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Home My WebLink AboutApplication and WC � $� �• 6Ja�2FRONr � a TOWN OF YARMOUTH BOARD OF HEALTH ti�, Ho SES � �� APPLICATION FOR LICE � - I ��5�� .� � ` * Please complete form and attach all n ss pi n �' e emD��l� g�5 ' � � Failure to do so will result in th f� p tio pacHEALTH DEP . �'(— ESTABLISHMENT NAME: s 'u rr h oz. e S aY iD: LOCATIONADDRESS: o EL.#: - 7- O�o MAILING ADDRESS: f E-MAIL ADDRESS: �r o,ca OWNER NAME: CORPORATION NAME (IF APPLICABLE): � i`v /' C I-r uSPS MANAGER'S NAME: TEL.#: (� - 3 - OG MAILING ADDRESS: 1 ' f S o �o?GG Y POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool O erator(s) and att ch a copy of the certification to this form. - _��,_L _ �arsons _ ---_ 2 _ ose�,� `__��y - _ ---- 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 all 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. /'"�2ooc . L �/C3(Yortt 2. vaSe � L �� 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 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 Deparhnent will not use past years' recards. You must provide new copies and maintain a file at your establishment. 1. 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 a11 times. Please list your employees trained in anti-chokmg 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. Z• 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 $55 �SWIMMINGPOOL$IlOea {}i _LODGE $55 _TRAILER PARK $105 _WHIRLPOOL $IlOea. FOOD SERVICE: ' LICENSE REQUIRED FEE PERM(T# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMTT# 0-100 SEATS $125 _CONTINENTAL $35 NON-PROFIT $30 >100 SEATS � $200 � COMMON VIC. $60 WHOLESALE $80 � —RESID.KITCHEN $80 � RETAIL SERVICE: LICENSE REQIDRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 =<25,OOOsq.ft. $150 —FROZENDESSERT $40 _TOBACCO $110 NAME CHANGE: $IS AMOUNT DUE _ $ 11 O • � *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** � \ ADMINISTRATION � * Under Chapter 152, Section 25C,Subsection 6,the Town of Yannouth is now required to hold issuance or renewal ,y 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 ATTACAED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED� OR �WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be limited to the temporary and short term occupancy,ordinarily and customarily 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 ar 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 Deparhnent to schedule the inspection three(3) days prior to opening. PLEASE NOTE: People are NOT allowed to sit in the pool area 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. POOL CLOSING: 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 Departrnent 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 obtamed at the Health Department,or from the Town's website at www.varmouth.ma.us under Health Department, Downloadable Forms. FROZEN DESSERTS: Frozen desserts must be tested by a State certified lab priar to opening and monthly thereafter,with sample results submitted to the Health Department. 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 Boazd of Health. OUTDOOR COOHING: Outdoar cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. NOTICE:Perxnits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 15, 2014. