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Home My WebLink AboutApplication and WC . - . KxN656uRsi Afi�'S ' d TOWN OF YARMOUTH BOARD OF HEALTH ` � � APPLICATION FOR LICENSE/P -�g036��Q � ��'-►` :4 (p�{ " * Please complete form and attach all necessary'8 ' nEs by bece be Failure to do so will result in the return of�O�°appkcation PT ESTABLISHMENTNAME: KinQsbury Apartments TAXID: LOCATIONADDRESS: 193 Camp street West Yarmouth TEL.#: 5nR-�AR-��A� MAILINGADDRESS: 20 North Main St , South Yarmouth , Mn n��h[� E-MAIL ADDRESS: mpurrier@thedavengortcomnan; aa �nm OWNERNAME: Davenport Realt� CORPORATION NAME (IF APPLICABLE): MANAGER'SNAME: Kelli Orava TEL.#: 508-398-2293 MAILINGADDRESS: 20 North Main St � Cniith y,arm.,,,r�� [H� g��G 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.W111 grovide i n thP c�ri n� tri .,,- t., .,�o.,; � Pool operators must list a minimum of two employees currently certified in basic water safety, 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 Tle at your place of business. 1. 2• 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments aze 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. 2• PERSON IN CHARGE: Each food establishment must have at least one Person In Chazge (PIC) on site during hours of operation. L 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. 1. 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. 2• 3. 4. RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $110 INN $55 CAMP $55 �.SWIMMING POOL$110ea.�Z� LODGE $55 TRAILERPARK $105 WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERM(T# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 _CONTINENTAL $35 NON-PROFIT $30 >I00 SEATS $200 COMMON VIC. $60 WHOLESALE $80 —RESID.KITCHEN $SO RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq.ft. $50 >25,000 sq ft. $285 VENDING-FOOD $25 —<25,000 sq.ft. $I50 _FROZEN DESSERT $40 _TOBACCO $1l0 NAME CHANGE: $15 AMOUNT DUE _ $ �( p . �O *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***"* �G�a � �'� � �g�� 1�� . , ADMINISTRATION - , , Under Chapter 152,Section 25C, Subsection 6,the Town of Yarmauth is now required to hold issuance or renewal of any license or permit ta operate a business if a person or company does not have a Certificate of Worker's Gompensation Insurance. THE AT`CACHED STATE WORKER'S CC}MPENSATIQN INSUI2ANCE AFFTDAVIT MUST BE COMPLETED AND SIGNELI, OR CERT. 4F INSURANCE ATTACHEI} XX OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taaces and liens rnust be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROP,RIATELY IP PAID: YES XX NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCI7PANCY: For purposes ofthe limitations of Motel or Hotel use,Transient occupancy shall be limited to the temporary and short term occupancy,ordinarily and custamarily assoa'rated with motel and hotel use. Transient occupants must have and be able to demanstrate that they maintain a principal place af residenca elsewhere.Transient occugancy shall generally refer to continuous occupancy of not more than thiriy(30)days,and an aggregate o£nok more than ninety(90)days within any six(6)manth period. Use af a guest unit as a resldence or dwelling unit shall not be considered transient. Oceupaney that is subjeet to the colIeetion of Room Occugancy Excise,as defined in M.G.L. c. 64G or 830 CMR 54U, as amended, shall generally be considered Transient. P4QLS POOL CIPENING:All swimming,wading and whirlpaols which have been closed far the season must be inspected by the Health Department prior