Loading...
HomeMy WebLinkAboutApplication and WC TOWN OF YARMOUTH BOARD OF HEALTH L. ' APPLICATION FOR LICENSE/PERMIT-2019 Please-,,.,.,ete form and attach all documents 9 8. - dygrE:ALL BU ii �.[ Q by Failure tondo so will resulttm the return V 1S". your application packet. ESTABLISHMENT NAME: !-11:.t- 't — TAX ID: '1 JV LOCATION ADDRESS: '11 D i1 t o)1 TEL..#: '-'f-I t. - Cocc:1.7 MAILING ADDRESS: E-MAIL ADDRESS: 13 AT,C21,9p .l�e....-‘t. oO . C--- 1"--,-- OWNER . 1"--, OWNER NAME: t_ = Z ga CORPORATION NAME(IF APPLICABLE): m O� MANAGER'S NAME: ` g oriNk TEL.#: `=r-ti—(O Ca�Z.7 . ; ( ) MAILING ADDRESS: .5 f VV`ej�- 1 = -- m ca) =H POOL CERTIFICATIONS: M v RI The pool supervisor must be certified as a Pool Operator,as required by State law.Please list the designated I o Pool Operators)and attach a copy of the�- ;.,.:�, .tO form. j --1 0 sc� �o0 1 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 at all times. Please list the employees below and attach copies of their certifications to thiThe Department will not use past y ' rds. You must provide new copies irnd maintain a file at your place of business. 1Gl• `C L4') Lce .P‘‘I r \ 2. �5 C \C:` ( - 3. •-T-Vantij, INA.T.,.►te.,At'r,s� 4. F FOOD PROTECTION MANA r ' - TIFICATIONS: All food service estab.^ ,,, , , -. to , , , least one full-time employee who is certified as a Food d Protection Manager,as. . , ,. , or Food Service Establishments,105 CMR 590.000. I C) Please attach of•- t. , • P Health Departmentmwill not use past yeas'records. J 3 You must provide new . ,, ���TTT tam a at establishment. 1. 2. PERSON IN CHARGE: Each food establishment ,,: , In Charge(PIC)on site during hours of operation. 1. 2. ALLERGEN CERTIFICATIONS: All food service establishments: , - .hav one full-time employee who has Allergen certification, as defined in the State Sanitary a F . - o .lishments,105 CMR 590.009(GX3Xa). Please attach rya tP g IN copies of certification to this:.. , H 2 . , - t will not use past years'records. You must 6 provide new copies and main 1 y: : ,eat. 1. 2. -O 1 i 1 HHE1MLICH CERTIFICATIONS: t. C t I All food service establishments with 25 or must have at least one employee trained in the Heimlichc Maneuver on the premises at all -. . ' 1$,.lo�yyees trained in anti-choking procedures below and O 15* O attach c of employee ;: „ ., ji .ea b D ry t will not use past years'records. ..-% N You must provide new copies ; , a place of business. `E tS' - V) I 1. 2.p p L O 3. .0 -C -C RESTAURANT SEATING: TOTAL# n a (_ OFFICE USE ONLY 1 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMITS LICENSE REQUIRED FEE 'q',,;, # `J B&B $55 CABIN $55 MOTEL 110 �IZ _LODGE $55 —TRAILER PARK $105 J_SWIIM�tLPOO1:S110oa ' O7ZAO! WHIRLPOOL $11044._44+,4071 FOOD SERVICE: LICENSE REQUIRED F PERM # L ROt�D FEE moms LICENSEREQUIRED FEE PERMIT#aTSF� Imo _COMMONVIC. $60 —WHOLESALE $80 RETAIL VICE: —RESID.KTTC1IEN'$80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <So sq a $50 >25,00 $285 VENDING-FOOD$25 43.000 sq.B. $150 —FROZEN SERT$40 =TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE = S `i'b•00 *****]!LEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** ADMINISTRATION Under Chapter 152,Section 25C,Subsection 6,the Town of Yarmouth is now required to,,I issuance or renewal of any license or permit to operate a business if a person or company does not have . Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S CO I s ATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR CERT.OF INSURANCE ATTACHED ' OR WORKER'S COMP.AFFIDAVIT Sic a AND ATTACHED Town of Yarmouth taxes and liens must be paid prior,, -, • or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO ' MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY:For purposes ofthe 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.640 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 Healthpriorto opening. Contact the Health Department to schedule the inspection throe(3)days prior to opening. 