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Home My WebLink AboutApp, License & Certifications Vi lI aSe G rePMote TOWN OF YARMOUTH BOARD OF HEALTH •:t g, APPLICATION FOR LiCENSE/PERMIT - 2021 * Please complete torn and attach all necessary documents by December 18, 2020. Failure to do so will result in the return of your application packet. ESTABLISHMENT NAME: V/ //6 � c-re eh /71 4:27el TAX ID: LOCATION ADDRESS: 37 ce .S/o(L v./hip d Sp pik,ieuX MAILING ADDRESS: S4 .e E-MALL ADDRESS: V gree /'1'1 7-e e./nevi A .0'177 .---_—_-- OWNER NAME: t4/#0-P, (And B 'y, /y �Ar CORPORATION NAME�aAPPLICABLE): / ./7477/3 MANAGER'S NAME: .` PV fr- Has/. TEL.#: 5�i ' �� 0 /`o ( MAILING ADDRESS:,.s'C(me dS a 'dye 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 fonll. (/ I D'/17GZ /I- A/ 2. //aWC 6s 7214 /74- 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. I. w(/i, m #a/-742. �L.)- VP/7y 'a'7 3. /QS. Ha P 4. V,,r-yS FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one hull-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' rct.urtls. You must provide new copies and maintain a file at your establishment. 1. JL\N a5 2021 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. 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. 3. 4. RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LODGING: • LICENSE REQUIRED FEE I'I:RMIT II LICENSE REQUIRED FEE PERMIT 11 LICENSE REQUIRED FEE PERMIT Ii B&B $55 ('ARIN 4:cc 1 r.A'Src1 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 't 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 I lotcl 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, shalt generally be considered Transient. POOLS POOL OPENING: All swimming, wading and whirlpools which have been closed for the season must he inspected by the I lealth 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 I lealth Department'three(3) clays prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven (7) clays of closing. FOOD SERVICE SEASONAL FOOD SERVICE OPENING: All food service establishments must be inspected by the Ilealth 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 I-lealth Department, or loom 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 1 Iealth 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 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. NOTICE: Permits run annually from January 1 to December 3 I. IT IS YOUR RESPONSIBILITY TO RETURN ......, ..r.. .r, r•mr r' n r xIr.ui A I A not IC`A mtr xiicA Nal r?r r i nn Fn FFFIC1 RV nFCFMRFR IR 7n71). The Commonwealth of Massachusetts Fee Town of Yarmouth $110.00 Lodging License Number: BOHL-14-0425-07 Issue Date: 1/1/2021 Mailing Address: Location Address: PMB INC. 33 &37 SEASIDE VILLAGE RD VILLAGE GREEN MOTEL SOUTH YARMOUTH, MA 02664 37 SEASIDE VILLAGE ROAD SOUTH YARMOUTH, MA 02664 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 UNITS-46; BEDROOMS-46 Board Hillard Boskey,M.D.,Chairman Mary Craig, Vice Chairman of Charles T.Holway, Clerk Debra Bruinooge Health Eric Weston 4IPJ i Bruce G. Murphy,MP ,R.S.,C /1 / llory R. Langler,R.S. Health Director/Assist.nt Health Director The Commonwealth of Massachusetts Fee Town of Yarmouth $35.00 Food Establishment License Number: BOHF-14-0432-07 Issue Date: 1/1/2021 Mailing Address: Location Address: PMB INC. 33 &37 SEASIDE VILLAGE RD VILLAGE GREEN MOTEL SOUTH YARMOUTH, MA 02664 37 SEASIDE VILLAGE ROAD SOUTH YARMOUTH, MA 02664 IS HEREBY GRANTED A 2021 LICENSE TO OPERATE: Continental Breakfast; 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. Board Hillard Boskey,M.D.,Chairman Mary Craig, Vice Chairman of Charles T. Holway,Clerk Debra Bruinooge Health Eric Weston ruc-G. Murphy, M'H,R.S., C O/Mallory R.Langler,R.S. Health Director/Assistant Health Director The Commonwealth of Massachusetts Fee Town of Yarmouth $110.00 Swimming Pool Operations License - Number: BOHSP-14-0431-06 Issue Date: 1/1/2021 Mailing Address: Location Address: PMB INC. 33 &37 SEASIDE VILLAGE RD VILLAGE GREEN MOTEL SOUTH YARMOUTH. MA 02664 37 SEASIDE VILLAGE ROAD SOUTH YARMOUTH, MA 02664 IS HEREBY GRANTED A 2021 LICENSE 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 OUTDOOR SWIMMING POOL Board Hillard Boskey,M.D.,Chairman Mary Craig, Vice Chairman of Charles T. Holway, Clerk Debra Bruinooge Health Eric Weston . 4 ruce G. Murp•y,MPH,R..., ' O/Mallory R. Langler,R.S. Health Director/Assistant Health Director The Commonwealth of Massachusetts --— Department of Industrial Accidents Office of Investigations e —=inL1= v 1 Congress Street, Suite 100 ==1j=, Boston, MA 02114-2017 '=►-��'� www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: p/2/8,277e d64- 1/I//die 0 /e-"e(2-27 • Address: a i % , /l ie - i► City/State/Zip' o I t/W 1 % / d,A 'hone #: 6---0? Y60 `c,2o� Are you an employer? Check the appropriate box: Business Type (required): 1.( ' l am a employer with 7 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. 