Loading...
HomeMy WebLinkAboutApp-License-Certifications The Commonwealth of Massachusetts Fee Town of Yarmouth $165.00 Sun Tanning Establishments License Number: BOHST-21-2810-01 Issue Date: 1/1/2022 Mailing Address: Location Address: KERRIE KIRBY 23D WHITES PATH UNIT 19 ISLAND TAN & WELLNESS SOUTH YARMOUTH. MA 02664 23 WHITES PATH SUITE D SOUTH YARMOUTH, MA 02664 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 L, r Bruce G. Murphy, MPH, R.S., 10(/James G. Gardiner Health Director/Assistant Health Director dear /OZO, 1 .Y _ TOWN OF YARMOUTH Board of Health `,-- _` 1146 ROUTE 28, SOUTH YARMOUTH,MASSACHUSETTS 02664-2 451 27,__,±7s: == -.:,� :' Telephone(508)398-2231.ext. 1241 Health Fax(508)760-3472 DEC RiUi21 HEALTH DEPT. SUN TANNING ESTABLISHMENTS APPLICATION dFOR LICENSE/PERMIT-2022 Address:d3 At 1 S P z 1 SII e. D Sb 3Lh4YfT)o 001 , /0,4OoC9e0/ CA Coy;( KrrIc mQt . C6 & Telephone No.: . pj -.3C4 - J 7 / - E-mail Cape_ .1 Cod 3Ld�Ci �LALe1Od d.G Mailing Address (If different from above): 5So h1 t.. Vil L4,1(Owner/Corporation Name: 6,rrlC kr (bj 8 SdS 314-Li Telephone No.:c5l -5 '1l' £74-i Owner/Corporation Address:028 ()nth_ Bak /jog So DL/1 Ann is, Ina. O (6 Manager's Name: KLr-ri -e K u r bj /jog Telephone No. ► ^' g 4 4'q 7 GULL 77?� ' I � cc ���JJ���� c U1 Manager's Address:o? G�� L f)Li S (ill SSBI "! ,DeonlJ � CI' Or La o c.J 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 andlies must be paid prior to renewal or issuance of your permits. Please check appropriately if paid: yes no LICENSE/PERMIT REQUIRED: Fee: $55.00 per device z #OF TANNING BEDS: l #OF OTHER TANNING DEVICES J. TOTAL 3 TANNING DEVICE INFORMATION: Manufacturer Model Number Serial Number Type of Bulb _49,2_ 33-0011 ulo 11l- I! c k - s /.05 CIA3 uJo 1 i. too e- Ro at_ sag IGIAt CQ5o079a uJv ll: /1,0 /e4 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 requir d prior to reopening. DATE: is 11/ aOa I SIGNATURE: �� titAbd I I'05/2019 ` A�CO�® DATE(MM/OD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 12/30/2021 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 CONTACT NAME: tulle Lmscoli ALMEIDA& CARLSON INSURANCE AGENCY PHONE t (508)888-0207 A/CFAX No: E-MAIL ADDRESS: Jdriscoll almeidacarlson.com PO Box 554 INSURER(S)AFFORDING COVERAGE NAIC# FALMOUTH MA 02541 INSURER A: AIM MUTUAL INS CO 33758 INSURED INSURER B: KERRIE KIRBY INSURER C: ISLAND TAN & WELLNESS INSURERD: 23 WHITES PATH SUITE D INSURER E: SOUTH YARMOUTH MA 02664 INSURER F: COVERAGES CERTIFICATE NUMBER: 730199 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 LTR TYPE OF INSURANCE ADDLINSUBRwPOLICY NUMBER POLICY EFF POLICY EXP LIMITS __._.. IMM/DD/YYYY1�!(MM/OD/YYYYI COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE I I OCCUR PREM SESO(EaENTED occurrence) $ MED EXP(Any one person) _ $ N/A PERSONAL 8 ADV INJURY $ GE 'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ _ POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABIUTY COMBINED SINGLE LIMIT $ (Ea accident ANY AUTO - BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE HIRED AUTOS _ AUTOS (Per accident) UMBRELLA UAB OCCUR EACH OCCURRENCE EXCESS UAB CLAIMS-MADE N/A AGGREGATE $ I DED I RETENTION$ I $ WORKERS COMPENSATION I X STATUTEPER ETH AND EMPLOYERS'LIABILITY Y/N ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 A 1OFFICER/MEMBEREXCLUDED? N/A N/A N/A VWC10060240222021A 05/17/2021 05/17/2022 (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 00) � N/A DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement INC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.govilwd/workers-compensation/investigationst Sole proprietor has not elected coverage. