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Home My WebLink AboutApplication and WC � TOWN OF YARMOUTH BOARD OF HEALTH APPLICATION FOR LICENSE/PERNIIT-2018 *Please complete frnm mid attach all necessary documents by December 1 S 2017. Failure to�so will resuit in the return of your applicaUon et. ESTABLISHMENT NAME: �'' 'Y • - - LOCATION ADDRESS: � TEL.#: � ' � 7� �`b�° MAILING ADDRESS: u E-MAII,ADDRESS: sa OWNER Nt�ME: , CORPORATION NAME(� PLIC ): MANAGER'S NAME: S TEL.#: � '� ' 4J��lo MAILING ADDRESS: POOL CERTIFIGATIONS: The pool snpervisor mast be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s)and attach a copy af the certification to this form. 1.�n c� �tt�'S6 i�S 2._, �S'C�1�l rJ'Yy =�n o � D � 1'00l operators must list a minimum of two employees currently certified in�Tstandard Fust Aid and Communrty r � Gardiopulmonary Resoscit$tion(GPR},having one certified employee onp�m ises at alI times. Please list the employees below ac�d attach copies of their certifications to this form.The Healt�Departmeat wiA not ase past s � � years'records. Yon mast provTide new cop�es�nd maintain a ille at your place of bd§iyiesa � rv fe' , � m o CC! ; i. , rs- a. •.��-�� c.� .—�'i � � 3. 4. FOOD PROTECTION MANAGERS-CERTIFICATIONS. y All food service establishments are requi�ed to have st least one full-time employee who is certified as a Food ��:� Protection Manager,as defin�in the State Sanitary Gode for Food Service Establishments,105 CMR 590.000. "f-, Please attach copies of certification to this application. T6e Health Department w�'ll not ase past yeais'records. �R -� You mnst pmvide new copies and maintain a file at yoar estabiishmen� s,;�.':` � 1. 2. � � ; �;; � PERSON IN CHARGE: � � Each food estaablisl�ment must have at least one Person In Charge(PIC�on site duting hours of operation. ..•- �� 1. 2. �': ALLERGEN CERTIFICATIONS: I All food service establishments are required tc>have at least one full-time employee who has Allergen certification, as defined in the Stete Sanitary Code for Food S�vice Establishments,105 CMR 590.009(GX3)(a). Please attach copies of certification to this application. The Health Department will not use past years'records. Yon mast provide new copies and maintain a 51e at your establishmen� L 2. HEIIvILICH CERTiFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the�emises at all times. Please list your enp1oye�es traix�ed in anti-choking proc�below and attach copies of employee certifications to ttris form. T6e HealthDepartment will not use past years'records. You mast provide new copies and maintain a file at yoar place of bnsiness. i. 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICfiN3E REQUlRFA FEE PERhfff# LICENSE REQIJIItFA FBfi PERMIT# LICENSE REQUIRF.D F�E PERMIT# B&B S55 CABIN S55 MOTEL $I10 2 —IIVN S55 GAMP S55 �SWIlNMIIJGPOOLSIIOea.. ' �'�IJ —LODGE $55 —TRAII,ER PARK $105 WHIItLPOOL E110ea. FOOD 9ER�'ICEs T;ICENSfi�tJiRfiD FF� PERMiT# LICENSE RBQCIIRFA F� PFdtM1Tl1 LICENSE RfiQLJiR� FEE PERMfT# 0-100 SEA S $125 _CONTINEIV'fAl 535 NON-PRO�IT E30 >100 SEATS 5200 _COMMON VIC. S60 �VHOLESALfi S80 — —RESID.K1TCH6N S80: RETAII.SERVICEs LIC�T3SE REC�tJIItED FfiE PERbIIT'# LICENSE REQi7iRfiD FfiE PERM[T# LICENSE REQUIRED FEE PERI�ffT# <50sq.