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMEN EMENT. RENOVATIONS MAY RE UIRE A SITE PL�N. // DATE: G z S SIGNATURE: (/ PRINT NAME&TITLE: � > O r�' Rev. Il/03/t4 � The Commonwealth ofMassachusetts Department of Industrial Accidents � I Congress Streey Suite I00 Boston,MA 02I14-20I7 www mass.gov/dia Workers'Compensation Ineurance Affidavit:General Businesses. . TO BE FILED WITH THE PERMITTING AUTHORITY. Apolicant Information Please Print LeQiblv Business/Organization Name:,�� S S lS 1�U PI' /pJ,��P("FJ'O�t t Tac�h h ouSPs Address: ` � City/State/Zip: �. �Q f YNU°�I/�t � / /�P �e�y �S�b g - 737- �f�o� Are you an employer?Check the appropriate bos: Business Type(reqaired): 1.� I am a employer with_ '� employees(full and/ 5• ❑Re[ail orpart-time).* 6. �RestautanUBaz/EatingEstablishwent 2.❑ I am a sole proprietor or parinership 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.❑ VJe aze a corporation and its officers have eacetcised 9. ❑Entertainment their right of ercemption per c. 152,§1(4),and we have 10.❑Manufaduring no employees. [No workers'comp.insurance required]* 11.❑Heakh Caze n 4.❑ We are a non-profit organization,staffed by volunteers, , , /-� j] �9 with no employees. [No workeis'comp.iasurznce req.] 12.�.Other -S W/nl m i OOO/ Or(J-C!'IL>YQ lt�S `Any applicant that checks box#1 must also 5ll out tl�e section bclow sLowing iLeQ wockeis'compensaOon policy info�eGon. «*If1Le camo:ate officas have er.empted ihemselves,but the coxpocation Las othet employxs,a workets'compensauon policy is nquueA and such an ocgenization should check box#1. I am an employer that is providing workers'compensa6on insurance for my emp[oyees Below is the policy information. Insurance Company Name: /� L[ fl,(q U/�q M Insurer's Address: � / / �c} / O PCl'3/4�(° .)� ��Ty�s,��Z�p: ,� m�.� f�,� M� o�� Policy#or Self-ins.Lic.#__�k�� Y00- 70„29/Do? -�pS uon nate: � �� 2D/G Attach a copy of the workers' compensation policy declaration page(showing the policy number and e iration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or onayeat imprisonment,as well as civil penalties in the foim of a STOP WORK ORDER and a fine � of up to$250.00 a day against the violator. Be advised that a copy of tlris statement may be forwazded to the Office of Investigations ofthe DIA for insurance coverage verification. I do hereby ce ' , under the pains enal[ies ofperjury that the inforn�ation prmided above ' bue and ronecG Si ature: � Date: li ,� Phone#: � — d� Officia!use only. Do not write in this areq to be comple[ed by city or town offuiaC . City or Town: Pecmit/License� Issuing Authority(circle one): 1.Bosrd of Heatth 2.Building Department 3.City/fown Clerk 4.Licensing Bosrd 5.Selectmen's Office 6.Other Contact Person: Phone#: � .. , www.mass.gov/dia .. .. . .. .. . �. M utua I A.I.M. Mutual Insurance Company Massachusetts Employers Insurance Company New Hampshire Employers Insurance Company INSURANCE COMPANIES Associated Employers Insurance Company �; RENEWAL PROPOSAL WORKERS' COMPENSATION Insurance Company:A.I.M. Mutual Insurance Company Policy#:AWC-400-7029102- 2015A Insured: Producer: 1005— 1 — 1 Bass River Watertront Townhouses HUB International New England LLC �;' 1376 Bridge Street-#19 pgg gallardvale Street C/o Peggy Parsons&Joe Frey Wilmington, MA 01887 South Yarmouth, MA 02664 Empioyers' Liability: Renewal Effective Date: 06/01/2015 Bodily Injury By Accident 100,000 Each Accident Anniversary Rating Date: 06/01/2015 Bodily Injury By Disease 500,000 Policy Limit Quote Date: 03/26/2015 Bodil In'u B Disease 100,000 Each Em