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Kerrie Kirby ACCORDANCE WITH THE POLICY PROVISIONS. 23 Whites Path Suite D AUTHORIZED REPRESENTATIVE South Yarmouth MA 02664 Daniel t C t M.CroWFey,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 26(2014/01) The ACORD name and logo are registered marks of ACORD ISLATAN-02 JDRISCOLL ACORO CERTIFICATE OF LIABILITY INSURANCE BATE(MM,DD/YYYY) 12/30/2021 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 NAMECONTACT Almeida&Carlson Insurance Agency,Inc PHONEFAX PO Box 719 (A/C,No,Ext):(508)888-0207 (A/C,No):(508)888-0550 Sandwich,MA 02663 AQDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Western World Insurance Company INSURED INSURER B: Island Tan&Wellness 23 Whites Path INSURER C Suite D INSURER D: South Yarmouth,MA 02664 INSURER E: INSURER 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. INSR ADDL SUBR! POLICY EFF POUCY EXP LTR TYPE OF INSURANCE INSD WVD POUCY NUMBER (NIJJ9(DDIYYYYI (MM/DD/YYYYI LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE I $ 1,000,000 CLAIMS-MADE ( OCCUR TBD 1/2/2022 1/2/2023 DAMAGE TO RENTED 100,000 PREMISES(Ea occrrence) `$ _ MED EXP(Any one person) i $ 5,000 _ PERSONAL&ADV INJURY $ 1,000,000 GE 'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY JECT I I LOC Included PRODUCTS $ OTHER: $ ACOMBINED SINGLE LIMIT AU LIABILITY jE.a acddent) $ _ — ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE _ AUTOS ONLY _ AUTOS ONLY (Per accident) $ _ UMBRELLA LIAB — OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER 0TH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory m NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 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 Kerrie KirbyTHE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. A.Y HORLZED REPRESENTATIVE fritiDala ACORD 26(2016/03) ©1988-2016 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD BED CLEANING INSTRUCTIONS Thoroughly cover the bed acrylic with the disinfectant* spray and let sit. While waiting for the disinfectant to sit for a minute, spray the towel and wipe off the pillow, the bed handle, the top acrylic and the sides of the bed. Wipe down the chair and check the rest of the room for cleanliness including the floor, vacuum when necessary. When finished, thoroughly wipe down the bottom acrylic being sure to apply pressure and remove all the disinfectant spray from the bed (two or more towels may be necessary). Reset the timer, and wipe down the door handles for that room. Put a clean towel on the bed and place the "Sanitized" sign on top of the towel. Disinfectant Spray: Australian Gold pH Neutral Disinfectant Sanitizer Use 2 ounces per gallon of water ACTIVE INGREDIENTS: Didecyl dimethyl ammonium chloride 2.54% n-Alkyl (C14, 50%, C12, 40%, C16, 10%dimethyl benzyl ammonium chloride 1.69% INERT INGREDIENTS- 95.77% TOTAL- ..100.00% For use in tanning salons: A multi-purpose, neutral pH, germicidal detergent and deodorant effective in hard water up to 200 ppm (calculated as CaC)g) in the presence of a moderate amount of soil (9% organic serum) according to the AOAC. Use-dilution Test Desinfects, cleans and deodorizes in one labor-saving step. A.I.M.Mutual Insurance Company A.I <.A-M M ' r t t ' aMassachusetts Employers Insurance Company 1. LI U New Hampshire Employers Insurance Company Insurance Companies Associated Employers Insurance Company nce 1989 05/21/2019 E 2. 