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Home My WebLink AboutApplication and WC TOWN OF YARMOUTH BOARD OF HEALTH APPLICATION FOR LICENSE/PE13ITT-2 2 „: NOV 1 2 Z019 * Please complete form and attach all necessary dOeum -_� : Dec be il:k -/fpn. Failure to do so will result in the return of your application pa e NOTE:ALL BUSINESSES WITH LIOUOR LICENSES MUST RETURN FORMS BY NOVEMBER 15g. ESTABLISHMENT NAME: "atfi.S o P �-Kifl ( e.. (Jr( TAX ID: LOCATION ADDRESS: X 33 e,,,5=ke k3 eptu & -G�f�WA '�73i'hL.#: -)`�'L)- .6391 MAILING ADDRESS:TO.)IC 403 1 L/mi�imz + Ei2ept, ei E-MAIL ADDRESS: /`/*,a7ifij /€ i1, a OWNER NAME: CORPORATION NAME(IF APPLICABLE): Fps MANAGER'S NAME:Z.e.ilnls Ceitie&I ,e TEL.#: 77 =J-23,9? 3f- MAILING ADDRESS: 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 copy990 the certification to this form. 1. /V ,4 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. GSH�/ li.1711114A1.4 2. -PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. 1. Ilyth-e 'PzsynrodY0 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. V1i3 (J1 Y) U 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. Fs�tOo ze-0 t y 1. /1ni fi4/M// 2. 4Za-'011 3. / 4. 150 kA 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 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 MG, 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 servir !' t is �hibi ed. T PERMIT CAP tiff&,TOBACCO PRODUC A tobacco permit holder who has failed to renew his or her permit within thirty e previous year's permit expiration date is considered an expired license,and the tobacco license cap is reduced. The Commonwealth of Massachusetts (=«. °4 -,,,, ,�,,,, Department of Industrial Accidents 1L "1 ►.=,eissoor f Office of Investigations a. 1I 1 Congress Street,Suite 100 irz Boston,MA 02114-2017 • _ " www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: / ' i % y1 7 Address: (i0d3 aill'7 , Op" , 02z97 City/State/Zip: A fA__�._ Argif Phone #:`3 `5 ' 'WO - '/ Are you an employer?Check the appropriate box: Business Type(required): I.❑ 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• 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. 0 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: e 1),38 Insurer's Address: /► A , 7,_ ' City/State/Zip: jaIkl' L .,l / il Policy#or Self-ins.Lic.# 6y_Sffi2 0/6 " 5170sP92 -1 i Expiration Date: 5'— 2O 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 he ' �� ',ainsanalties of perjury that the information provided above ' true and correct. Sign. gor �� Date: 1/�� 9 Phone#: 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 VDAC C H U WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY TYPE AR INFORMATION PAGE WC 00 00 01 ( A) POLICY NUMBER: (6562UB-4705P92-8-19) RENEWAL OF (6562UB-4705P92-8-18) INSURER: ACE AMERICAN INSURANCE COMPANY 1. NCCI CO CODE: 12165 INSURED: PRODUCER: SONS OF ERIN CAPE COD INC BRYDEN & SULLIVAN INS PO BOX 403 PO BOX 1497 SOUTH YARMOUTH MA 02664 SOUTH DENNIS MA 02660 Insured is A CORPORATION Other work places and identification numbers are shown in the schedule(s) attached. 2. The policy period is from 08-02-19 to 08-02-20 12:01 A.M. at the insured's mailing address. 3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers Compensation Law of the state(s) 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: $ 100000 Each Accident 0••••••=eBodily Injury by Disease: $ 500000 Policy Limit Bodily Injury by Disease: $ 100000 Each Employee C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here: COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06B itimmmo D. This policy includes these endorsements and schedules: os SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE 0= 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. Ali required information is subject to verification and change by audit to be made ANNUALLY. DATE OF ISSUE: 07-18-19 WC ST ASSIGN: MA OFFICE: RMD CHUBB 24M PRODUCER: BRYDEN & SULLIVAN INS 75BKG 009183 C HUB B' WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY EXTENSION OF INFO PAGE-SCHEDULE WC 00 00 01 ( A) POLICY NUMBER: (6S62UB-4705P92-8-19) INSURER: ACE AMERICAN INSURANCE COMPANY 12165-MA INSURED'S NAME : SONS OF ERIN CAPE COD INC RATE BUREAU ID: 000101187 PREMIUM BASIS ESTIMATED RATES ESTIMATED TOTAL ANNUAL PER $100 OF ANNUAL CLASSIFICATION CODE REMUNERATION REMUNERATION PREMIUM LOCATION 001 01 FEIN ENTITY CD 001 SONS OF ERIN CAPE COD INC 633 ROUTE 28 WEST YARMOUTH, MA 02673 SIC CODE : 8641 NAICS: 813990 CLUB NOC & CLERICAL 9061 67228 .90 605 o MIMEO o= .950 MERIT RATING MODIFICATION (9885) $ 30 TOTAL ESTIMATED ANNUAL STANDARD PREMIUM 575 EXPENSE CONSTANT(0900) 250 0.0300 TERRORISM (9740) 20 3.83% MA WC SPECIAL FUND AND TRUST FUND 22 *.= TOTAL ESTIMATED PREMIUM 867 DEPOSIT AMOUNT DUE 867 DATE OF ISSUE: 07-18-19 WC ST ASSIGN: MA SCHEDULE NO: 1 OF LAST 009184 REINSTATEMENT NOTICE NAME AND. Hudson Excess Insurance Company KIND OF POLICY: ADDRESS 100 William Street Commercial Umbrella/Excess Liability OF INSURANCE POLICY/APPLICATION/BINDER NO.: HXS 1000579 02 Typist COMPANY New York NY 10038 DATE OF MAILING: 9/18/2019 NAME AND ADDRESS OF AGENT/BROKER: NAME AND. Sons of Erin Cape Cod Inc Quaker ADDRESS PO Box 403 120 Front Street,Suite 510 OF INSURED South Yarmouth MA 02664 Worcester MA 01608 The coverage provided by the policy number shown above and previously cancelled,nonrenewed or scheduled for termination is being reinstated effective 9/18/2019 at 12:01 AM standard time at the insureds mailing address. (DATE) (HOUR) AUTHORIZED REPRESENTATIVE NAME AND . ADDRESS OF ADDITIONAL INTEREST (E)GU 560a(Ed.8-03)UNIFORM INSURED'S COPY Page 1 of 1