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Home My WebLink AboutApplication and WC • � „ T3RENlu100�� a � TOWN OF YARMOUTH BOARD OF HEALTH �� APPLICATION FOR LICENSE/PERM�1' ;�(Il ' � _ ' �.��,�f� >� f�� E A (U14 ` * Please complete form and attach all necessary docu�tenYs�bX l)ere er IS 2014. Failure to do so will result in the return ofyour application p ke��7y pEp� ESTABLISHMENT NAME: u,�t ` � TAX ID• � LOCATION ADDRESS: ��/ A4Rr�n.' � i �'i ..�5' TEL.#��4�)y'/�- �Si L MAILING ADDRESS: S /A � � � E-MAIL ADDRESS: � OWNER NAME: CORPORATION NAME (IF APPLICABLE): N + M 2E��i TR-uS� MANAGER'S NAME: /.(/�l�iG 1-FJ�i.rY{ TEL.#:('�r��, - Q�i� MAILING ADDRESS� c�, / /�lf?rni,C i � 1 ,�� 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. � � l.�i/iin ,�C�f,%e.:it 2. �i c�, - c�i,�,'S�M / ICr'c.l! Pool operators must list a minimum of two employees currently certified in basic water safery, standard First Aid and Community Cardiopulmonary Resuscitation (CPR), having one certified employee on premises at a11 times. Please list the employees below and attach copies of their certifications to this forxn.The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1.�� l�zlY.,�rf-L 2. �uCC. - Pht''+S�o�Pt Ki�. ) 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are 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 at[ach 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 Charge (PIC) on site during hours of operation. 1 - _ � _ _ __. _ 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 establishxnents 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 at[ach 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. L 2. 3. 4. RESTAURANT SEATING: TOTAL# ADMINISTRATIdN Under Chapter 152, Section 25C, Subsection 6,the Town of Yazmouth is now required to hold issnance or renewal of any license or permit to operate a business if a persaiz ar company does not have a Certificate af Warker's Compensation Insurance. THE AT7'ACkIED STATE WORKER'S CQMPENSATION INSUILANCE AFFIDAVIT MUST BE COMPLF.TEA AND SIGNED, OR CERT. OF 1NSURANCE ATTACHED_y� OR WORK.ER'S C4MP. AFFIDAVIT SIGNED AND A"CTACH�I} t,� Town of Yannouth Yaxes and liens must be paid prior to renewal ax issuance of your permits. PLEASE CHECK APPROPRIATELY IP PAII}: I'ES V' NO_ Mt}TELS ANT3 Q'I'HGR LODGING ESTABLTSHMENTS T[tA.NSIENT OCCUPANCY: Foz purposes ofthe limitations ofMotel or Hotel use,Transient occupancy shall be Iimited ta the temporary and short term occupancy,ordinarily azid customarily associated with motel and hotel use. Tzansient occupants must have and be able to demonstrate tl�at they maintain a principal place of residence elsewhere.Transient occupancy shall generally refer to continuous occupancy of not�nore than thirty(30)days,and an ag�regate of not more than ninety(44}days within any six(6}month periad. Use of a guest unit as a residence ar dwelling unit shall not be cansidered transient. Clccupancy that is subject to the collection of Room Ocoupancy 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 far the season must be inspected by the Health Department prior to opening. Contact the Health Department to schadnte the inspection three(3) days prior to ogening. PLEASE NQTL: People are N01'allowed to sit in the pool area until the pool has been inspected and opened. POOL WATER TESTING: The water must be tested far pseudc�monas,total cofiform and standazd plate count hy a State certified lab, and suhmitted to the Heaith Department three {3) days prior to opening, and quarteriy therea8er. POOT. CLO5ING: Every outdoor in graund swirnming pool rnust be drained or covered within seven(7)days of closing. FOOD SEt2VICE SEASONAL FOQD SERVICE OPENING: All faod service establishments must be inspected by ihe Health Department prior to apening. Please contact the Health Deparhnent to schedule the inspection three (3) days prior to opening. C"ATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmauth Hea]th Dapartment by filing the required Temparary Food Service Application forna 72 hours prior to the catered event. These farms can be obtaitted at the Health Deparimenf,or from the Town's website at ww�v.varrnouth.ma.us under Health Department, Downloadable Forma k'ROZEN DESSERTS: Frozen desserts must be tested by a State certified lab prior to opening and monthly thereafter,with sample results submitted ta the I-Iealth Department. Failure ta da so will result in the suspensian ar revocation of your Frazen Dessert Permit until the above terms have been rnet. OUTSIDE CAFES: Qutside cafes(i.e.,outdaor seating with waiter/waitress servica),must have prior approval fram the$oard of Health. QUTAOOR COQHING: Outdoar coaking,preparation,or dispiay of any faod product by a retaii ar food service establishment is pro6ibited. � � t� The Commonwealth ofMassachusetts Department of Industrial Accidents Office oflnvestigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legiblv Business/OrganizationName: Q3�n�c✓��7A n,i�,rv� ,'nr,✓ Address: PIG-� � ��;�,' �'i �C.i � Ci /State/Zi � . ��6 P ty P� �x� Ml� hone#: � 8 ' - fs�i L Are you an employer? Check the appropriate bos: Business Type(required): 1.