5 17 I v a KERRIE KIRBY. ISLAND TAN &WELLNESS 23 WHITES PATH SUITE D SOUTH YARMOUTH, MA 02664 WrOrkOn5 Corny 1 r15ura n e L Re: Workers Compensation Insurance 0331 11 Policy Number. VWC-100-6024022-2.8 " Policy Period: 05/17/2019 to 05/17/2020 Dear: KERRIE KIRBY Welcome to the A.I.M. Mutual Insurance Company. Your workers compensation policy with us is currently being processed, and your policy number is noted above. I am a member of the customer service team assigned to your policy. If you have any questions or requests, please feel free to call or email me. If you prefer, you may contact any of these areas directly. Certificates of Insurance Fax: 781-270-5690 Email: certificateregeust@aimmutual.com Phone: 781-270-8740 or 781-270-89:_'6 Premium Receivable Department Dawn Hurley: (781) 270-8724 Richard Federico, Supervisor 781-221-8638 Claim Online: www.aimmutual.com Phone: 866-270-3354 Fax: 781-270-5599 We look forward to being of service to you. Sincerely, 71 Ariana Yin (781)221-8618 ayin@aimmutual.com cc: Almeida &Carlson Insurance Agency PO Box 719 Sandwich, MA 02563 54 Third Avenue•P.O. Box 4070•Burlington, MA 01803-0970•Tel: 781.221.1600/800.876.2765• Fax:781.270.5599 CONNECTICUT • MAINE • MASSACHUSETTS • NEW HAMPSHIRE • VERMONT sponsored by Associated Industries of Massachusetts BOOTH CLEANING INSTRUCTIONS Spray a clean towel with the disinfectant* spray. Thoroughly wipe the door handle, the handles inside the booth and the floor of the booth, wipe down the chair and check the rest of the room for cleanliness including the floor, vacuum when necessary. Reset the timer, and wipe down the door handles for that room. Put a clean towel on the table. Disinfectant Spray: Australian Gold pH Neutral Disinfectant Sanitizer Use 2 ounces per gallon of water ACTIVE INGREDIENTS: Didecyl dimethyl ammonium chloride 2.54% n-Alkyl (C14, 50%, C12, 40%, C16, 10% dimethyl benzyl ammonium chloride 1.69% INERT INGREDIENTS- 95.77% TOTAL- ..100.00% For use in tanning salons: A multi-purpose, neutral pH, germicidal detergent and deodorant effective in hard water up to 200 ppm (calculated as CaC)g) in the presence of a moderate amount of soil (9% organic serum) according to the AOAC. Use-dilution Test Desinfects, cleans and deodorizes in one labor-saving step. The Commonwealth of Massachusetts Print Form Department of Industrial Accidents z7�= l Office of Investigations • _sa= 1 Congress Street,Suite 100 %!= Boston,MA 02114-2017 0 E C 3 0 2021 t"� www.mass.gov/dia =A LTH DEPT. Workers' Compensation Insurance Affidavit: General Businesses- Applicant Information Please Print Legibly Business/Organization Name: L et rick loll Address: t)J W/l t Le S Pa L / 5 of 1-e_ ✓ .30UL'1 )JaP'flR)J/ ') ' ne City/State/Zip: #: ��8- 3�y� y Are y an employer?Checlk,the appropriate box: Bus ss Type(required): 1.HO I am a e •Toyer with Employees(full and/ 5. Retail .* 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.❑Health Care 4.❑ We are a non-profit organization,staffed by volunteers, ht3n�/ )4S 1.1.0 TO Y1� with no employees. [No workers' comp. insurance req.] 12.0 Other / q " o, *Any applicant that checks box#1 must also fdl out the section below showing their workers'compensation policy infonnation. **1f 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 insurance for my employees. Below is the policy information. Insurance Company Name: irile_Ida La(L O Insurer's Address: �, 6. K. 1 I City/State/Zip: 5n rd uk(ki r a 001.56 3 Policy#or Self-ins. Lic.# \VJL 100(0()a)-1Oc oaO A Expiration Date: 5 i'Z a Attach a copy of the workers' compensation policy declaration page(showing the policy number nd ira ton 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'y,under the pai and pe allies of perjury that the information provided a ov�ejis rue and correct. las // Signature: Date: / Phone#: ,5-63 1' _�� , 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