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Home My WebLink AboutApplication and WC TOWN OF YARMOUTH BOARD OF EAII I I APPLICATION FOR LICENSE/PE'= m 0_ , -` MAY 1 7 2019 * Please complete form and attach all necessary d ,l N, ;,I, t,-" e , ' 1___I , DEPT Failure to do so will result in the return of your application pac - . ESTABLISHMENT NAME: v,1-iJue t7 MOTOL_ )01A/ TAX ID: LOCATION ADDRESS: q6/ AT .2-8' TEL.#cSoSI ) A 4"-(2_ MAILING ADDRESS: /q - E-MAIL ADDRESS: / OWNER NAME: .,/fv rorditt - Xi ,-J F4104%19 Teusr CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: Nyh?t / uynA TEL.#( Sog ) -Q{f1Z MAILING ADDRESS: q6 r ft - co: yki,tun./ A44 D.2G 6 el 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. Gbr;S I orAc - K)EJ 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. C_l it iS-to pAer Ki tr iJ 2. Ai:9)M ' ' ' "4 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. 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. You must provide new copies and maintain a file at your establishment. 1. 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. 3. 4. RESTAURANT SEATING: TOTAL# 8 - 4)— —C 405-off 01,1s9 —1��O'-4 06—o S- OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE P IT# B&B $55 CABIN $55 MOTEL $110 --c'f2 _INN $55 CAMP $55 SWIMMING POOL$110ea. (off LODGE $55 _TRAILER PARK $105 _LWHIRLPOOL $1IOea.,# — -- FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE 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: LICENSE REQUIRED FEE PERMIT# 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: $15 AMOUNT DUE = $ 330,O0 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** f ' 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 V- OR OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED V 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 CAFÉS: 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, 2017. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.),MUST BE REPORTED TO AND APPROVED BY HE BARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE%AN / DATE: 17- 1 C SIGNATURE:____ ,^ PRINT NAME &TITLE: ,/ A k,e%i A uc fi7,4 Rev. 10/12/17 The Commonwealth of Massachusetts Department of Industrial Accidents _ Office of Investigations s. SIT= 1 Congress Street, Suite 100 -zr"�= Boston, MA 02114-2017. www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Artn 71l vo o6 ,til ere Al Address: 47G 1 ,e% <,2_c( /State/Zi X64.4 City/State/Zip:p: So: }`- i.1ov7f/ ,' ,q Phone #c:_. ) gg/2— Are you an employer? Check the appropriate box: Business Type(required): 1.[ I am a employer with employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/Eating 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] 8. El 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]** 11.0 Health Care 4.❑ We are a non-profit organization,staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.0 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. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: •.4hi . 1(i ,f) way , 'INS • Insurer's Address: p.•O goy -H /6 S 4l Sc r <7- City/State/Zip: IAA L i e s - Barre— p,A /e70 Policy#or Self-ins. Lic. # Q S e 7 t c Expiration Date: $ — 16 - r Gr 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 certify,un r the p ns and enalties of perjury that the information provided above is true and correct. Signature: /? Date: J / Phone#: "( S 4) /Z 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 Berkshire Hathaway GUARD r / P.O. Box A-H • 16 S. River Street `v'Berkshire Hathaway Wilkes-Barre, PA 18703-0020 fO G U A R D Insurance 570-825-9900 (Toll-Free 800-673-2465) 4/11111Companies FAX 570-823-2059 www.guard.com June 13, 2018 Brentwood Motor Inn Inc Agent: DOWLING & O'NEIL INSURANCE AGENCY 961 Route 28 973 Iyannough Road P.O. Box S Yarmouth, MA 02664 MA 0 Hyannis, MA 02601 Phone: 508-775-1620; Fax: 508-778-1218 Binder #: 000072144 Note: A binder from the Workers' Compensation Policy #: R2WC959715 Plan Administrator, which you may have Policy Period: 08/16/2018 - 08/16/2019 already received or will be receiving shortly, serves as your proof of coverage until cancelled or your policy is issued. WELCOME TO Berkshire Hathaway GUARD! As the servicing carrier selected by the state to handle your policy, Berkshire Hathaway GUARD Insurance Companies (specifically, our subsidiary, AmGUARD Insurance Company) is pleased to have the opportunity to provide you with the superior customer services you deserve. If you have a question about your Workers' Compensation coverage or have a particular need, our professional staff and automated resources will be available to assist you. Our Customer Service Department is available by phone at 800-673-2465 Monday through Friday, 8:00 AM to 7:30 PM EST. After hours, you can leave a voice mail, send an e-mail (csr@GUARD.com), FAX us (570-823-2059), or complete an on-line form (accessible from the Customer Service section of our Policyholder Service Center at www.guard.com). Our mailing address is listed in the upper right corner. To make a payment: We accept payment via check, bank check, direct draft (EFT), and credit card. Payments can be mailed to PO Box 785410, Philadelphia, PA 19178-5410. To report a claim or loss: Call us immediately at 888-NEW-CLMS (888-639-2567) — 24 hours a day, seven days a week. To report fraud: Call our Fraud Special Investigative Unit via our Fraud Hotline at 800-673-2465, ext. TIPS — 24 hours a day, seven days a week. To request Certificates of Insurance: You can either fax us at 570-823-2059 or call our Customer Service Department at 800-673-2465. Either way, be prepared to provide the company name, address, fax number, and contact person of the entity requesting the certificate. To obtain service from a specific discipline: You can feel free to address your issue to the attention of the following individuals. Department Contact Name Email Address Extension Fax Number Claims Lisa Krzywicki csr@guard.com 1300 570-825-0611 Billing Lori Decker csr@guard.com 1300 570-825-6211 Audit Tami Hoover csr@guard.com 1300 570-829-4587 Underwriting Tami Hoover csr@guard.com 1300 570-820-7968 Loss Control Tony Ellis csr@guard.com 1300 570-825-2990 HQ: MA/WC Your Business is Our Business sm DECTO I