HomeMy WebLinkAboutApplication and WC ,*17" - ., a /5 121
TOWN OF YARMOUTH BOARD OF HEA TH c(�
APPLICATION FOR LICENSE/PERMIT- 020N u v
* Please complete form and attach all necessary docum nts gl.de P 1 '01' ..
Failure to do so will result in the return of your ap i ' • e n pac e .
NOTE:ALL BUSINESSES WITH LIOUOR LICENSES MUST RETURN FORMS BY NOVEMBER 1.0.
ESTABLISHMENT NAME: 12#0124VS(72~ TAX ID:
LOCATION ADDRESS: '1S S its ` vt9 S' oo4 TEL.#: 5'oS 3q$ 2.880
MAILING ADDRESS: -76150)( 4't SIr(tmoti *( y a 2/073
E-MAIL ADDRESS: tjc-rvv_SlaNitJL f 4- aim okstrs OST—
OWNER
JCTOWNER NAME: 1:)I t_lciC-.- Mk0 ( c cl�wly s"�tia4A
CORPORATION NAME(IF APPLICABLE):"!aidadiS1 -nis P-V4sor I..V�
MANAGER'S NAME: 1240k \ot ;CY>grv-Gtt_ TEL.#:5Q839$'L4880
MAILING ADDRESS: `159 h U& Sfil'R-� ' r �i• {�pMMor 02&o4
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. 1-4:101•) 9Vi1.10 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
yearsrecords. You must provide new copies and maintain a file at your place of business.
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1. FA 1 N`U� 2. c�az7olJ arD
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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. w 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. N1'q 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. NPi 2.
3. 4.
RESTAURANT SEATING: TOTAL#
LODGING: OFFICE USE ONLY b5w.-ts--t'3
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT
B&B $55 CABIN $55 MOTEL $110 c,70-0c)-d.
INN $55 CAMP SWIMMING POOL$110ea.
LODGE $55 TRAILER PARK $105 WHIRLPOOL $110ea
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
0-100 SEATS $125 00 SEATS $200 —CONTINENTAL $35 NON-PROFIT $30
_COMMON VIC. $60 WHOLESALE $80
RETAIL SERVICE: —RESID.KITCHEN $80
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 _ $ p?p9-0.0 a
*****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 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.
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 13,2019.
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 :(&k( dç'UJ,4J QUIRE A SITE AN.
DATE: u0O (17 ��a SIGNATURE: ,,,,
PRINT NAME&TITLE: P rVU 14-0 &Ui
Rev.10/15/19
The Commonwealth of Massachusetts
Department of Industrial Accidents
t.__:%....—. ..._ l Office of Investigations
--a-77:411=-7-., _. 1 Congress Street, Suite 100
ii4 =irr=
., : Boston, MA 02114-2017
"-t.y1,, www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name: 1%14124U.C---'
Address: 1 a "��'�¢j
City/State/Zip: � V� V vY10tilik Phone : 508 ,;cleseeo
Are you an employer?Check the appropriate box: Business Type(required):
1.❑ I am a employer with ?j employees(full and/ 5. 0 Retail
or part-time).* 6. 0 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. ❑ Nop-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.] I2.�ther YY1v
*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'coensation insurance for my employees. Below is the policy information.
Insurance Company Name: 1 V�. , 1t}}til�,
Insurer's Address: /IA, AteiV5 '
City/State/Zip: INMD4Prin l) 62-0
Policy#or Self-ins.Lic. # V1‘ l k A S B 5 k Expiration Date: cam? 1t® '2,41 7-0
Attach a copy of the workers' compensation policy declaration page(showing the policy number and a piration 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 ,und
er the ains d pen ties of perjury that the information provided above is true and correct.
Signature: , Date: NOU Co 9,42-19
Phone#: --IriLk. 421 62,-21)
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
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EM PLOYEES _ EM PLOY EES
The Commonwealth of Massachusetts
DEPARTMENT OF INDUSTRIAL ACCIDENTS
600 Washington Street, Boston, Massachusetts 02111
617-727-4900 - http://www.mass.gov/dia
As required by Massachusetts General Law,Chapter 152, Sections 21,22 &30,this will give you notice
that I(we)have provided for payment to our injured employees under the above-mentioned chapter by
insuring with:
NORFOLK & DEDHAM MUTUAL FIRE INSURANCE COMPANY
NAME OF INSURANCE COMPANY
222 AMES STREET, DEDHAM, MA 02026
ADDRESS OF INSUANCE COMPANY
WE114835A 05/18/2019
POLICY NUMBER EFFECTIVE DATES
ROGERS & GRAY INS. AGENCY, /NC DEENNIIS,MMA 02660 $
SOUTH DENNIS OFFICE
NAME OF INSURANCE AGENT ADDRESS PHONE#
PARKERS RIVER RESORT LLC SOODUTHHY59 ARMOUTH MA 02664 508-775-0280
EMPLOYER ADDRESS
04/08/2019
EMPLOYER'S WORKERS'COMPENSATION OFFICER(IF ANY) DATE
MBDICALTFEATMENT
The above named insurer is required in cases of personal injuries arising out of and in the course of
employment to furnish adequate and reasonable hospital and medical services in accordance with the
provisions of the Workers'Compensation Act. A copy of the First Report of Injury must be given to the
injured employee. The employee may select his or her own physician. The reasonable cost of the ser-
vices provided by the treating physician will be paid by the insurer,if the treatment is necessary and
reasonably connected to the work related injury. In cases requiring hospital attention,employees are
hereby notified that the insurer has arranged for such attention at the
NAME OF HOSPITAL ADDRESS
TO BE POSTED BY EMPLOYER
Form WC 88 20 01 C Printed in U.S.A.
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
IRE Account No:
FEIN:
ttt
ITEM 1. NAMED INSURED AND MAILING ADDRESS: AGENT NAME AND ADDRESS:
PARKERS RIVER RESORT LLC ROGERS & GRAY INS.
759 MAIN STREET AGENCY, 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: 05/18/2019 To: 05/18/2020
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 3.A. 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: $ 231 Annual Premium: $ 549
Audit Period: SAL Additional/Return Premium:
Comments
Issued At:
Date: 04/08/2019 Countersigned by
WC 00 00 01 A Copyright 1987 National Council on Compensation Insurance
INSURED COPY