms and conditions of the olic � P Y• I i i PRODUCER OF RECORD Current Policy Expiration Date 07I18J2015 � Renewal Policy Effective Date 07/18i2015 � Renewal Policy Number AWC-400-7023125-2015A I CODE Estimated Total $j�� Estimated Annual Premiums NO Annual Remun- Subject to Remuneration ecation Mod�cation 'v��her SEE EXTENSION OF INFORMATIOfd PAGE TOTAL ESTIMATED ANNUAL PREMIUM 620.00 TOTAL MA ASSESSMENT 343.00 x 5.8% 20.00 DEPOSIT PREMIUM 640.00 DEPOSIT ASSESSMENT TOTAL AMOUNT DUE 640.00 FOR COMPANY USE ONLY _ NET AMOUNT OF CHECK ��r �„v . �, .�,i��,�:: Placing Office: 400-113-2 initiai&Date AP 4921 (9-89) 54 Third Avenue• P.O. Box 4070•Burlington, MA 01803-0970•Tei: 781.221.1600/800.876.2765•FaX•781.270.5599 BRIDGEWATER•BURLINGTON•CONCORD,NH•HOLYOKE•MARLBOROUGH sponso�d byAssociated Industries of Ma.�sachuseti