HomeMy WebLinkAbout2025-260 D
(,/t't
HEAr .].H
D
rru.=
2025
El)?
I.,ICENSE
FEE: S I 50.00
TO\!N oF YARI}IOTITH BOARD OF HEALTH
202512026 HANDLING AND STORAGE OF TOXIC OR HAZARDOUS MATERIALS
LICENSE APPLICATION
PLEASE COMPLETE THIS APPI,ICATIoN AND RETURN IT WITH THE LICENSE FEE BY
JUN E t0, 2025
PLEASE COMPLETE ALL QUESTIONS
NAME oF BUStNEss CaPe Shore lnn BUSINESS 1 6;_. 6 508-694-7969
BUSTNESS ADDRESS tN yARMOU1H 793 MA-28, South Yarmouth, MA 02664
MATLING ADDRESS 793 MA-28, South Yarmouth, MA 02664
€s 0I ' r!lt(vlYllrL
EMATL ADDRESS capeshoreinn ma@gma il. com
REOu!EED MANAGER/CONraCt pEpSON Shyam Patel
TELEPHONE t 77 4-5s2-86s2
REQUIRT]D OWNER NAMI., RiNA PATEI
HOME ADDRESS 793 MA-28, South Yarmouth, MA 02664
1E1-.s 603$7 4-2317
CORPORAI lON NAMt, (lF APPI.ICABLU) Blue Bird Hospitality Corp
CORp9RATTON 4ppqFss 793 MA-28, South Yarmouth, MA 02664
MATLINC Aoonrss 793 MA-28, South Yarmouth, MA 02664
1p1 a 508-694-7969
rAx ID (FEIN oR ssN) REQLiIREI) 85-2598803
LICENSES RUN ANNUAT-I-Y FROM JUI,Y I TO JUNE 30. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S) BY JUNE 30. FAILURE TO DOSO WILL
RESULT IN CLOSURE OF YOUR ESTABLISHMENT UNTIL THE REQUIRED APPLICATIONS(S) AND
FEE(S) ARE RECEIVED. A HEARINC BEFORE THE BOARD OF HEALTH MAY BE REQUIRED PRIOR
TO REOPENING.
Town of Yarmouth taxes and liens mrrst be paid prior to renewal or issuance of your permits. Please check
appropriately ifpaid: yes 7 no n a_
Under Chapter 152, Sec. 25C. subsection 6. the Town of Yarmouth is required to hold issuance or renewal of any
license or permit to operale a business ifa person or company does not have a Certification of Workers Compensation
insurance. As part ofrenewal or issuance ofyour permils, you must complete the enclosed Workers Compensation
Arlidavit. lfnot applicable, please explain:
REGISTRATION FORM SIGNED AND COMPLETED
CHECK AND WORKERS COMP AFFIDAVIT ENCLOSED
ALL SAFE'I'Y DATA SIIEI]TS ON FILE
Y
Y
ANY NEW CHl]MI('At,S MT]51'BT] PRE-APPROVEI) BY I'HE HEALTH DEPARTMEN'T.
NF,W APPLICATION
N
N
(
,#);
RENEWAL APPLICATIONy'
APPLICANT'S SIGNATURH
DATE 09/13/2025
The Commonweulth of lassochusetts
Depurtnrcnt of Industrial .Atcide nts
Ollice of I nvestigalions
I Congress Street. Suite 100
Bl$on, ll,4 021l4-2017
tt tt tt'.moss.gov/dia
Workers' Compensalion Insurance Affidal'it: General Businesses
I I nfornration
Busincss/Organization Namc: Blue Bird Hospitality Corp d/b/a Cape Shore lnn
Address: 793 MA-28
Prinl Form
P
Are you rr employer? Check the approprirte bor:
l. VI I am a employer with 3 emplo"vees (full andr
or pan-timc).'
3. fl I am a solc pr(,priclor (lr pannr:rship uud ltarc rru
crnployc'-s r,rorking lbr mc in an) capacrtt.
INo uo*ers' conrp. insurance rcqurrc'dl
.1. fl Wc are a corJrorotion and its o{Iiccn har c crcrciscd
their right of cxernption per c. l5l, \l(4).andr,r'chavc
no employecs. [No workers' conrp- insurance required]+'
4. I Wc arc a non-prolil organization, stalTcd by volunrccn,
with no enrployr'es, [No workers' cornp, insurancc rcq,]
('it1' State.'Zip: South Yarmouth, MA 02664 phone #: s08-694-7969
llusintss .l
1pe (rcquired)
5
6
1
Rctail
Rcstarrant/Bar/Eating Fstablishmeltt
Oflicc antl,or Salcs {incl. rr,-al cstalc. sulo, ctc.)
