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Home My WebLink AboutApplication and WC �� a TOWN OF YARMOUTH BOARD OF HEALTH JAN Z O 2O�§ APPLICATION FOR LICEN�� I1S� * Please complete form and attach all necess. e�lts�liy p e emB�E�Y F3 .T. Failure to do so will result in the return-o€yciut applic�tion pac e . ESTABLISHMENT NAME: C/kp L S � h 7 TAX ID: N.a L � LOCATION ADDRESS: � q3 � � �k TEL.#: (S'�8�/ �'9 5 2 � ) MAILINGADDRESS: �l �K}`^c,�'f� -o2�C E-MAIL ADDRESS: -�o�ersv k� C� �ma r I._e-+-<-.`�+.� . c_mM OWNER NAME: c CORPORATION NAME (IF APPLICABLE): S f�i�P� 'I�t�s(� ��L� r MANAGER'S NAME: `pl L�� c✓,y�^Is� c�A TEL.#: � 9 4 C9 MAILING ADDRESS: �2 K�+ �'� 28-, S `�d�^-� t`�--i� e 2 CC� POOLCERTIFICATIONS: �lU. P� � �� C�P�� a� C-��5 �� OPC�ING, 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. i. D l Lt G' l�ps��-�� -ti-A� 2.� � 4� A �'�r�'A G�/�-2�A Pool operators must list a minunum of two employees currently certified in basic water safety, 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 form.The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. �. �� n-+� / � s� 2 z. � Q� 3. a�� 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 Protec6on 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. 1. 2• ALLERGEN CERTIFICATIONS: All food service establishments aze 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 Deparhnent will not use past years' records. You must provide new copies and maintain a file at your estabiishment. l. Z• 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 REQUIREp FEE PERMIT# �.. BBcB $55 CABIN $55 1 MOTEL¢3"tS-0`t'D$110 � ' �INN $55 CAMP $55 �SWIMMINGPQQL,$7.10ea. �, _LODGE $55 _TRAILER PARK $l05 _WHIRLPOOL�V�'°9'tTOea. � FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE P T# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 1 CONTINENTAL $35 �fr�-(60 _NON-PROFIT $30 —>100 SEATS $200 COMMON VIC. $60 WHOLESALE $80 —RESID.KITCHEN $80 �� RETAIL SERVICE: '. LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# i <50 sq.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 � _QS,OOOsq.ft. $l50 _FROZENDESSERT $40 _TOBACCO $110 � NAME CHANGE: $15 AMOUNT DUE _ $ c�S� � � � **•**PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** � ADMINISTRATION Under Chapter 152,Section 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 COMPENSA�TION oI�TSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR � � �,�1 �-2 CERT. OF INSURANCE ATTACHED �� INQ,t,� OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED ��'`��, Town of Yarmouth taxes and liens must be paid priar to renewal or issuance of your permits. PL�E CHECK APPROPRIATELY IF PAID: YES_�_ NO MOTELS AND OTHER LODGING ESTABLISHMENTS ! TRANSIENT OCCUPANCY: For purposes of the limitations ofMotel or Hotel use,Transient occupancy shall be limited to the temporary and short term occupancy,ordinarily and customazily associated with motel and hotel use. Transient occupants must have and be able to demonstrate that they maintain a principal place of residence elsewhere.Transient occupancy shall generally refer to continuous occupancy of not more than thirty(30)days,and an aggregate of not more than ninety(90)days within any six(6)month period. Use of a guest unit as a residence or dwelling unit shall not be considered transient. Occupancy that is subject to the collection of Room Occupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient. POOLS POOL OPENING: All swimming,wading and whirlpools which have been closed for the season must be inspected ' by the Health Department prior to opening. Contact the Health Departrnent to schedule the inspection three(3) days prior to opening. PLEASE NOTE: People are NOT allowed to sit in the pool azea until the pool has been inspected and opened. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, and submitted to the Health Department three (3) days prior to opening, and quarterly thereafter. PO�L CI.OSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE SEASONAL FOOD SERVICE OPENING: All food service establishments must be inspected by the Health Department prior to opening. Please contact the Health Department to schedule the inspection three (3) days prior to opening. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtazned at the Health Department,or from the Town's website at www.vannouth.ma.us under Health Department, Downloadable Forms. FROZEN DESSERTS: ! Frozen desserts must be tested by a 5tate certified lab prior to opening and monthly thereafter,with sample results submitted to the Health Departxnent. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Heaith. OUTDOOR COOHING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RE'I'[.TRN i THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER I5, 2014. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW , EQUIPNIENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR i TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: { I 2a � � � SIGNATURE: PRINT NAME & TITLE: �1 �- � � � � �� Rev. 11/03/14 � The Commonwealth of Massachusetts � Department of Industrial Accidents O�ce of Investigalions I Congress Street, Suite I00 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Af�idavit: General Businesses Applicant Information Please Print Legiblv Business/Organization Nazne: /�j��, S l-f o t� f N �`� Address: `� � �ru� 2�-_ o�G�j City/State/Zip: s o c�Tl-1 `(��nou`jY(, r+w - Phone#: � � C Are you an employer?Check the appropriate box: Business Type(required): 1.❑ I am a employer with employees(full and/ 5. ❑ Retail or part-time).' 6. ❑ RestauranUBaz/Earing Establishment 2.❑ I am a sole proprietor or paRnership 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 officers have exercised 9. ❑ Entertainment their right of exempfion 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 organization, staffed by volunteers, �� with no employees. [No workers' comp. insurance req.] 12.�Other �y *Any applicant thai checks box#1 must also fill out the section below showiag the'v workers'compensation policy infotmatioa �� ••If the corporate officers have exempted ihemselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#I. I am an employer that isp�oviding workers'compensarion insurance for my employees. Below is the po[icy information. Insurance Company Name: �(��C,/� p f�I`L�� '1�'�1 Insurer's Address: (�- o - � � SS-�� R 2 City/State/Zip: ►�6,5 t Z� te-F � M� ' 6 2 2e� ,s Policy#or Self-ins.Lic.# �S`�2 G 03 � �S"3 E�cpiration Date: 7 � (Lt �S Attach a copy of the workers' compensation policy declaration page(showing the policy nnmber and espiration date). Failwe to secure coverage as required under Secrion 25A of MGL c. 152 can lead to the imposition of criminal penalries of a ' fine up to$I,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 Invesfigarions of the DIA for insurance covernge verificarion. I do hereby certify,under the pains and penalties ofperjury thai the information provided above is true and correcG Si ature: -_— Date: � � � Phone#: �� G `� 7`� � Officdal use only. Do not write in this area,to be cornpleted 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 ��,. � � !�l �.�r I.v t L� 13 9z i 7-1 � �1 R B E'L L A 2ass2 �6-�p� �-��I., ��-�„? �PL �,,� y� � .�sr,,:w�E:�,o,,. . POBox-553s2 1-800-AqBELLR I qqBELL�.COM B�ton, MA02205-5392 INVOlCE 612034193 . .- — .— .112/23/2014 ' $25.00 -----_—______ $25.00 : 01/15/2015 Customer: Agent:28-gg2 ? SARKAR HOSPITALITY LLC TANNA INS INC " DBA CAPE SHORE INN HOTEI 101 CAMBRIDGE ST 793 MAIN ST RTE 28 SUITE 220 SOUTH YARMOUTH, MA 02664 BURLINGTON, MA 01803 781365-1362 BILUNG SUMMARY To make a�payment on.hne visit www arbella cam To pay 6y�phone,call 1-800-ARBELLH. ='°m-m -�- _ .5,.� ..� ... .. � �..,— ' ' - ' ' �:._ _ ?:�::a_ - - _ ;:: .. � .. �: . � �caa_.., ' �__^� . .x.. .:.� . ,__ _ .-�'�._ � .- . '�.. � .