lo ee Unit 1 - Bass River Waterfront Townhouses Massachusetts From 06/01/2015 to 06/01/2016 Totai ESUmated Rate Per Estimated Annual $100 of Mnual Classifications . � Code No. Remuneration Remuneration Premium CLERICAL OFFICE EMPLOYEES NOC 8810 If any 0.08 0 BUILDINGS NOC-OPERATION BY OWNER OR LESSEE 9015 8,042 2.99 240 Manuai Premium 240 Standard Premium 240 Loss Constant 20 260 6Qense Constant 250 570 Terzorism Act Surcharge 2 512 7ota1 Estimated Premium 512 DtA ASSESSMENT 5.80% 14 526 Total Estimated Premium&Surcharge(s) 526 54 Third Avenue• P.O. Box 4070• Burlington, MA 01803-0970•Tel: 781.221.1600/ 800.876.2765• Fax: 781.270.5599 BRIDGEWATER• BURLINGTON•CANCORD, NH . HOLYOKE• MARLBOROUGH �...............�r.�,�,.,.,.,.:�.,..i.,..+..,...:..,.,.aee..,.,...,.�.....,...,. M utua 1 A•I.M. Mutual Insurance Company �� Massachusetts Employers Insurance Company ._._ New Hampshire Empioyers Insurance Company 1NSURANCE CQMPAfVIES Associated Employers Insurance Company RENEWAL PROPOSAL WORKERS' COMPENSATION Insurance Company: A.I.M. Mutual Insurance Company Policy #: AWC-400-7029102- 2 1 Insured: i Producer: 1005— 1 — 1 Bass River Waterfront Townhouses ; HUB International New England LLC 1376 Bridge Street- #19 ' 2gg gallardvale Street C/o Peggy Parsons &Joe Frey � Wi�mington, MA 01887 South Yarmouth, MA 02664 Renewal Effective Date: O6/01/20t5 ; Anniversary Rating Date: 06/01/2015 ' Quote Date: 03f2612015 Unit 1 - Bass River Waterfront Townhouses Billing Payment Mode: Annual Initiai Payment Items Premium $512 DIA Assessment $14 Total to Remit $526 invoice Schedule Due Date 06/01/2015 Annual Installment $526 Total 5526 Units Billed to this Unit Rating Unit# Unit Name State 1 Bass River Waterfront Townhouses MA ..� n�R03-�9��•Tei: 781.221.1600/800.876.2765• FaX: 781.270.5599 _._..._.._ ....o�nnon��ru - A. Yi. Mutual A.I.M. MutualInsuranceCompany Massachusetts Employers Insurance Company �— New Hampshire Employers Insurance Company lIVSURANGE COMPANIES Associated Employers Insurance Company RENEWAL PROPOSAL WORKERS'COMPENSATION TEL.# (800) 876-2765 P�EASE MAKE REMITTANCE TO � Date 03/27/2015 A.I.M.Mutual Insurance Co P.O.Box 4070 Burlington, MA 01803-0970 iMPORTANT: COVERAGE WILL NOT BECOME Bass River Waierfront Townhouses EFFECTIVE UNTIL YOUR POLICY EFFECTIVE 1376 Bridge Street-p19 DATE. C/o Peggy Parsons&Joe Frey South Yarmouth,MA 02664 PLEASE PAY THE TOTAL AMOUNT DUE SHOWN BELOW NO LATER THAN: INSUREO May 12, 2015 HUB international New England LLC payment of the deposit premium will constitute 299 Ballardvale Street the employer's acceptance of antl agreement io W iimington,MA Ot 887 ihe terms and contlitions of the policy. PRODUCEROFflECORO � Current Policy Expiretfon Date 06lOV2075 �enewai�olicyEffeciiv.Uat2 06i0�ir29�5 Renewal Policy Number AWC-400-7029102-2015A ; Estimated Total i Rates Per � Estimated Annual Premiums �! CODE ; I St00of ' ' NQ Annuai I Remun- ' Su6�ectto I �� Remuneratio^ ' erat:on � Modificatioo AllOther ' � I I � I � SEE EXTENSION OF INFORMATION PAGE � TOTAL ESTIMATED ANNUAL PREMIUM 512.00 TOTAL MA ASSESSMENT 240.00 x 5.8% 14.00 DEPOSIT PREMIUM 526.00 DEPOSIT ASSESSMENT TOTAL AMOUNT DUE 526.00 � ' � . � � � � FOR COMPANY USE ONLY � , . NET AMOUNT OF CHECK Placing Office: 400-109-2 ; - � Initial&Date 54 Third Avenue• P.O. Box 4070• Burlington, MA 01803-0970•Tel: 781.221. . . . , . BRIDGEWATER• BURLINGTON • CONCORD, NH • HOLYOKE. MARLBOROUGH