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Home My WebLink AboutApplication and WC � � �-+-�5-ooi �o�l sT-/5-/Z�� 7 ��s � � °` � TOWN OF YARMOUTH Boazdof � Health = 1146 ROUTE 28, SOUTH YARMOUTH, MASSACHLISETTS 02664-2445 �� Telephone(508)398-2231, ext. 1241 �� Faac(508) 760-3472 � . � n�visinn _ ��.3 �°ut� u � �u�4 SUN TANNING ESTABLISHMENTS � (l0 HEALTH DEPT. APPLICATION FOR LICENSE/PERMIT -2015 Name of Establishment: � �A'n 2�' r<� VI !1S Taac ID (FEIN or SSN)• � Address: I � L�h � p d�l d �f i v� TelephoneNo.: SO8- �60 — a-3Q� E-mail:�� 22a S-0 O� Co�rc41�'•i�ea- Mailing Address (If different from above): �6S [�OS�( {�as � Rd. ��C �� . f�dbv✓�� p1776 OwnerlC.or�acar�taon Name• �� J - J h C . _Tglegl�one I�Tn�:-_- __ _ Owner/Corporation Address: Manager's Name: � �' '�� Telephone No.: Manager's Address: Under Chapter 152, Sec. 25C, subsection 6, the Town of Yannouth 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 AfFdavit must be completed and signed. Town of Yarmouth ta�ces and lie must be paid prior to renewal or issuance of your pernrits. Please check appropriately if paid: yes � no LICENSE/PERMIT REOUIRED: Fee: $55.00 per device X 2 � � �� •� #OF TANNING BEDS:� #OF OTHER TANNING DEVICES TOTAL 2 TANNING DEVICE INFORMATION: lLlanui'acfurer Niodel Nam�r " -Serial Number vne o Su __ �fGr�-��nd 19hh;45 �5 er Q � SS �/� v I-4 «�� tiad Tr+hn��4 cS`�FdG2z.i�r- s�J B i� s6 �� Notice: PERMITS RUN ANNLJALLY 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)aze received. A hearing before the Boazd of Health may be required prior to reopening. DoATE: O CL � , �� I � SIGNATURE: f�J � - � The Commonwealth ofMassachusetts ' Department of Industrial Accidents O�ce oflnvestigalions ' I Congress Street, Suite I00 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insuraace Affidavit: General Businesses Applicant Information Please Print Leeiblv Business/Organization Name: Vv � �( T 5 C. � [� �' ��s�e� ��'� ��fl' �SirS o��f Address: l'7 L��i 5 PUh �( pf( ✓e City/State/Zip: _ �//�d✓�� Phone#: Sd8— 7�,0— Z-?�� Are ypu an employer? Check the appropriate boa: Business Type(required): 1.� I am a employer with��employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ RestauranUBar/Eating Establishmern _. 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 aze a corporation and its o�cers 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]* 4.❑ We are a non-profit organization, staffed by volunteers, 1 L� Health Caze with no employees. [No workers' comp. insurance req.] 12.�Other F1 �11 Qfs C��'I�� 'Any applicant thai checks box#1 must also 811 out the section below showing their workeis'compensation policy iaformation. **If the coxpomte officess have exempted themselves,but the corporation has otlier emp(oyees,a workecs'compensation policy is reqn'ved and such an organization should check box#1. - I am an employer that is providing workers'compensation insurance for my emp[oyees. Below is the policy information. Insurance Company Name: F�rS �- F iT��J- �{.f�r<^�C r�o✓/� 1'4 c f Insurer's Address: P -O. D 0?j � � �8 ciry�srate/ziP: '�t' �-�� -5 y I� �/VL 2�q �9 Policy#or Self-ins.Lic. # �� f�J — (�So� Expiration Date: � 3u 1O� ,� Attach a copy of t6e workers' compeasation policy declaration page(showing the policy number and eapirafion date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposirion of criminal penalties of a P.ne ag to $t,500.00 and/or one-year imprisorunent,a�well as civiY p�n3tiiesin�fie iorm o�'a S'I'aFWbAK 6R�EI�an�a�e - 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 covernge verification. I do hereby certify,under thepains andpenalties ofperjury that the information provided above is true and correct S�nature: I V/�(f'�5 .