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� '311 PIVOH IU11O}AI IVA,IO MMOI
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 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 inspectionthree (3) days prior to
inspected PLEASE NOTE:People are NOT allowed to sit in the pool area until the pool has been 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 wwwyarmauth.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].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 REQUIRE A SI I'E PLAN.
DATE: 17-I VI 11 SIGNATURE:
PRINT NAME& TITLE: ?Mat f U\11(MEN
Rev.10/15/19
The Commonwealth of Massachusetts
Aft z
e- Department of Industrial Accidents
� Office of Investigations
,.. 1 Congress Street,Suite 100
Boston,MA 02114-2017 •
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name: b ASS L fi�\RI JUISI N E
Address: �4 BOUT 2
City/State/Zip: ESC N cK "OUTh1 k P. DZ.b 3Phone#: 0 1a 51
Are you an employer?Check the appropriate box: Business Type(required):
1.2!I am a employer with 2. 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. ❑ Office and/or Sales(incl.real estate,auto,etc.)
employees working for me in any capacity.
[No workers' comp. insurance required] 8. 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]**
4.ElWe are a non-profit organization,staffed by volunteers, 11.❑Health Care
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 or my emplo ees. Below is the policy information.
nn
Insurance Company Name: K.T. R M V T U M_ I N\S U tSMN CE u OW-1\1\1\1
Insurer's Address: 5-4 -1-Rano MalU
City/State/Zip: M M_I N 61 Ott M •01%O 3
`r q
Policy#or Self-ins.Lic.# V� C10 0—�0�44 20 O1"I
Expiration Date: 111 51 I 20 2
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,under the pains and penalties of perjury that the information provided above is true and correct.
Signature: / — S` Date: 121 O t 126 qt01 .
Phone#: 5 b t — U ' Boo
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
4+c CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY)
11/04/2019
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND, OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to
the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER 01720-001 NAmEACT Branch 1720-1
Kerry Insurance Agency Inc (A/CNN. A (508)255-8000
PO Box 1945 MAIL (A1C Na (508)240-1860
N.Eastham,MA 02651ADDRESS:
INS RER(S)_A-FFORDING COV.ERAG€......_-----._.........._.---.__..._._ NAIC# _......_..
INSURER A A.I.M.Mutual Insurance Company 33758
{ INSURED INSURERB
Pracha Somkitcharoen
Basil Thai Cuisine ..INSURIR.0_
594 Main Street
West Yarmouth, MA 02673 INSURER D......__....--___..........._.
{
INSURER E-...._____
JNSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
IN — E.. -- — ADDL SUER — — POLICY EFF POLICY EXP
TYPE OF INSURANCE NSR WVD POLICY NUMBER jMM'o LIMITS
GENERAL LIABILITY � �'�'YI (MM/DDIYYYY�
_--.. EACH OCCURRENCE $
COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED
.CLAIMS- OCCUR
_... _.....ES LEaoccurrences
MADE ( ,
MED EXP(Any one person) $
PERSONAL&ADV INJURY $
GENERAL AGGREGATE $
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $
O
OLICY ECT....
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
(Ea accident)
ANY AUTO BODILY INJURY(Per person) $
ALL OWNED I SCHEDULED -
AUTOS AUTOS BODILY INJURY(Per accident)
$
HIRED AUTOS NON-OWNED PROPERTY DAMAGE
....__.._ AUTOS /Per accident)..... $
$
UMBRELLA LIAB OCCUR EACH OCCURRENCE J$
EXCESS LIAB CLAIMS MADE AGGREGATE $
DED 1 RETENTION $
I�IIE �SOC�E(P �dNWE WC SLIMIT OTH-
L LABILITY X TORY LIMITS I ER
ANY RSP ETpR Y/N
A AOFFICER/M�IMBER/P CC�NERI CECUTIVE y NIA VWC-100-6024120-2019A 7/31/2019 7/31/2020 E.L.EACH ACCIDENT $ 100,000.00
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000.00
If es describe nder -- --
DEYSORIPTION�F OPERATIONS belowE.L.DISEASE-POLICY LIMIT $ 500 0(10.00
i
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required)
* proof of coverage
The workers compensation policy does not provide coverage for Pracha Somkitcharoen
CERTIFICATE HOLDER CANCELLATION
Pracha Somkitcharoen
Basil Thai Cuisine SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
594 Main St THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
West Yarmouth,MA 02673 ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
OO 1988-2010 ACORD CORPORATION.All rights reserved.
ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD