Loading...
HomeMy WebLinkAboutApplication and WC TOWN OF YARMOUTH BOARD OF HEALTH I APPLICATION FOR LICENSE/PERMIT-2019 *Please complete form and attach all necessary documents by December IS 20,18. I NOM:ALL BUSINESSES WITH LIORLICENSES STRETURNFORMS BYNIOVEMBERJI5 Failure to do so will rest in the return of your application packet. ESTABLISHMENT NAME: f COI/16-10Q TAXID• LOCATION ADDRESS: 55 2ruJ a?£t1 14.1.uf._!1i'v 10�' _ TEL.#: 5 fi'-44-1,Q G�59 MAILING ADDRESS: c,9 pp,L d g tri e5. nC4�i M A. i. G 3'; E-MAIL ADDRESS: eco\AO(N r a\ci -414 ,tort_ n�} U OWNER NAME: DPS(tipry 1 U CORPORATION NAME(IF APPLICABLE): 'D i P t L L.L MANAGER'S NAME: .j-{ctrcni NATEL.#: cj(3k-441-6 6 95 MAILING ADDRESS: 53 l a g VI,,y cvrtiv7o Lain M/! na 441 POOL CERTIFICATIONS: 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. 'G.r1al- m c taL4 2. RI cRI ' D om^. roil C 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 = NU employees below and attach copies of their certifications to this form.The Health Department will not use past m © Q years'records. You must provide new copies and maintain a file at your place of business. R -p I. -OA k SIh, Rka r2. SIel PA/1 C4 131,iart-. -1 O° 0 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. d You must provide new copies and maintain a file at your establishment, . N ..-- 1. 1. 2. 1 PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. 1. 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. Yon must provide new copies and maintain a file at your establishment. I. 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 file at your place of business. 1. 2. B044L-1 q-6593-QS 3. 4. 80 ;-14---QSiy-0tc RESTAURANT SEATING: TOTAL# 600-14-{696-05 LODGING: OFFICE USE ONLY LICENSE REQUIRED $ FESE PERMIT# LICENSE REQUIRED $55FEE PERMIT# LI ENS MOTEL sue FEE P: $55 CABIN $170 4* 7 111 =LODGE =TRAILER PARK $105 'It WHIRLPOOL p OL L$11 Om RL"Lt•(�( FOOD SERVICE: j�q LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE 1P, 1 LICENSE REQUIRED FEE PERMIT# + 0-100 SEATS $125 CONTINENTAL $35 p NON-PROFIT $30 >100 SEATS $200 COMMON VIC. $60 —WHOLESALE $80 RETAIL SERVICE: =RESID.KITCHEN`$80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# L(CENSE REQUIRED FEE PERMIT# <50 LICENSE 0 ft. $285 225,1•t sq'ft' $150 —FROZEN DESSERT$40 VENDING-FOOD$2S `i'OBACCO 5110. NAME CHANGE: $15 AMOUNT DUE *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** 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 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 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 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.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. 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 i 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 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 REQUIRE A SITE PLAN. DATE: I /30/. 0ia SIGNATURE: /// PRINT NAME&TITLE: ft Ve S C3V116 - " Rev.10/23/18 +' The Commonwealth of Massachusetts Department of Industrial Accidents NI° Office of Investigations 1 Congress Street,Suite 100 Boston,MA 02114.2017. www.massgovldia Workers' Compensation Insurance Affidavit: General Businesses Annlicant Information Please Print Le ibly Business/Organization Name: i i LA_C_ _ gC3‘n &eqe Address: tk ,42 City/State/Zip: A a. al ' - Phone#: (cc y Are you an employer?Check the appropriate box: Business Type(required): 1.9- I am a employer with employees(full and/ 5. 0 Retail or parttime).* 6. Q Restaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and 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] g• ❑Non-profit 3.0 We are a corporation and its officers have exercised 9. 0 Entertainment their right of exemption per c. 152,§1(4),and we have 10.0 Manufacturing no employees.[No workers'comp.insurance required]** 11.❑Health C 4.0 We are a non-profit organization,staffed by volunteers, with no employees.[No workers'comp.insurance req.] 12.0 Other I-lo't d *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 chedc box#1. I am an employer that is providing workers'compensation Insurance for my employees Below is the policy information. Insurance Company Name: t" -N e^ t1. k tAAA,Lookt u 1 w&4 ]NikSurCo'y re.c^A1 a vt tc. Insurer's Address: 91-3 1 rvwv-a-t -rsek Vicifv1\ Ci /State/Zi ty P V9v�irntiviS M� - fib?(�o, Policy#or Self-ins.Lic.# 1 °S)Did r 9 CD Co 6) Expiration Date: I 1/094/1.411 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 MOL 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 certify,under the pains and penalties of perjury that the information provided above Is true and d correct Signature: Date: 11/$4 Phone#: 5A-11-5- (3"5 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): I.