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 10.0 Manufacturing no employees. [No workers' comp. insurance required]* 11.0 Health Care 4.fl We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] l 2. o�Other 11-707-11 `Any applicant that checks box 4'1 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 41. I am an employer that is providing workers' compensation�ioinsurance for my employees. Belowois the policy information. (s� Insurance Company Name: Wes/ eae-G' �/ /'I5. �D T)(`°kkck,ke ',%' tclaz/ L°(.ta' i 7{15 Insurer's Address: Pi-7 ax 7 (',.53-7 0 City/State/Zip: 'A// .Je o/7,a P1 /7/7V'' __576-9z, Policy # or Self-ins. Lic. # 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 cert, under the pains and penalties of perjury that the information provided above is true and correct. Signature( . ' - �' / - Date: _ .1z)v2Gr Phone #: 56-)e-' r 02- 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 4: I Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the' receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However, the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL--chapter 152, §25C(7)states "Neither the commonwealth nor any of its political subdivisions shall enter into any contact for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply your insurance company's name, address and phone number along with a certificate of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license_ap_plicationsinany given year, need only submit-one affidavit indicating current policy information(if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture(i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 www.mass.gov/dia Form Revised 7/2010 7'/4 /fit) (74", c� �' Bill To: r� �C f/ / Inc 14'�;�Berkshire Hathaway P. O. 39 fe�e, 1.z4 - Sr 4+. ^ outh Yarmouth, MA 02664 bids C C-)�! l Al Insurance Companies._�� !� � \ �v ` " 1 Customer ID: 709 ` ' -1"/'4// . ___ 1r 1 Workers' Compensation Insurance Premium Bill For Policy Number PMWC147418 as of 5/25/2020 Policy Cost: $ 1,617.00 Policy Period: 06/29/2020 - 06/29/2021 Billing Fees: $ 0.00 Carrier: NorGUARD Insurance Company Total Payments: $ 0.00 Agent: SYLVIA &COMPANY INSURANC Account Balance: $ 1,617.00 508-995-4553 Policy Premium - Down Payment $ 323.40 AMOUNT DUE 06/28/2020 $ 323.40 The down payment for your renewal policy is required by the due date shown for uninterrupted coverage to continue If not received, this policy will be canceled in accordance with state law. Payment Terms: 20% Down Payment, 9 Monthly Installment(s) ► Please see Important Messages on the back of this bill. 1 Make your check payable to WestGUARD Insurance Company and remit with the coupon below. Due Date: 06/28/2020 1,1 kVir' Account Number: 16132303147418 Berkshire Hathaway Current Amount Due: $ 323.40 fti$ ARD Insurance Total Amount Due: $ 323.40 Companies Amount Enclosed P M B Inc IllsIlllllllull„IIIIIIII,,PIIUI,IIIII'illlllllll,llllllll,l,) P. O. Box 39 WestGUARD Insurance Company South Yarmouth, MA 02664 PO BOX 785570 PHILADELPHIA, PA 19178-5570 Policy Number: PMWC147418 Customer ID: 709034 06282020 161323031474183 000323400 000323400 4 5-. SL m .0. m o• C c m 0 n tfl n ,.co O n =a. C m a O co f' fIflE CT 10 -• 0, 0_ co g m E., ..,,, 7z) m is0 5- _ 3 @ e, ..< ,c, -A a 1;12 v n a'i 9 3 a Scu 3 aCII 9 o m o = H 01 z- ° h m " N a N m -• CD C n n, n O n °. ci, o CD 2 ril --7., aQch N 7 rn c C II.<=; o 3 n T n fl- _ O O O o 1'n n m „ o a " a. m, co "4 N W mi o.�� C C r) A 3 - 7j II ec a N �/ W n 111) n a 9 W 4 o. 3 - N 7 3 (D �F ri- c `0nO' O -+_ � � Xi � � � m a. 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VION.,0-,...7- 0t7:- .L7 -' ,, Ik .7. - • ..*.!:,-.. ..z , z--_-,...^ .,_ __-_, ....,,..k,,-- ,.?- ...!..'',OPIIM,;:r...4.04/44.14/w.4 ;40,.:„ , `J 0 cy 2 D � j Do oIIIP • m3111111 111 M v l¢ \ Ji 0 11 sp m 0 0 o rt o my — m n m41) 0 w 0RI co x rt a 0 v -CI ,0 n HI ,.)TJ 0 to rt n♦ a c. y Q `° D =am X . z � D 0 11aQ00 Q N N rtC CO ¢tte mew ID \ / A" ie D10 rt ,,:,44-4,-.4•!,-i'.Z.1F ( O T aO �k �. n =m a rv m + O c„ n w a) -: ,-,_ ‹. 0 ,i, U 10, ^ o PP -0 si) i "k —I o -0 lDno e x ") 5 n o m = c � XIMP ›. o w ?":1,ET S O C7 o D CD m 10 PMB INCORPORATED DBA I Account#0094 1843 0578 I January 1,2021 to January 31,2021 Service fees The Monthly Fee on your Business Advantage Checking account was waived for the statement period ending 12/31/20.A check mark below indicates the requirement(s)you have met to qualify for the Monthly Fee waiver on the account. O $2,500+ in new net purchases on a linked Business credit card $15,000+average monthly balance in primary checking account • $35,000+combined average monthly balance in linked business accounts • active use of Bank of America Merchant Services active use of Payroll Services • enrolled in Preferred Rewards for Business For information on how to open a new product,link an existing service to your account,or about Preferred Rewards for Business please call 1.888.BUSINESS or visit bankofamerica.com/smallbusiness. Page 6 of 10