8. ! Non-profit
9.
l0
lt
Entcrtilinment
IvlanLrlacturing
H{nlth Care
t2 p ttrhcr Hospitality
'An) applicaart ltBt ch€rlr bor ;rl mus( also iill ou thc s!'rtion bclow shoivin! rhcir \,r'orler!i compcnsrrioo |x icy information.
oryEnizrtirxr sbould chccl box n l-
I um un tmpk4'er lhat is provitlhtg rtorle'rs' tttmptnsution insuran<'e.litr nty employees. Eelo* is tht polit'y information.
Insurance Company \arnc: THE TRAVELERS INDEMNITY COIVPANY OF CONNECTICUT
lnsurcr's Adrlrcss: P.O. Box 4614
C i t y., S sn1" 2 ; n' _Euffalo IY,14Z4!4-614-
Policy d or Setr'-ins. l-ic. .* UB-8W420411-25-42-G I xpiration Dote 5t1812026
Attrch o copy ofthc workrrs' ({)mpcn$stion policy declrrrtlon prgc (sho*ing thc policy numbcr 8nd erpirstlon detc),
Failure to su'curc covcrage as reqtrired under Scctirrn 2.5A of MCl, c. l-52 can lcad to thc impositiun of criminal penalties ol'a
finc up to $ I .5(X).00 and or one -\'e ar in4rnsorntrcnt. as rvcli as cir rl prnaltit'r in Ihc lirnn ol'a STOP WORK ORDER and a finc
ofup lo 3250-00 a day rgainst thc violattrr. llc adviscd dlirl a cop! of this st.ltr'nrcnr nral be' t'orwardcd to thc Ot'llcc of
Invcstigations ofthe DIA tbr insurance co\crag!- \!'rificalion.
I do htrtbl' ccrti.[1', undr thr, pains ani pcntlti* t,l pprjury thut th.' inlhru ion prolidcd ahove is true o dcorrutt.
Si Dutc: toi222o2s
Phonc #: (508) 694-7969
*wrv-masr por r.lia
Olltcial use onlr. Do not wrirc in this area,lo be complcted b.t'ci4'or tox'n offtt'iul-
Issuing AuthoritY (circle onr):
l. Boerd of Helth 2. Building Departmcnt -1. Cityflown Clerk ,1. Licensing Bo.rd 5. Selcctmcn's Olfice
6. Olher
Conlrrl Penion: Phone #:
Prrntit/l-ittnsu fCllt' or To*n:
+-NOTICE TO EMPLOYEES
THE COMMONWEALTH OF MASSACHUSETTS
DEPARTMENT OF INDUSTRIAL ACC!DENTS
,11...!
IF YOU ARE I NJURED ON THE JOB:
lmmediately notify your employer that you have been injured.
Employer HR/Workers' Compensation Contact Phone Number
Tell the medical provider that you have been injured at work and give the
information below:
lnsurance Carrier
THE TRAVELERS INSURANCE
COMPANIES
Address
P. O. BOX 4 514
BUFFALO, NY 1i1240-4514
Phone Number
(800) 238-6225
Address
793 ROUTE 28
SOUTH YAR]i{OUTB
MA 02664
lf the employer fails to report the injury to the insurer, the employee may
file an Employee's Claim (Form 110).
Additional information regarding your rights and eligibility for benefits
pursuant the Workers' Compensation law may be obtained by contacting
the Department of lndustrial Accidents at 617.727.4900 or visiting
www.mass.qov/dia.
IF MEDICAL TREATMENT IS NEEDED:
Injured workers may select their own medical provider. Medical treatment
costs that are reasonable, necessary, and related to the work injury wit! be
paid by the above-named insurer.
lf medical facility information is provided below, the above-named insurer
has a preferred provider arrangement and the insurer has arranged for your
initial treatment at:
Medical Facility:
Phone Number:
Address I
tr
+
Revised JUNE 2024
irr
t
ll
Employer
BLUE BIRD HOSPITA],ITY CORP
tr.l
EMPLOYER: THIS NOTICE MUST BE FILLED OUT AND POSTEO WHERE EMpLOyEES CAN REAOtT PURSUANT M.G.L. C. 152, SECTTONS 21, 22, 30, AND 758 (2). EiTpLOyERS MAy NOTRETALIATE, OISCRIMINATE (lN ACCORDANCE WITH ANY APPLICABLE STATE OR FEDERALLAWS WHICH INCLUDES IMMIGRATION STATUS), OR PROVIDE FALSE INFORMATION ABOUTTHE WORKERS' COMPENSATION PROCESS TO THEIR EMPLOYEES, THIS NOTICE MUST BEUPDATED, POSTED ANO REOISTRIBUTED WHEN THERE ARE CHANGES IO THE INFORMATION.
w20P1K24
tr
u