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HomeMy WebLinkAboutApplication and WCI�rTMW 4-1 ST Ft, TOWN OF YARMOUTH BOARD OF HEALTH APPLICATION FOR LICENSE/PERMIT - 2019 " Please complete form and attach all necessary documents by December IS 2018. NOTE:ALLSUSLNWSSESLf7THLI UORLICENSESMUSTRETURNFO"SB NOVEMBER]5'4. Failure to do so will result in the return of your application packet. ESTABLISHMENT NAME: Mill Hill Residence TAX ID• LOCATION ADDRESS: 164 MA 28, West Yarmouth, MA 02673 TEL.#: (774) 470 - 5174 MAILING ADDRESS: 164 MA 28, West Yarmouth. MA 02673 E-MAIL ADDRESS: millhilled@maplewoodsl.com OWNER NAME:_ (See Below) CORPORATION NAME (IF APPLICABLE):Maalewood Mill Pond, LLC MANAGER'S NAME: Joanna LovelV TEL.#• (774) 470 - 5174 MAILING ADDRESS: 164 MA 28, West Yarmouth, MA 02673 POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator, as required by State law. Please list the designated Pool Operators) and attach a copy of the certification to this form. 1. 2. 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. Juanita Weiss 2. Janet Kissel - PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. Juanita Weiss' 2. Mohammad Arshad 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. 1. Juanita Weiss 2. Janet Kissel HERVILICH 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 file at your place of business. 1. Juanita Weiss 2. Kim_b_eriy Dixon 3. Mohammad Arshad 4, RESTAURANT SEATING: TOTAL # 62 (Second Floor Dining) OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT # B&B $55CABIN $55 MOTEL $110 —INN $55 —CAMP S55 =SWIMMING POOL $110M —LODGE $55 =TRAILER PARK $105 WHIRLPOOL s110ea FOOD SERVICE: LICENSE REQUIRED FEE P LICENSE REQU%!D FEE PERMIT # LICENSE REQUIRED FEE PERMIT # �0 100 SEATS $125 CONTINENTAL S35 NON-PROFIT S30 >100 SEATS $200 A—COMMON VIC. $60 —WHOLESALE S80 RETAIL SERVICE: —RESID. KITCHEN $80 LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT # <50 sq.& $50 >25,000 sq.fL $285 'VENDING - FOOD S25 =Q5,000 sq.ft $150 FROZEN DESSERT S40 ` 0BACCO $110 NAME CHANGE: $15 AMOUNT DUE = S 185. bb *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM" ••• x = EO D rr CC': UR r 0) _ R N M 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 X 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 X 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 inthepool area until the pool has been inspected and opened ount POOL Lab and submitted o the Health Department G: The water must be ted for three (3) days priorto opening, total coliform and and nerlymtherrelafter. by a State 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 b filing the required Department, or from the ToFood Service wn's websilication te at 72 hourswwwyarmouth ma us underior to the rHealth event.peartrnen Downe forms can loadable d rms. at the Health 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. TOBACCO PRODUCT PERMIT CAP A tobacco permit holder who has failed to renew his or her permit within thirty (30) days of the previous year's permit expiration date is considered an expired license, and the tobacco license cap is reduced. NOTICE: Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATIONS) AND REQUIRED FEE(S) BY DECEMBER 15, 2018. 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 COMMEN�y/�CEMENT. RENOVATIONS MTanna UIRE A SITE PLAN. DATE: 12/62018 SIGNATUREPRINT NAME & TITL Lovely, Executive Director ate. i=3na The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations I Congress Street, Suite 100 Boston, MA 02114-2017. www.massgov/dia Workers' Compensation Insurance Affidavit: General Businesses Annlicant Information Please Print Legibly Business/Organization Name: Mill Hill Residence Address: 164 MA -28 City/State/Zip: W Yarmouth, MA 02673 Phone #: e you an employer? Check the appropriate box: 1.121 I am a employer with 0 f' employees (full and/ or part-time).* 2. ❑ I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required] 3. ❑ We are a corporation and its officers have exercised their right of exemption per c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required]* 4.[--] We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp.. insurance req.] 508-827-1908 Business Type (required): 5. ❑ Retail 6. ❑ Restaurant/Bar/Eating Establishment 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment I01� Manufacturing I I.Health Care 12.n 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 check box #1. lam an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: The Memic Group Insurer's Address: 180 Glastonbury Blvd #304 City/State/Zip: Glastonbury, CT 06033 Policy # or Self -ins. Lic. # 3102804908 Expiration Date: 6/1/2019 Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required[eder 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 WORK ORDER and a fine of up to $250.00 a day against the vi&ator Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for ins coverage verification. y I do hereby cert, under the p Jf' s "14 penalties of perjury that the information provided above is true and correct. 5iggg erre• /XA Date: � �/� 4 sr Phone #: taa -�> 15�-U(17-7-1 Offu:ial use only. Do not write in this area, to be completed by city or town offuiaL 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 Contact Person: Phone #: www-mws.gov/die MEMIC Indemnity Company (A Stock Company) 1750 Elm Street Suite 500 Manchester NH 03104-2920 I I 1. Named Insured and Address MAPLEWOOD SENIOR LIVING LLC ATTN: MELISSA ALGARIN ONE GORHAM ISLAND STE 100 WESTPORT CT 06880-0000 Workers Compensation and Employers Liability Insurance POLICY INFORMATION PAGE Policy Number Policy Period From To 310 2804908 06/01/2018 06/01/2019 12:01 A.M. Standard Time at the described location Renewal of Transaction Renewal of 310 2804908 I RENEWAL DECLARATION Agent M&T INSURANCE AGENCY INC 332637 285 DELAWARE AVE BUFFALO NY 14202 Telephone: 716-853-7960 NCCI 38563Carrier # 91 91D #88 I Unemployment ID # I Entity of Coed Other Workplaces not shown above: SEE ATTACHED ADDITONAL WORKPLACES SCHEDULE 2. The Policy Period is from 06/01/2018 to 06/01/2019. 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: CT, MA B. Employers Liability Insurance: Part TWO of the policy applies to work in each state listed in Item 3A. The limits of our liability under Part TWO are: Bodily Injury by Accident $ 1,00 , 0, 000 Each accident Bodily Injury by Disease $ 1,000,000 Policy limit I Bodily Injury by Disease $ 1, 000, 000 Each employee C. Other States Insurance: Part THREE of the policy applies to the states, if any, listed here: I AK, AL, AR, AZ, CA, CO, DC, DE, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MD, ME, MI, MN, �d MO, MS, MT, NC, NE, NH, NJ, NM, NV, NY, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WI, i WV, D. This policy includes these endorsements and schedules: SEE ATTACHED ENDORSEMENT SCHEDULE 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates, and Rating Plans. All information required below is subject to verification and change by audit. SEE EXTENSION OF INFORMATION PAGE Minimum Premium $ 750 Total Estimated AnnualPremium $ 1,220,027 Expense Constant $ 338 Premium Discount $ -161,696 Deposit Premium $ 1,220,027 Assessments and Taxes $ 55,164 ❑ This is a Three Year Fixed Rate Policy Premium Adjustment Period: © Annual; ❑ Semiannual; ❑ Quarterly; ❑ Monthly Countersigned this Day of I Issued Date: 06/05/2018 Issuing Office: 1750 Elm Street Suite 500 Manchester NH 03104-2120 I 1�,4L-, Au ize V epresentative WC 00 00 01 A (Ed. 8-17) INSURED' S PDF COPY Page 1 of 8