Loading...
HomeMy WebLinkAboutApp-License-Certifications The Commonwealth of Massachusetts Fee Town of Yarmouth $165.00 Sun Tanning Establishments License Number: BOHST-19-2186-02 Issue Date: 1/1/2022 Mailing Address: Location Address: CORE FITNESS OF SOUTH YARMOUTH 7 LONG POND DR PLANET FITNESS SOUTH YARMOUTH, MA 02664 166 GROVE STREET FRANKLIN, MA 02033 IS HEREBY GRANTED A 2022 LICENSE This license is granted in conformity with the statutes and ordinances relating thereto, and expires December 31, 2022 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 Bruce G. Murphy, M , R. ., CHO Health Director The Commonwealth of Massachusetts Fee Town of Yarmouth $165.00 Sun Tanning Establishments License Number: BOHST-19-2186-01 Issue Date: 1/1/2021 Mailing Address: Location Address: CORE FITNESS OF SOUTH YARMOUTH 7 LONG POND DR PLANET FITNESS SOUTH YARMOUTH, MA 02664 166 GROVE STREET FRANKLIN, MA 02033 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. Board Hillard Boskey, M.D.,Chairman Mary Craig, Vice Chairman of Charles T. Holway, Clerk Debra Bruinooge Health Eric Weston ;� c -7 I-I t �' Bruce G. Murphy, 4PH, R.S., CHO Health Director ,,,, °F.....r,9 TOWN OF YARMOUTH Board of Sp.. � ■�, Health --ilk __ ,..-44-46 ''OUTE 28, SOUTH YARMOUTH, MASSACHUSETTS 02664-24451 YATTACMEESE Health " __�' Telephone(508)398-2231,ext. 1241 Fax(508)760-3472 Division „i-,G P':r\-TH DEPT: ' SICAT O "FOR LCENSE/PERMITS 2021 Name of Establishment: MIN If Tax ID (FEIN or SSN): g a 414-e 114 Address: I i 1..01 Ted 'N.V.( Telephone No.:5 r 1100 r DD E-mail• 'l-44 1 r l-- �1ri'k. L Mailing Address (If different from ab ve) mcl-C�l ,G\jvrbVIA 63Owner/Corporation Name: r { r Telephone No.13-S Owner/Corporation Address: Pot(1-11-, 11 Y Dab 3 5 Manager's Name: 1:11/1")191 i ( i16?.b Telephone No.: 1+01-53 6-(8 Manager's Address r1 ios14 t l.L t_71— Z 1. -k b2-4515 Under Chapter 152, Sec. 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. Town of Yarmouth taxes andli must be paid prior to renewal or issuance of your permits. Please check appropriately if paid: yes V no LICENSE/PERMIT REQUIRED: Fee: $55.00 per device #OF TANNING BEDS: I #OF OTHER TANNING DEVICES TOTAL 3 TANNING DEVICE INFORMATION: Manufacturer Model Number Serial Number Type of Bulb CM, L-A1(11.Ul) Notice: PERMITS RUN ANNUALLY from January 1 to December 31. It is your responsibility to return the completed application(s)and required fee(s)by December 31. Failure to do so will result in closure of your establishment until the required application(s)and fee(s)are received. A hearing before the Board of Health may be required prior to reopening. DATE: 04 I O(t,11 SIGNATURE. S c.,.. , 11/05/2019 /s °f- -, TOWN OF YARMOUTH Board of Health t _i 1146 ROUTE 28, SOUTH YARMOUTH, MASSACHUSETTS 02664-24451 11ATTACNEESE Health %am0 e Telephone(508)398-2231, ext. 1241 Division:_' � Fax(508)760-3472 X1 ' � NOP SUN TANNING ESTABLISHMENTS Nps\-_ AP.f ICATIO FOR LICENSE/PERMIT -gal Dc -e— Na of Establishment: G Ile,- hilcss Tax ID (FEIN or SSN); a-41 GICe 114 q Address: I 1 1ohi 'TA d Dv' ' Telephone No.:50 -1190 -Do E-mail• 1 P-14 Ie-t� Jt4e/AT`-" " . �'ory- Mailing Address (If different from ab ve)a '.1-11/Yl nl(L' -5°z- ,6bv(1)V A b n _ Owner/Corporation Name:S Q Telephone N o.: ! `� -5 3- `157q � � ant- Owner/Corporation Address: 5 G-0)35/1 irt, Y � 0 az . Manager's Name: P(01 7l ti1O Z,b Telephone No.: 70/53 6--18- 3 Manager's Address 1-)rtffl lac,in k_(L L4 4 '3')L fb'4-10O(i i \-A_ b-3$ Under Chapter 152, Sec. 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. Town of Yarmouth taxes and li9es must be paid prior to renewal or issuance of your permits. Please check appropriately if paid: yes V no LICENSE/PERMIT REQUIRED: Fee: $55.00 per device #OF TANNING BEDS: I #OF OTHER TANNING DEVICES" TOTAL :-.-- TANNING -�TANNING DEVICE INFORMATION: Manufacturer Model Number Serial Number Type of Bulb 6e€, ck-)t[,.06 Notice: PERMITS RUN ANNUALLY from January 1 to December 31. It is your responsibility to return the completed application(s)and required fee(s)by December 31. Failure to do so will result in closure of your establishment until the required application(s)and fee(s)are received. A hearing before the Board of Health may be required prior to reopening. DATE: 0— I( I a 1 SIGNATUREq s c..,..