HomeMy WebLinkAboutApplications and WC ` Pc.q,u�-T Fr��`ss 'I
� TOWN OF YARMOUTH BOARD OF HEALTH
� l� � APPLICATION FOR LICENSE/P ��20 p����d��
� �'�:�.a�( ;
* Please complete forrn and attach all necessary�ic�c A�by�ecemL"er 5 2��. 2 2 1011
Failure to do so will result in the return of your apphcation pac et HEALTH DEPT.
ESTABLISFIMENTNAME: � C � � Q/f l�+h� Fi tirft T •
LOCATIONADDRESS: I1 Wh�j {�aNc� r��✓t TEL.#: �°8�760 -?3c�
MAILING ADDRESS:
OWNER NAME:
CORPORATION NAME(IF APPLICABLE): W G� T ti c
MANAGER'S NAME: C 1�� hahi t TEL.#: S�8'�g a'�3uu
MAII.ING ADDRESS: cuutic
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 2.
Pool operators must list a minimum of two employees currently certified in basic water safety, standard Fust Aid
and Community Cazdiopulmonary Resuscitation (CPR). Please list these employees 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�le 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 certif'ication to this application. The Health Department will not use past years'records.
You must provide new copies and maintain a�le at your establishment.
1. 2•
PEASQN IN CHABGE: __ _- -- -- _ - _ -_
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operafion.
1. 2•
HEIMLICH CERTIFICATIONS:
All food service establishments with 25 seats or more must have at least one employee uained in the Heimlich
Maneuver on the premises at all 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. 2•
3. 4.
RESTAURANT SEATING: TOTAL#
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMTT# LICE(VSE REQUIRED FEE PERIv1IT N
B&B $55 _CABIN $55 _MOTEL $55
INN $55 _CAMP $55 _S�VIMMING POOL SSOza
LODGE $55 _1RAII.ERPARR $105 _WkIIRLPOOL $80ea
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMTT# LICEIVSE REQUIRED FEE PERMIT#
0-100 SEATS $85 _CONTINENTAL $35 _NON-PROFIT $30
>100SEATS $160 _COMMONVIC. $60 _VVHOLESALE $80
RETAII.SERVICE: —RESID.KITCHEN $80
� LICENSE REQUIRED FEE PERMTf# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
<50 sq.fr. $50 _>25,OW sq.fr. $225 �VENDING-FOOD $25 r�-u(OJ
_<25,000 sq.ft. $80 _FROZEN DESSERT $40 _TOBACCO $95
NAME CHANGE: $15 AMOUNT DUE _ $ 2S.o 0
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� �"� The Commonwealth ofMassachusetts
Departmeat of/ndustrial AcciJents
N�IC�Niw�tllMs
600 Washington Slreet, 7`"Floor
Boston,Mass. 02111 .
. : . Worlcera'Compeesatioe Iroaraace Affldavit�� � � .. . .
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nafoe: . . . .
addtess: _ __ _ ____ _—
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❑ I am a homeowner peifotming all wmk myself.
�❑ mn a sole proprietor and have no one working in ary capacity. �
am an employer pcovidi�wmkers compensati�for my employees wodcing�t6is job.
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t6e following wodcers wmpec�sation polices:
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Technology Insurance Company
A Stock Ineurance Company
20 Trefaigar Square,Suite 459
Nashua,NH 03063
WORKERS COMPENSATION WC 99 00 0'i B
AND EMPLOYERS LIABILITY �°f 4
INSURANCH POLICY INFORMATION PAGE
Ncci Code: 39071
1. Insured: Pollcy Number: TWC3288104
P&P Gym Inc&WGY Inc
Individual Partnership
108 Clematis Avenue X Corporation or
Suite K
W alfham MA 02453 Federal Tax ID: 042734569
Other workplaces not shown above: Risk Id:
See Extension of Information Page Renetival of: TWC3254874
Producer:
AmTntst North America,Inc.
do TA Insurance,fac.
One Griflin Brook Drive,Suite 100
Methuen MA 01844 --
L The pplicy period is from 9/2/2011 to 9/2/2012 12:01 a.m.at the insured's mailing addmss --
3. A Warlce[s Compensarion I�s�nce: Part Qoe of the policy applies tn the ZYoriceca Compensetiaa I-aw of
t6e states listed here: Massachusetts
B. Employers Liability Insurance: Part Two of the policy applies to work in each stated listed in item 3.A.
The limits of our liabiliry under Parc Two are:
Sta[e Bodily Injozy by Accident Bodi�y FnPII3'63'Ihs�s�_ Bodily Injury•by"I�sease
MA $ 500,000 each accident S 500,000 poticy timit S 500,009 each e�loyee
C. Other Sfates 7nsurance: PaR Three of the policy applies to the states,if any,listed here:
A!i states except ND,OH,WA,WY and Sbte(s)DEsiSnated in Item 3A.
D. This policy includes these endarsements and schedules:
WC 00 00 00 B,W C 99 00 01 B,WC 00 01 13A,WC 00 0414,W C 20 01 01,W C 20 03 01,WC 20 03 02,W C
20 03 03C.WC 20 04 01,WC 20 04 05,WC 20 06 01A,WC 20 O6 04 __
4. The premium fox Hus policy will be determined by�our Manuals of Rules,Classifications,Rates and Raring
plans, A11 infommGon required belmv is subject to verification and change by audit.
See Extension.of Information Page
TOTAL ESTIMATED ANNUAL P1tEMiUM z'429
132
STATE ASSESSNIENT 2,561
TOTAL ESTIMATEA COST
411
Minimum Premium 374
Deposit Premium
Issue Date: 7/11/2011 Countersigned by: __T _-..
Authorized Represemative