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Home My WebLink AboutApplication and WC REgENEELD TOWN OF YARMOUTH BOARD OF HEALTH UEC i 0 2118'` APPLICATION FOR LICENSE/PEPr9-641 3 N DEPT. * Pleasemmpplete form and attach all documents I .a y f :. NOTE:ALL BUSJNI SSES LIQUOR LICENSES RE + 'i '1- ' 'NS'1" Failure to do so will result m the return of your application packet. ESTABLISHMENT NAME: .-' �-Ka pC K I aa-. t c TAX ID: LOCATION ADDRESS: ‘•:- 1'4\ (2Xfl n }- TEL.#: 6311,`-1 ` ',fuel_) MAILING ADDRESS: VO -0O X 415 W ria Gtr i '1' 024 7-3 E-MAIL ADDRESS: tli; "Z- gj V IZ a n C r " OWNER NAME: CORPORATION NAME(IF APPLICABLE): MANAGER'S NAME: yZ ZGSc:c . TEL.#: 5-0 9 �je.d2 , ) MAILING ADDRESS: ?t, l?xd)( 44G w , �I- -0 rY10 t 02.-fo"] POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool 17A' Operator,as required by State law. Please list the designated Pool Operator(s)and attach a copy of the certification to this form. Op 1. v c�N sCel)1KO 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 this form.The H Department will not use past years' records. You must provide new copies and maintain a file at your place of business. Y4176V •� 2. \ tvY:1. FP�t ) 1CC. 4. 3 V.;1\1. t a. 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: QC 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(GX3Xa). 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: 7 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 HealthDepartment will not use past years'records. You must provide new copies and'maintain a file at your placeoff business. � _ &IA-�- i-1,735--oy t9- 043 1. B0�45P-LS- 173c.-ol-R 2. cPc c) 419--ory07 3. _ 4. 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 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 swimmmg,wading and whirlpools which have been closed for the season must be'1:1, :w :s by the Health Department prior to opening. Contact the Health i , , ".. a t to schedule the inspection three(3) prior to opening.PLEASE NOTE:People are NOT allowed to sit in ' e 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 fi : the required Temporary Food Service Application form 72 hours prior to the catered event These forms can be . + -, 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 m 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. The Commonwealth ofMassachusetts =,_ _ _- Department oflndustrialAccidents — Office oflnv stigations _nom �,., �� 1 Congress Street,Suite 100 "— Boston,MA 02114-2017 - ' www.nassgov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please- Print Legibly Business/Organization Name: VM1.--Te--V + LA--C....) Address: "1. -' 1 11, -r- City/State/ �� e#`� mac) Are yo n employer?Check the appropriate box: Business Type(required): 1. I am a employer with 4✓ employees(full and/ 5. 0 Retail or part-time).* 6. 0 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] 0. ElPr° fi 3.❑ We are a corporation and its officers have exercised 9. 0 Entertainment fir right of exemption per c. 152,§1(4),and we have 10.0 Manufacturing no employees.[No workers'comp.insurance required]" 11 ❑ Care 4.❑ We are a non-profit organization,staffed by volunteers, . with no employees.[No workers'comp..insurance req.] 12.WI Other ti *Any applicant that cis 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 las other employes,a workers'compensation policy is required and such an action should chat box#1. I am an employer that iswor ' , • , ,n tit, l raeece for my employees. Below is die policy information. Insurance Company Name ()►�- z Yom.. Insurer's Address: Ili- Aw ' City/State/Zip: 'D t -14--- /91.6.117° Policy#or Self-ins.Lic.# 'Al t I ' AS S5 AT Expiration Date: 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. Ido hereby w, , , ,, , , ."f, of drat the information provided is true and correct. Sim;,,,,,, .. : %O Dace: 1�2-- 3 iie osi - 1 -I.:4 exctom " . _. Official use only. Do not write in this area,to be completed by city or town ofetaL City or Town: Permit/License# Issuing Authority(circle one): . 1.Board of Health 2.BuMing Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: Q www.mass.gov/dia WORKERS COMPENSATION AND EMPLOYERS'LIABILTY INSURANCE POLICY—INFORMATION PAGE INSURER: POLICY NO: WE114835A NORFOLK & DEDHAM MUTUAL FIRE INSURANCE COMPANY 222 AMES STREET RENEWAL DEDHAM, MA 02026 NCCI Company No: 21059 -11 Account No: FEIN: 26-1913272 k.f ITEM 1. NAMED INSURED AND MAILING ADDRESS: AGENT NAME AND ADDRESS: PARKERS RIVER RESORT LLC ROGERS & GRAY INS. 759 MAIN STREET ABY, INC SOUTH DENNIS SOUTH YARMOUTH, MA 02664 OFFICE 434 ROUTE 134 SOUTH DENNIS, MA 02660 AGENT NO.: 20577 LEGAL ENTITY: LIMITED LIABILITY COMPANY (LLC) OTHER WORKPLACES NOT SHOWN ABOVE: (See Workers Compensation Classification Schedule) ITEM 2. POLICY PERIOD: From: 05/18/2018 To: 05/18/2019 Effective 12:01 A.M.Standard Time at the Insured's mailing address. ITEM 3. COVERAGE: 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 3A The limits of liability under Part Two are: Bodily Injury by Accident $ 500,000 each accident Bodily Injury by Disease: $ 500,000 policy limit Bodily Injury by Disease: $ 500,000 each employee C. Other States Insurance: Part Three of the policy applies to the states,if any,listed here: SEE ENDORSEMENT WC 20 03 06 B D. This Policy includes these Endorsements and Schedules: See Schedule of Forms and Endorsements. ITEM 4. PREMIUM:The premium for this Policy will be determined by our Manuals of Rules,Classifications, Rates and Rating Plans. All information required on the Workers Compensation Classification Schedule is subject to verification and change by audit. Total Estimated Minimum Premium: $ 242 Annual Premium: $ 542 Audit Period:ANNUAL Additional/Return Premium: Comments: Issued At Date:04/09/2018 Countersigned by WC 00 00 01A copyrigft 1987 National Council on Compensation Insurance coev