&�� SSQ >25,Q00 & 5285 VENDING-FOOD S2S =<25,OOOsq:R 5150 =FROZEN�ESSERT S40 =TOBACCO 5110 NAME CHANGE: TIS AMOUNI�DUE = S �IO �� awaeYLEASE T[7RN OVER AND COMPLETE OTHER SIDE OF FORM"ssax w� �o�s P-1 S-23"�s--o3 k ADIVIINTSTRATION Under Chapter 152,Se�tion 25C,Subsection 6,the Town of Yatmouth is now required to hold issuance or renewal of any licen,�e or permit to opetate a business if a person or company does nat 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.AFFIDAVTf SIGNED AND ATTACI�D�, . Town of Yarmouth ta�ces and liens must be paid prior to renewat or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES_„� NO MOTELS AND OTHER LODGING ESTABLISFIltiIENTS TRANSIENT OCCITPANCY: For purposes of the limitations ofMotei or Hotel use,Transient occupancy shall be limited to the temporary and short teisn occuPaacY,ordinarily and customarilysssocisted with motel and hotcl use. � Transient occupants must have and be able to demonstrate that they maintain a principai glace of residence elsewhere.�ransient occupaacy shall genera[ly refer to contint�ous occupancy ofnot more than Uvriy(30)�ays,:aud an aggregate of not more than ninety(90)days within any siac(�month period Use of a guest unit as aresidence or dwelling unit shall not be considered transient. Occupancy that is subject to the colledion of Room Occupancy Excise,as defined in M.G.L.c.64G or 830 CNiR 64G,as amended,shall generally be considered Transient. POOLS POOL OPENING:All swimming,wading and whirlpools wlrich have been closed for the season must be inspected by the Health Department p�rior to�opening. Contact the Health Department to schedule the inspection three(3) days prior to opening.PLEASE NOTE:People are NOT allowed to srt in the pool area until the poal has been inspected and opened POOL WATER TESTING: T'he�vater 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 c}uarterly thereafter. POOL CLOSING:Every autdoor in gound swimming pool must be dra.ined or covered within seven('�days of closing. FOOD SERVICE °'"" SEASONAL FOOD SERVICE OPENING: All food service establishments must be inspected by the Health Departm�nt prlor 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 Departme�nt by filing the required Temporary Food Service Applicarion form 72 hours prior to the catered event. These farms can be obtained ai the Health Depariment;or fram the Town's weiuite at www:yarmouth.mans under Health D�epar6nent, Downloadable Fotms. ` FRO�EPF DESSERTS: F�zen desserts must be tested by a State certified lab prior to opening and monthly thereafter,with sample results submitted to the Health Depariment. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAF�S: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have�ior approval from the Boazd of Heahh. OUfDOOR COOHING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohfbited. NOTICE:Permits run annually from January 1 to December 31.TT IS YOUR RESPONSIBILTTY TO RETURN Tf�COMPL.ETED RENEWAL APPLICATION(S)AND REQUIRED FEE(Sj BY DECEMBER 13,2017. ALL RENOVATIONS TO ANY FOOD ESTABLISHIvIENT, MOTEL OR POOL (i.e., PAINTING,NEW EQUIPMENT,ETG.),MUST BE REPdRTED TO AND APPROVED BY'THE BOARD OF HEALTH PRIQR TO GOMIviENCE NT. RENOVATIONS MAY REQ A SITE P DATE: D I I7 SIGNATURE: �� PRINT NAME&TITLE: i�2 c��'- r'✓" x�.iorivi� , � The Commonwealth of Massachusetts Prirtt Ft�rm Deparhnent of IndustriaZAccidents Office of Investigations 1 Congress Street,Suite 100 Boston,MA 02114-201� www mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Analicant Information Please Print LeEiblv Business/Organization Name: ��,�'� r�i��✓' j��4,�,�-�/`s,,,t ��, 1��S�S Address: � �� City/State/Zip: ,� a/'�pu 7�� /� o P one#: ,.