{l�f� Date• l �- I ( � 3� l�J Phone� °(Z g— �j43 — �9 8� Official use only. Do not write in this area,to be comp[eted by city or town officiaL City or Town: Permit/Licease# 7ssuing 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 � GENERAL LIABILITY EVIDENCE OF INSURANCE F''IRST , For members of �''LIGHT Fitness Insurance, ILC, Risk Purchasing Group INSURANCE 10333 East Dry Creek Road, Suite 250 �.iROUP, ING. Englewood, CO 80112 NAMED INSURED 8 ADDRESS: WGY,Inc.Planet Fitness Yarmouth EVIDENCE#:FIT1000-000504 365 Boston Post Roatl,PMB 384 ISSUE DATE: 6/23/2014 Sutlbury,MA 01776 PERIOD OF INSURANCE: FROM: 6I30/2014 70: 6I3012075 Each at 12:01 AM Local Slandard Time PREMIUM: PREMIUM: $3,517.00 7ERRORISM: Excluded INSPECTION FEE: $0.00 RPG FEE: $275.00 FILING FEE: $0.00 SURPLUS LINES TAXES: $105.51 STAMPING FEES: - $0.00 _ TOTAL PREMIUM: $3,897.51 DEDUCTIBLE: No Dedudible CARRIER&POLICY NUMBER: Certain Underwriters at Lloyds London-FIT1000 COVERAGE INFORMATION: General Liability tor Fitness Centers MAS7ER POLICY NOTICE: The Member named above(the"Insured")is hereby notified ihat the following insurance has been effected with Certain Underwriters at Lloyds,London(not incorporated)under Master Policy Nbr. FIT1000(the"Masler Policy")issued to Fitness Insurance,LLC,a Risk Purchasing Group,Inc..The Insurance is provided in accordance with the terms of the Master Poliq,a copy of which is attached hereto.The original Master Policy may be inspected at Fitness Insurance,LLC,a Risk Purchasing Group,Inc.which are located at 10333 East Dry Creek Roatl,Suite 250,Englewood,CO 80112. Please read and review the Master Policy carefully for a tull description of its terms and contlitions. LIMIT OF LIABILIN: $1,000,000 Each Occurtence $2,000,000 General Aggregate $2,000,000 Producls&Completetl Operations Limit - $1,000,000 Personal&Advertising Injury Limit $1,000,000 Fire Damage to Rentetl Premises Excludetl Medical Payments Limit(Any One Person) $1,000,000 Hired and Non Owned Auto Included Professional Liability Occurrence Includetl ProfessionalLiabilityAggregate $1,000,000 Sexual and Physical Abuse Oaurrence $2,000,000 Sexual and Physical Abuse Aggregate ADDITIONAL INSUREDS: Any Additional Insured shown on this Certificate is only covered for legal liability arising vicariously out of the regular operations of the above insuretl in wnnection with his or her operations. NOTICE OF CANCELLATION: In the event of cancellation of this certificate, the company wili endeavor to mail 30 days wriCer nctice o` cancellation to CERTIFICATE HOLDER and/or ADDITIONAL NAMED INSURED, but failure to mail such notice shall impose no obliga6on or liability of any kintl upon the companies, its agents or representatives. CANCELLATION FOR NON-PAYMENT-10 day notice of wncellation shall apply for cancellations due to non-payment of premium. This document(evidence of insurance)is issued as no6ce oi insurance tor information only. It does not constitute a legal contract of insurence. The Master Policy antl the application of the Specifietl Member, ii any,form the entire contrad. This evidence if furnished in accordance with, and in all respeds is subjecl to, the terms ot the Master Policy. This evidence replaces any other evidence previously issued covering the insurance described herein. . UNDERWRI7ERS CORRESPONDENT: This certificate has been providetl by First Flight Insurance Group, Inc., acting in an underwriting capacity on behalf of underv✓riters who, under binding authonty agreement, B1294L13570 , have given us authoriry to confirm insuring terms, conditions,and premiums. CLAIMS REPORTING PROCEDURES: See claims reporting insiruction reported in the policy. COVERHOLDER First Flight Insurance Group,Inc. P.O.Box 1046,Kitty Hawk,NC 27949 USA �iy..��_�� "cTlif4 . . .Robert Wells Fitness Insurance,LLC,10333 East Dry Creek Road,Suite 250,Englewood,CO 80712 Randy Schumacher