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 total coliform and standard plate count by a State certified lab,and submitted to the Health Department three )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.yarmondtma.us under Health Department,Downloadable Forms. FROZEN DESSERTS: - Froae desserts must be tested by a State certified lab prior to openingamd monthly thereafter,with sample results submitted to the Health Department Failure to do so will result in the suspension or revocation of your Franc Dessert Permit until the above tams have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with visitor/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 APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15,2018. ALL RENOVATIONS TO ANY FOOD ESTAB a I V I MOTEL OR POOL(i.e., PAINTING,NEW EQUIPMENT,ETC.),MUST BE REPORTED TO 7,:41 ..PROVED 'Y r ►OF HEALTH PRIOR TO CO r iv, C (.RENOVATIONS MAY�'�_.4 Iii, ti S j air'f i��� DATE: \k I U SIGNATURE: 1 iv 0 ` WREdOref , PRINT NAME&TITLE: i'\11 p Rev.10/23/I8 ` \ The Commonwealth of Massachusetts _ Department of Industrial Accidents 1. Office of Investigations _4 • 1 Congress Street,Suite 100 �1�'" Boston,MA 02114-2017. =ti, www.mass gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Leuibly Business/Organization Name: Holly Tree Condominium Trust Address: 412 Route 28 City/State/Zip: West Yarmouth, MA 02673 Phone#: (508) 771 —FF77 Are you an employer?Check the appropriate box: Business Type(required): 1.® I am a employer with 19 employees(full and/ 5. ❑ Retail or parttime).* 6. ❑Restaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnershipand have no 7. 0 Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers' comp.insurance required] 8. 0 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 E Health C 4.❑ We are a non-profit organization,staffed by volunteers, with no employees.[No workers' comp.insurance req.] 12.0 Other Time share (hotel) *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. I am an employer that is providing workers'compensation insurance for my employee& Below is the policy information. Insurance Company Name: Liberty Mutual /ni,in Casualty Tnsuranc-P Company Insurer's Address: 9450 Seward Road City/State/Zip: Fairfield, Ohio 45014 Policy#or Self-ins.Lic.# XWO (19) 57 85 57 75 Expiration Date: 4/1/19 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration 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 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 verification. I do hereby iAik - 171%, allies of perjury that the information provided a ve is tru and correct. Ir i)'hone#: (508) 771-6677 Official use only. Do not write in this area,to be completed by city or town official 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.mass.gov/dia Workers Compensation And Employers Liability Insurance Policy niW * 0 01 A i Coverage Is Provided In: Policy Number: Is �• . Liberty The Ohio Casualty Insurance Company IXWO(19)57 85�i�TilS Mutual. Prior Policy Number: INSURANCE IXWO(18)57 85 57 75 NCCI Co.No. 1113631 MA Risk ID 01382081660 Workers Compensation and Employers Liability Insurance Policy Information Page ITEM 1:The Insured &Mailing Address Agent Mailing Address&Phone No. HOLLY TREE CONDOMINIUM TRUST (310) 530-0099 DBA: HOLLY TREE RESORT THE ARMSTRONG COMPANY INSURANCE 412 MAIN STREET CONSULTANTS WEST YARMOUTH, MA 02673 2780 SKYPARK DR STE 440 TORRANCE, CA 90505-7518 _Individual_Partnership X Corporation or Assocation or other ORG FEIN: NAICS.721110 s Other workplaces not shown above: ITEM 2 The policy period is from 04/01/2018 to 04/01/2019 12:01 am Standard Timeat the insured'smailingaddress. ITEM 3 A.Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B.Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident $1,000,000 each accident Bodily Injury by Disease $1,000,000 policy limit 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: See Extension of Information Page D.This policy includes these endorsements and schedules: See Policy Forms and Endorsements Summary ITEM 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. Classifications Code Premium Basis-Total Rate per Estimated No. Estimated Annual $100 of Annual Remuneration Remuneration Premium See Extension of Information Page(s) Total Estimated Annual Premium $9,284.00 Total Surcharges and Assessments $393.00 Minimum Premium $317.00 MA Total Estimated Cost $9,677.00 If indicated below, interim adjustments of premiums shall be made. Deposit Premium $9,677.00 Countersigned by: Issue Date 03/29/18 To report a claim, call your Agent or 1-800.362-0000 WC 00 00 01 A (WC 30 10 E) © 1987 National Council on Compensation Insurance, Inc. 03/29/18 57855775 N0080283 280 GCAOPPNO INSURED COPY 001823 PAGE 7 OF 40