�a$' 73� ��v'G Are you an empioyer?Check the appropriate bog: Business Type(required): 1.� I am a employer with___,a___employees(full and/ 5. ❑Retail or part-time).* 6. ❑RestaurantBarlEdting Establishment 2.❑ I am a sole proprietor or partnership and have no 7, �Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers' comp.insurance required] g• ❑Non-profit 3.❑ We are a corporarion and its officers have exercised 9. ❑Entertainment their right of exemption per c. 152,§1(4),and we ha�e 10.❑Manufacturing no employees.[No workers' comp.insurance required)* 1 l.❑Health Care 4.❑ We�re a non-profit organization,staffed by volunteers, n r r with no employees.[No workers'comp.insurance req.] l2•�Othe�' l.d n�Drf'1/�1>u''''/ �4/ 'Any applicant that checks box f/1 must also fill out the section below showing their workers'compensation policy information. �sIf the coiporate officers have exempted themselves,but the corporation has other empioyees,a workers'compensation policy is required and such an organization shouid check box#1. I am an employer that is providing workers'co ensation insurance for my employees. Below is the policy information. Insurance Company Name: /t� cr�a � 1 S /'4hc �o � Insurer's Address: < n J/" Cf } l� r4 �ISD3-a�7� ; City/State/Zip: U r` / O�ll j ,Q L/ l ! Policy#or Self-ins.Lic.# 1 1�� 70� ' �o��/��'�b� xpiration Date: G r ' Attach a copy of the workers'compensation policy declaration page(showing the policy number a d e iration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposirion 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 verificarion. I do hereby certi ,under the p and penalties of perjury that the information provided above ' hue and correc� � Si ature: � Date: 1� /�7 �7 Phone#: I�U ' � — OJftcial use only. Do not write i�e this area,to be complded by city or town oJficiaL City or Town: Permit/License# Issuin Authori circle one : g h'( ) 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: www.mass.gov/aia , � ' • _ - �� ; WORKERS COMPENSATiON NFORMAT ON PAGE B�L�TM �NSURANCE POLICY A.I.M. Mutual Insurance Company 54 Third Avenue, Burlington, Massachusetts Oi 803-0970 ' • (800} 87fi-2765 NCCI NO 26158 POLICY NO. AWC-400-7029102-2017A' PRIOR NO. j AWC-400-7029102-2016A'; ITEM 1. The insured: Bass River Waterfront Townhouses DBA: ., ... Mailing address: 1376 Bridge Street-#19 FEIN: C/o Peggy Parsons&Joe Frey South Ysrmouth,MA 42664-0000 Legal Entity Type: Other Other workplaces not shown above: See Locafion � 2. The policy period is from 06i01;2017 to 06/01/2018 12:01 a.m,standard time at the insured's mailing address. 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B. Empioyers'Liability Insurance: Part Two af the policy appiies t4 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 empioyee C. Other States insurance: Coverage Replaced by Endorsement WC 20 03 06 B D. This Policy inciudes these Endorsements and Schedules: SEE SCHEDUIE 4. The premium for this policy will be determined by our Manuals of Rules,Ciassifications, Rates and Rating Plans. All information required below is subject to verificaron and change by audit. Classificatians Premium Basis Rates ; � Code ; Estimated Per$100 ! Estimated � No. i Total Annual Of ' Annual ! Remunsration ' Remuneration ; Premium j � � ' � r , INTRA 0119515 ' � ' ; i � ' INTER SEE;CLASS CODE SCHEDULE j i � � , ' i Minimum Premium S290 Total Estimated Annuai Premium $528 GOV GOV Deposit Premium $542 STATE CLASS State Assessments/Surcharges MA 9015 $14 $256.00 x 5.6000% � �:�T��`..Q�Sr'"�t This policy,including all endorsements,is hereby countersigned by 05/26/2017 Authorized Si�ature Date ge��p{�e; HUB fntemational New England LLC 54 Third Avenue 299 Ballardvals Street 8ur�ington MA 01803 Wilmington, MA 41887 WC 00 00 01 A(7-11) - ---�--�__...,...