�:.� :»-.. � _ _ ._.. _ _ e. ..y_ - _.�.��.='� �_.....:_. _� _ "' _. � "'�._ _�: - _..._ _..._ '_ ' ' - __ � .. .. _ . - _... _ ._ ___ _ _ . - _ 7520031653 Arbella Protection Businessowners 07/12/2014-07/12/2015 $0.00 $0.00 Premium: $0.00 $0.00 $0.00 Fees: $25.00 $25.00 $25.00 Total: ��v�_�_. _ ="-��=°;" ____==s`=;;_ ___ _. �:.,_ .w�=u.=- _ _-m . ?.tik="��.' _ ACTNfTY SINCE LAST INVOICE �.m_.�„_ _:,�, ___.. __ ._r�:m_..__ . . :. w- . __ .-�m_-M..M �.: . � �um .. ' �. _ ' -_`_ _ - _ _- . ._._v___ ._ _..� m.: ._ _.. ___ i�, .m __ .___ .._ � . .=-�=_-. _._ __ __......:_ .:.. ' ��-�::-� � . r _ _ __ _..._...::_... _.....:_._�..:-�,_:-: 11/21/2014 Previous Balance $25.00 Ending Balance $25.00 If you have any questions regarding this imoice or want to make changes to Report all claims 24 hours a day: your policy,including your mailing address,please conWct your agent. Toll Free 1-800-ARBELLA Detach tfie stub below and�retum rt tiith your payment in the envebpe provbed.Write your AccourN pum6Y!on.yout ci�edr,payaMe ho/trpyhs�ngyre�e p�oup SARKAR HOSPITALITY LLC � DBA CAPE SHORE INN HOTEL A R B E L LA° 793 MAIN ST RTE 2S SOUTH YARMOUTH, MA 02664 , aoo ,,RaE«, ,pRaE«,.�oM 612034193 �01/15l2015 $25.00 j $25.00 Arbetla Insurance Group PO Box 55392 Boston, MA 02205-5392 ^ � 006612034193000000000000000�00250000q0�02500AD9 � � �� WORKERS COMPENSATION AND EMPLOYERS' LIABILTY � � � ' INSURANCE POLICY -•-- INFORMATION PAGE INSURER: POLICY NO: WE128033A NORFOLK & DEDHAM MUTUAL FIRE INSURANCE COMPANY 222 AMES STREET RENEWAL DEDHAM, MA 02026 NCCI Company No: 21059 Account No: FEIN: 45-2162975 ITEM 1. NAMED INSURED AND MAILING ADDRESS: AGENT NAME AND ADDRESS: SARKAR HOSPITALITY LLC DSA RED MILL MOTEL BOYNTON INSURANCE AGENCY, 793 MAIN STREET RT 28 INC YARMOUTH MA 02664 �> 72 RIVER PARK STREET NEEDHAM, MA 02494 AGENT NO.: 20272001 LEGALENTITY: LIMITED LIABILITY COMPANY (LLC) O7HER WORKPLACES NOT SHOWN ABOVE: (See Workers Compensation Classification Schedule) ITEM2. POLICYPERIOD: From: OS/15/2013 To: O5/15/2014 Effective 12:01 A.M. Standard Time at the Insured's mailing address. ITEM 3. COVERAGE: A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers' Liability insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits of liability under Part Two are: Bodily Injury by Accident: $ 100,Q00 each accident Bodily Injury by Disease: $ 500, 000 policy limit Bodily Injury by Disease: $ 100, 000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: SFsE ENDORSEMENT WC 20 03 06 A D. This Policy includes these Endorsements and Schedules: See Schedule of Forms and Endorsements. ITEM 4. PREMIUM: The premium for this Policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required on the Workers Compensation Classification Schedule is subject to verification and change by audit. Total Estimated Minimum Premium: $ 231 Annual Premium: $ 257 Audit Period: ANNiTAL Additional / Return Premium: Comments : Issued At: Date: 04/OS/2013 Countersigned by WC 00 00 01 A . Copydght 1987 National Council on Compensation insurance . INSURED COPV _ ___ _ ____ ----- -- - _ __ ----- — -- - — + --- —� _ Q1/21/15 01:21AM HP LASERJET FAX 17B13651369 p. 01 �'�" ' �� '� ��`1 w onTe�Mrsoonvrr� A�!� CERTIFICATE OF �tABILITY INSURANCE i�zo��ois THIS C�tiTIF1CA7C 18 188UED AS A MATTER �F INFORMAl10N ONLY AND CONPL'ft8 NO RIGHTS UPON TNE CfiRTIFICATE HOID�R� THIS CERTPICATE OOE9 NOT AFFIRMA7IV@LV OR NE6ATIVELY AM&Nb� �XTENO OR AITER TN2 C6VERAC3H AFPORDLD BV THB VOl1GE3 HEI.OW. TNIS CERTiFICATB OF INSURANCE DOCS NOT CONSTITUTB A CON7RACT BETWEEN 7HB (SBUING INSURER�S), AUTHORIZED RP.PFtEBCNTAT9VE OR PtiODUCER AND TW6 CEiiTiPiC f1TC M10lPER• IMNOR7ANT: II tbu CORiflcate beld6r la an AqDITIONA4 1 SUR&B,the pollcy�ie8)�nust bo 9ndors0d. I1 SUBROGATION 19 WAIVBD,aubJoct to t�e termx and eondttlons of tM1e policy,Cortaln policios may raqulfe an¢ndor9ament. 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