HomeMy WebLinkAboutApp, WC & License The Commonwealth of Massachusetts Fee
Town of Yarmouth $110.00
Lodging License
Number: BOHL-15-1735-06 Issue Date: 1/1/2021
Mailing Address: Location Address:
PARKERS RIVER RESORT LLC 759 ROUTE 28
PARKERS RIVER RESORT WEST YARMOUTH. MA 02673
P.O. BOX 445
WEST YARMOUTH, MA 02673
IS HEREBY GRANTED A 2021 LICENSE
TO OPERATE:
Motel
This license is granted in conformity with the statutes and ordinances relating thereto,
and expires December 31, 2021 unless sooner suspended or revoked and is not
transferable.
Conditions
*24 UNITS; 24 BEDROOMS. I MANAGER UNIT- 2 BEDROOMS.
Board Hillard Boskey, M.D.,Chairman
Mary Craig, Vice Chairman
of Charles T. Holway, Clerk
Debra Bruinooge
Health Eric Weston
it •
4 OF
Bruce G. Murphy,MPH,R.S.,f'HO/My'ory R. Langler, R.S.
Health Director/As istant faith Director
Car Kers Le-t '?? c,,,e-
`oF.... TOWN OF YARMOUTH BOARD OF HEALTHr-E11\
APPLICATION FOR LICENSE/PERMIT - 2021
* Please complete form and attach all necessary documents by Decenr Per t' Q02f? 2020
Failure to do so will result in the return of your application pack- .
HEALTH DEPT.
ESTABLISHMENT NAME: A-(LY-- 2_4 1 � sosrt- LLC TAX ID: -
LOCATION ADDRESS: �,: ��� )n1 S Z9 TEL.#: $i `i 's s,,/
MAILING ADDRESS: `VO F70 X 4 Vd • (L. t' 1
E-MAIL ADDRESS: r,; E � L '_( L, -*ILA AP II
OWNER NAME: r'P, (LlCJ1'.—,w4Y-1,w z7ct.cistlwi (--'��`PsaNI 1e.
CORPORATION NAME (IF APPLICABLE): g.S-14. R` Q-}'
MANAGER'S NAME: � 1.. � ..„4 I•1141Q. Pr$'t = EL.#: i 'i
MAILING ADDRESS: b Ifox 4E \49 , yocc24126 t\" IN/1A— c Zb
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. Nf 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. DEU i 5 2020
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. PC 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.
I. Iv i 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. NK 2.
3. 4.
RESTAURANT SEATING: TOTAL#
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# L CENSE REQUIRED FEE PERMIT#
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The Commonwealth of Massachusetts
Department of Industrial Accidents
_t—
=-1-7-'3' l Office of Investigations
41= p 1 Congress Street, Suite 100
• Tax•�—
-- Boston, MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name: -120-0, 12.,--,
Address: ' N sr --\z*„ „oA mi-a24,10
City/State/Zip: ► rD '`-)-- Phone #: �� �)
Are y an employer? Check the appropriate box: Business Type(required):
1. I LTAj I am a employer with b 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.ROther
*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: N ),L Q _L l 10,4- J rSv(t (f
Insurer's Address: A
City/State/Zip: 1%G- 1 O'
Policy # or Self-ins. Lic. # W V 1 \ ` ‘-1 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.
I do hereby certi* der the 'ns and lties perjury that the information provided� above is true and correct.
Si ature: 411 �AL, Date: .Z- r ) z )
Phone#: � -7{V L%0e6
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.eov/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
Account No:
{ FEIN: 26-1913272
ITEM 1. NAMED INSURED AND MAILING ADDRESS: AGENT NAME AND ADDRESS:
PARKERS RIVER RESORT LLC ROGERSGRAY, INC. SOUTH
759 MAIN STREET DENNIS OFFICE
SOUTH YARMOUTH, MA 02664 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: 05/18/2020 To: 05/18/2021
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: ANNuAL Additional/Return Premium:
Comments :
Issued At:
Date: 04/08/2020 Countersigned by
WC 00 00 01 A Copyright 1987 National Council on Compensation insurance
INSURED COPY