�e II A.I.M. Mutual Insurance Company insured: 7029102 Producer: 01005-001-001 ; Bass River Waterfront Townhouses HUB International New England LLC 1376 Bridge Street-#19 299 Baliardvale Street C/o Peggy Parsons&Joe Frey Wilmington, MA 01887 ; South Yarmouth, MA 02664-OQ00 � Insured FEIN: "=*�"` Issue Date: 05/26/2017 s Policy Number: AWC-400-7029102-2017A Endorsement Effective Date: 06/01/2017 F Policy Period: 06/01/2017-06/Oi/2018 Endorsement Number: ENDORSEMENT SCHEDULE The forms listed below are included ln this policy: � Form No. Form Description Applicabte States Policy Effective Date PRIVACY Privacy Notice 06/Ot/2017 ' POOL-Please Important Notice for Poot Policies 06/D1/2017 AIMIMPT AtM - important Policyhoider Notices 06/01/2017 AIM-3 AIM Waiver of Subrogation Notice 06i01/2017 AIM-4 MA Benefits Ciaim and Aggregate Deduc#ibie Program 06/01/2017 AIM-5 AIM Commitment of Service 06/0��2a17 AIM-61 AIM -Servicing Carrier 06/01/2017 Servonl Services Online Instructions 06t01/2017 WCRIB WCRIB Gircular Letters Notice MA 06/01/2017 Locstion Location Schedule ��2017 Ctass Code Classification Code Schedu{e 06/01l2017 installment Instatlment Schedule 06/01/2017 06101/2017 Rating Summary Rating Summary by State O6/01/2017 AIM-1A Dividend Cfassification Endorsement Q6101/2017 AIM-2 MA Workers Compensation Assigned Risk Pool p�i01/2017 WC 00 00 00 C Policy Conditions 06J01/2017 WC 00 04 04 Pending Rate Change End. �A 06/01/2017 WC 00 0414 Notification of Change in Ownership 06/01/2017 WC OQ 04 22 B Terrorism Risk Endarsement pg/p�/2017 WC 20 03 01 MA Limits of Liability Endorsement MA MA 06/01/2017 WC 20 03 02 A MA Assessment Charge MA pg/p1/2017 WC 20 03 03 D MA Notice to Policy Hoider Endorsement 06/01/2017 WC 20 03 05 A MA Exciusion of Coverage for Leased Employees MA as�a��2a1� WC 20 03 06 B MA Limited Other States Insurance Endorsement �A a6/01/2017 WC 20 03 07 MA Assigned Risk Pooi Eligibility Endorsement MA p�p��2017 �yC 2p p4 p5 MA Premium Due Date Endorsement MA 06/01/2017 WC 20 04 01 MA Pending Premium Change Endorsement MA pgi01/2017 WC 20 06 01 A MA Cancellation Endorsement MA pg/01/2017 WC 20 06 04 � MA Policy Definition Endorsemertt MA pg/01/2017 EMPNOTICE MA Notice to Employees � i � i i E„�,��h caa») Insured � ,-"�� . :k` • � �� A.I.M. Mutual Insurance Company sured: 7029102 Producer: 01005-001-001 Bass River Waterfront Townhouses HUB international New England LLC 1376 Bridge Street-#19 299 Ballardvale Street C/o Peggy Parsons&Joe F�ey Wilmington, MA 01887 South Yarmouth, MA 02664-0000 Insured FE1N: '="'`" Issue Da#e: 05126/2017 Policy Number: AWC-400-7029102-2017A Endorsement Effective Date: OfI01/2017 ; Policy Period: 06/01/2017-06/01/2018 Endorsement Number: LOCATION SCHEDULE Insured Unit:d01 Workplace:001 Business Type:Other Business Type: Bass River Waterfront Townhouses 1376 Bridge Street Yarmouth, MA 02664 ' TAX ID:043123897 8usiness Type: Business Type: ; Business Type: Business Type: Buslness Type: Business Type: Business Type: Business Typs: Business Type: Business Type: • • {11/11)LocationSch