to opening. Contact the Hea11:h Department to schedule the inspection three(3) days prior to opening. PLEASE NOT'E: Ferople are NQT allowed to sit in the poal area until the pool has been inspected and opened. PQOL WATER TESTING: The water must be tested for pseudomonas,tota!coliform and standard plate count by a State certtified lab, and submitted to the Health Deparhnent three (3) days prior to opening, and quarterly therea8es. I'O{3L CLf}STNG: Every outdaor in ground swimming pool must be drained or covered within seven{7}days of closing. FO011 SERVICE SEASONAL FOOD SERVICE OPENING: All food service establishmenis must be inspected by the Health Department prior ta opening. Please contact the F�ealth Department ta schedule the inspectian three (3)days prior to opening. CATF.RING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarniouth Health Department by filing the required Temparary Food Service A.pplicatian form 72 hours priar to the catered event. These farms can be obtained at the Health I7epartment,or from the Town's website at www.yarmouth.ma.us under Health Deparhnent, Downloadahle Forms. FROZEN DESS�RTS: Prozen desserts must be tested by a State certified lab priar to apetling and monthly thercafter,with sample results subnnitted to the I-Iealth Depaztment. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit untit tl�e above terms have been met. CtUTSII3E CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval frorn the Board af Health. (JUTDOOR COOKING: Outdaor cooking,prepazation,or display of any faod product by a retail or food service establishmant is prohibited. NOTICE:Parmits run annually from January I to December 3 L IT I5 YOUR KESPONSIBILITY 7'O RE'I't.JRN THE CdMPI,ETED RENEWAL APPLICATION{S}AND REQUIRED FEE(S}BX DGCEMBER 15, 2014. ALL RENOVATI�NS TO ANY FOOD �STABLISHMENT, MO'I'EL OR PQOL (i.e., FAINT�ING, NEW EQUIPMENT, ETC.}, MUST BE REPORTEI}TO AND AFPROVED BY THE BOARD OF HEAI,TH PRIdR TO COMMENCEMENT. RENOVATIONS MAY I2EQUIRE A SITE PLAN. DATE� 11-18-14 � SIGNtI'TCTRE: ' 1�K� 1��:.��,,�,,�{�-�� PRINTNAMB &TITLE: Marv Pu rier, Asst . Gantroller Rev.lf703174 - � � The Commonwealth ofMassachusetts Department of Industrial Accidents Office oflnvestigations 1 Congress Street, Suite 100 Boston,MA 02I14-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Analicant Information Please Print Legiblv Business/OrganizationName: Davenport Realtv / KinQsburv Apts . Address: 20 North Main St . City/State/Z1p: So .Yarmouth, MA 02664 Phone#: 508-398-2293 Are you an employer? Check the appropriate box: Business Type(required): 1.❑X I am a employer with employees(full and/ 5. ❑ Retail or part-time).* 6. ❑ RestaurantlBaz/Earing 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] g• ❑ Non-profit 3.❑ We aze a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4), and we have 10.❑ Manufacriuing no employees. [No workers' comp. insurance required]* 4.❑ We aze a non-profit organization, staffed by volunteers, 11.❑ Health Caze with no employees. [No workers' comp. insurance req.] 12.