❑ I am a employer with employees (full and/ 5. ❑ Retail ozpart-time).* _ 6. ❑ RestauranUBaz/Earing Establishment _ 2.❑ I am a sole proprietor or partnership and have no �, � Office ancllor 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. ❑ Entertauunent their right of exemption per c. 152, §1(4), and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]* 11.❑ Health Care 4.❑ We aze a non-profit organizarion,staffed by volunteers, 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'u workeis'compensation policy infotmation. ••If the corporate officers have exempted themselves,but the corporalion has other employees,a workers'compensation policy is required and such an organi�ation should check box#1. I am an employer that is providing wotkers'compensation insurance jor my employees. Below is the policy inforntation. Insurance Company Name:�rr�i+2� cro�.�;nn re, �nM nu Insurer'sAddress: P.� . 13vv p -,:f � i(o S . K�'�er S"� City/State/Zip: L,,�;/}-� ._ �,z,,.M ,p, A ib7a� - �%O.R-c7 i Policy#or Self-ins.Lic.# lL,.� �.ici 57� 7o.ft� Expiration Date: `.� - '(v - � S Attach a copy of the workers' compensation policy declaration page(showing the policy number and espiration date). - Fai}w�e-t�secure cA\lP�e as requireflvndei�ection 25A�fMGL c._L5�s,an leasLt4_th�im�zosition of criminal penalties 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 Investigations of the DIA for insurance coverage verification. I do hereby certify,unde thepai and enalties ofperjury that the information provided above is true and correct. Si ature: -� Date: / - -f - i Phone#: - y � 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 Hea1tL 2. Building Department 3. City/Town Clerk 4.Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone#: www.mass.gov/dia BERKSHIRE HATHAWAY Worker's Comoeasation and Emulover's Liabiliri Policv G UA RD INSURANCE AmGUARD Insurance Company - A Stock Company COMPANIES Policy Number R2WC507029 - Renewal of NEW � NCCI No. [21873] Policy Irfiormatlon Page (AR) �----__.- - -�_ ... _-- ----- __...---___._------------ --_._...__-1 [1]Named Insured and Mailing Address Agency� i i Brentwood Motor Inn Inc DOW LING&O'NEIL INS AGY i 961 Rou[e 28 973 Iyannough Road j S Yarmouth, MA 02664 P.O. Box 1990 Hyannis, MA 02601 i � Agency Code: MADOW L10 i � Federal Employer's ID Insured is Corporation i I L . ._. ._ —__._...._. __._ ... .___ __._.._� __— '_._—_. ._._,... I . . .__.._— .... .---... _ . .....'"— � �2] Poiicy Penod _-- ---.__ --._ _- --. _— ' � From August 16, 2014 to August 16, 2015, 12:01 AM, standard time at the insured's mailing address. I I �37 Coveroge �,_ ------- ------� ; I � A. W orkers' Compensation Insurance - Par!One of this policy applies to the W orkers' Compensation j iLaw of the following states: Massachusetts ; I B. Employer's Liability Insurence - Part Two of this policy applies to work in each of[he states lis[ed in item [3]A. The limits of our liability under Part Two are: ' 8odily Injury by Accident - each accident $100,000 ! � Bodily Injury by Disease - each employee $100,000 '�, Bodily Injury 6y Disease -policy limi[ $500,000 ' i C. Refer to Resldual Market Limited Other States Insuronce Endorsement-WC 00 03 26A ; D. This policy inciudes these endorsements and schedules: ' 1 See EMension of Information Page - Scheduie of Forms �� e.. _.W. _. ._- —_— _-------- -...... ___.._ 1 . _._.._..----- --------_..___ ..__ r[4] Premium � The Premium 8asis and, therefore, [he premium will be de[ermined by our Manual of Rules, � Classifcations, Rates, and Rating Plans. All required information is subject to verification and change � by audit. (Continued on another page) Total Estimated Policy Premlum $ 1,001 Total Surcharges/Assesaments ; 43.00 ToWI Estimated Cost g 1,044.00 �nrertrva�u5e oa Page - 1 - Informa6on Page wGA : R2WC507029 WC OOOOOlA Dare : 07/18/2014 MANOTE Issuing Office: P.O. Box A-H, 16 5. Rlver Street, Wflkes-Barre, PA 18703-0020 •www.guard.com