___._____. 11/05/2019 DEC 1 3 2021 DEQ HEALTH HEALTH L` Manufacturer - JK Light, 41 West Washington Ave, Suite 8,Jonesboro AR 72401 Model Serial Number Type Install Date ERGOLINE PASSION 40/3 1362664 BED 12/28/2018 ERGOLINE SUNRISE 480 1368762 BOOTH 12/28/2018 ERGOLINE SUNRISE 480 1368766 BOOTH 12/28/2018 Bulb: PASSION 40/3 : (16) 120W (CANOPI' TOP) & (24) 160W (BENCH / BOTTOM), (2) 15w, (3) 520w Sunrise 480: (48) 200W LAMPS ARD ® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD1WY) 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 have ADDITIONAL INSURED provisions or 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 __ .. CONTACT HAUSER _ NAME: Jenn Garibay 5905 E.Galbraith Rd, Ste 9000 (Ac°.No. Ext): 513-745-9200 FAX No):513-745-9219 Cincinnati OH 45236 AAIL DDRESS: jgaribay@thehausergroup.com C 1 n r O?1 INSURER(S)AFFORDING COVERAGE NAIL# DE INSURER A:Acadia Insurance Company 31325 INSURED PT PLANFIT-07 INSURERS:Union Insurance Company 25844 CDM Fitness Holdings, LLC • L-' DEP 2 Hampshire Street H� INSURER c:Liberty Insurance Corporation 42404 Foxboro MA 02035-3171 �_ INSURERD:Fireman"s Fund Insurance Co 21873 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:434762143 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. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DDIYYYY) A X COMMERCIAL GENERAL LIABILITY Y CPA5468537 2/3/2021 2/3/2022 EACH OCCURRENCE $1,000,000 CLAIMS-MADE X OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $1,000,000 _ MED EXP(Any one person) _ $5,000 PERSONAL&ADV INJURY $1,000,000 _ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO LOC PRODUCTS-COMP/OP AGG $3,000,000 X JECT OTHER: $ B AUTOMOBILE LIABILITY Y MAA5468538 2/3/2021 2/3/2022 COMBINED SINGLE LIMIT $1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED x SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS X HIRED X NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) $ A X UMBRELLA LIAB X OCCUR Y CUA5468539 2/3/2021 2/3/2022 EACH OCCURRENCE $5,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $5,000,000 _ DED RETENTION$ $ C WORKERS COMPENSATION WC5-Z91-472621-041 2/3/2021 2/3/2022 X PER ERH- AND EMPLOYERS'LIABILITY YIN STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 0 Excess Liability Y USL002648202 10/21/2020 10/21/2021 OCCURRENCE 5,000,000 AGGREGATE 5,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Information Only AUTHORIZEDREPRESENTATIVEn 9.At ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts ----- Department of Industrial Accidents 1',ti . Office of Investigations 02 _roil�...... 1 Congress Street,Suite 100 =', ,'� - Boston, MA 02114-2017 H-r,LTH DEPT www.mass.gov/dia 1 Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Oran' : 'on Name: - Address. , I �� o Jr ) t r , OA, City/State/Zip , a.(fli(j>L. Phone #: -�(/ ( Q 0Are you an employer. eck the a propriate box: Business Type(required): 1.0 I am a employer with I employees(full and/ 5. 0 Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2.❑ 1 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] $• ❑ Nor-pro.it 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]** 11.0Health Ca 4.❑ We are a non-profit organization,staffed by volunteers, Cer4e& with no employees. [No workers' comp. insurance req.] 12.IK Other ✓rit 4 *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 fomy employees. Below is the policy information. Insurance Company Name: Li k t_2; "1,30/An t e Insurer's Address: '15 &( 64._ SJ- Ci /State/Zi : 419'1 Gam- J..� 1 ty p k> Policy#or Self-ins. Lic. # )3C 5- lot 1 -'AID LJ .4-.)14) Expiration Date: ) I 3 /ay 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 hi 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 r nder the pains and.penalties of perjury that the information provided above is true and correct. Si at I I _ !h.1 Date: OA I p Phone#: �7 8 ) '0 El b L 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