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 ' "" THANKS FOR SELECTING US • I/Berkshire Hathaway c, N ARD G U Companies www.guard.com • In cooperation with Dipti, LLC DOWLING &O'NEIL INSURANCE AGENCY 59 Route 28 West Yarmouth, MA 02673-8105 A WARM WELCOME FROM Berkshire Hathaway GUARD AND DOWLING & O'NEIL INSURANCE AGENCY! DOWLING &O'NEIL INSURANCE AGENCY and Berkshire Hathaway GUARD Insurance Companies are pleased to have the opportunity to serve you by providing the superior products and customer services you deserve. If you he ?. a question about your Workers' Compensation Policy or have a particular need, our combined professional staff will be available to assist you. Contact Your Agent for: Contact Berkshire Hathaway GUARD Insurance Companies for: • Any inquiries about coverage issues, features • Any inquiries about billing when you are under that have been incorporated into your policy, a direct bill payment plan and receive and endorsements. statements in the mail from us. • Requests for issuance of Certificates of • _Questions about the status of a claim or Insurance. available safety services. Phone: 508-775-1620 Phone: 800-673-2465 FAX: 508-778-1218 FAX: 570-823-2059 E-Mail: csr@GUARD.com Available during regular business hours Monday through Friday; 8:00 AM to 7:30 PM EST (E-mail and voice mail after hours) To obtain copies of Posting Notices that may be required in your state as well as needed managed care and/or claims information that may need to be shared with your employees, visit: www.guard.com/postingnotices To report a claim or loss, call us immediately at 888-NEW-CLMS—24 hours a day, seven days a week. The information below will be needed by you to complete this process. Specific instructions on reporting claims are included in the enclosed policy packet. • YOUR POLICY NUMBER IS DIWC966617. • YOUR INSURANCE CARRIER IS NorGUARD Insurance Company. • YOUR POLICY EFFECTIVE DATE IS 11/24/2018. We have also supplied a list of medical providers who are qualified to treat work injuries. Please review all attached documents carefully. Additional value-added services available to all policyholders: • A unique Cooperative Care Program that integrates loss control, claims, and medical management activities and focuses on quality care for your injured employees and a fast return to work. • A Fraud Special Investigative Unit and Hotline at 800-673-2465. • AND MUCH MORE! We appreciate your business and look forward to the opportunity to serve your insurance needs. Please keep a copy of this letter with your Berkshire Hathaway GUARD Insurance Companies policy for future reference. enclosed: Workers' Compensation Policy and a customized List of Providers (Your premium bill will be sent to you shortly. Failure to pay the down payment and all subsequent installments will result in cancellation of this policy in accordance with state law.) HQ: MA/WC Commercial Property & Casualty Insurers DECTO I i A Worker's Compensation and Employer's Liability Policy I/Berkshire Hathaway NorGUARD InsueCmpanyo. Insurance Policy Number DIWC966617 Oa �, GUARD Companies Renewal of DIWC879978 NCCI No. [25844] Policy Information Page [1]Named Insured and Mailing Address Agency Dipty, LLC DOWLING &O'NEIL INSURANCE AGENCY DBA/TA Econolodge 973 Iyannough Road 59 Route 28 P.O. Box 1990 West Yarmouth, MA 02673-8105 Hyannis, MA 02601 1 Agency Code: MADOWL10 Federal Employer's ID Insured is Limited Liability Co. (LLC) Additional Names of Insured (N2) Econolodge [2] Policy Period From November 24, 2018 to November 24, 2019, 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. Employer'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: Bodily Injury by Accident - 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 [3]A. 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 will be determined by our Manual of Rules, Classifications, Rates,and Rating Plans. All required information is subject to verification and change b) 1 audit. (Continued on another page) Total Estimated Policy Premium $ 1,447 Total Surcharges/Assessments $ 40.00 • Total Estimated Cost $ 1,487.00 INTERNAL USE XX Page - 1 - Information Page MGA : DIWC966617 Date : 10/20/2018 WC 000001A MANOTE Issuing Office: P.O. Box A-H, 16 S. River Street,Wilkes-Barre, PA 18703-0020 • www.guard.com h 41/ Berkshire Worker's Compensation and Employer's Liability Policy frit Berkshire Hathawa NorGUARD Insurance Company - A Stock Co. � Ins wayPolicy Number DIWC966617 Renewal of DIWC879978 to ���� Companies NCCI No. [25844] Policy Information Page [4] Premium (cont.) Massachusetts Classification Code Premium Basis: Rate per Estimated Total Estimated $100 Annual Annual Remuneration Premium Remuneration Effective: 11/24/2018-11/24/2019 HOTEL-ALL OTHER EMPLOYEES 9052 73,410.00 1.49 1,094 ncreased Limits Emp Liability, 500K/500K/500K 9807 1.0% 11 mt to Bal Inc Lim 39 Merit Modification 0.95 -S/ otal Estimated Annual Premium for MA 1,087 Policy Totals Total Estimated Standard Premium for Massachusetts 1,087 Expense Constant 338 Total Terrorism MA 9740 0.03 73,410 22 Minimum Premium MA $281 Total Estimated Annual Premium 1,447 MA State Assessment 11/24/2018-11/24/2019 3.8300% 40 Total Estimated Cost for DIWC966617 1,487 INTERNAL USE XX Page - 3 - MGAInformation Page : DIWC966617 Date : 10/20/2018 WC 000001A MANOTE Issuing Office: P.O. Box A-H, 16 S. River Street,Wilkes-Barre, PA 18703-0020 • www.guard.com V.' I(' erksh Workers' Compensation and Emulover's Liability Policy ire Hathaway NorGUARD InsuraneCompanyStoCo. PNb9Insurance/®�► G UARD In s u ra ice Renewall of DIWC879978 CCCI No. [25844] -Sole•Proprietors, Partners, Officers and Others Endorsement • Policy Effective Date 11/24/2018 Issued 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 policy includes the remuneration of such persons. Schedule Persons State Others: Devang S Patel INTERNAL USE XX MGA : DIWC966617 WC000310 Date : 10/20/2018 MANOTE P.O. Box A-H • 16 S. River Street • Wilkes-Barre, PA 18703-0020 •www.guard.com