� Other 'Any applicant that checks box#1 must also fill out the section below showing the'v workers'compensalion policy in£otmation. *•If the coiporate officers have exempted themselves,but the cocporation has other employees,a workers'compensalion policy is required and such an organization should check box#1. I am an employer that is providing workers'compensation insurance for my employees. Be[ow is the policy information. InsuranceCompanyName: Zurich American Ins . co. Insurer's Address: s e e a t t ached City/State/Zip: Policy#orSelf-ins.Lic. # WC8196132 ExpirationDate: 3-1-15 Attach a copy of the workers' compensation policy declaration page(showing the policy number and espiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalries of a fine up to$1,500.00 and/or one-yeaz 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 forwazded to the Office of InvesUga6ons of the DIA for insurance coverage verificarion. I do hereby c ify,under the pgi�qs and penaUies ofperjury that the informafion provided above is true and correct. Si ature:� �-�-� �� l/�it�C�1 Date: 11-1 II-14 Phone#: 508-3 8-2293 O�cia[use only. Do not write in this area,to be comp[eted by city or town officiaL City or Town: Permit/License# Lssuing 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 � �✓� � � � � . . DAVEN-1 OP ID:AK , '4�� CERTIFICAT.E OF LIABILITY INSURANCE oare�mm�oomrv� �� 01/15/2014 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 CERTIFIGATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S�, AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. � . IMPORTANT: It the certificate holder is an ADDITIONAL JNSURED, the policy(ies) must be endorsed. If SUBROGATION IS WANED, subjec[to� � the terms antl 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 oi such entlorsement(s . � � . PROOUCER Phone:610•279-8550 CONTACT The Addis Group, Inc. . ""ME: 2500 Renaissance Blvtl.Ste 100 Fax:610•279-8543 pH�NNo Ex[: qIC No: King of Prussia, PA 19406-2772 � E-MAi� Jeffrey A.Grebe ADDRE55: INSURER S AFFOR�ING COVERHGE NAIC M iNsuReRa:Zurich American Insura�ce Co. 16535 iNsuReo DavenportRealtyTrust MSURERB: - Stephen Aschettino INSURERC: � 20 North Main St. - � South Yarmouth, MA 02664 INSURER 0: - 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 POLIGES DESCRBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. � � INSft rypE OF INSURANCE AD�L SUB POLICY EFF POLICV E%P LTft POLICV NUMBER MMI�DIYYYV MM/OOM"/V LIMITS GENERALt1AeIL1TY � EACHOCCURRENCE $ ��OOO�DOO A X COMMERCIALGENERALLIA9ILITV GLO$196255 . 03/01I2014 03/01/2��$ pREMI5E5 Eaoccurtence 5 $0�,0�0 CUIMS-MADE � OCCUR � MED E%P(Any one pe�son) 5 ��,�� PERSONALBADVINJURV $ ��DOO�OOO I GENERALAGGREGATE 5 Z�OOO�OOO GEN'LAGGREGATELIMITAPPLIESPER: PRODUCTS�COMPIOPAGG E E�OOO,OOO X POLICV PR� LOC 5 AUTOMOBILELIABILITY EOM�BctlE�DSINGLELIMIT a ��OOO�OOO A X qNVAUTO BAP8196256 03/01/2014 03/01/2075 BODiLYINJURY(Perpereonj 5 AILOWNED SCHE�ULED BODILYINJURV Peraccitlenp 8 At1TOS AUTOS � ( NON-OWNED PROPERTY DAMAGE x HIREDAUTOS I�qUT05 �. Petaccitlent $ � 5 UMBRELLALIAB OCWR EACHOCCURRENCE 8 �EXCE55 LIPB CLNMS-MADE AGGREGATE S DED RETENTION$ g WORKERSCOMPENSATON WCSTATU- OTH- ANO EMPLOYERS'LIABILITV X T RV IMIT A nNYPROPRIETORIPARTNERIE%ECl1TIVE Y� C8196132 03/01120�4 03/01/2O�S E.LEACHACCIDENT E �,OOO,OOO OFFlCERIMEMBEREXC�U�ED9 NIA (MantleloryinNH� � EL.DISEA9E-EAEMPLOVEE E ��OOO�OOO Ifyes,0escnbeuntler ELDISEASE-POLICYLIMIT $ � �� DESCRIPTION OP OPERATIONS Oelow ' OESCRIPTION OF OPERATION51 LOCATION51 VEHICLES �Atta[h PCORD 101,Atltlitional Remerks Sc�eOvle,i�more cWce is requlretl� � CERTIFICATE HOLDER CANCELLATION � YARMO-0 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TOWf10fY3�mOUth . THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN � ACCORDANCE WITH THE POLICV PROVISIONS � Route 28 South Yarmouth� MA O�L6BG � qI1THORI2EDREPRESENTATIVE T�� ' . OO 1985-20'10 ACORD CORPORATION. All rights reserved. ACORD 25(2010/OS) ' The ACORD name and logo are registered marks of A'CORD �