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Home My WebLink AboutApplication and WC, - � TOWN OF YARMOUTH BOARD OF HEALTH �M��P Gvti t��r� �� APPLICATION FOR LIC�iK,SE �RMI t2014 ��'«��d��° • * Please complete form and attach all$nebess�-��yc�vnts by D ember,l(� ` Failure to do so will result in t�ret�q,�yp�t�i;pplieaho pack t. HE�L i H DEP7. ESTABLISHMENT NAME: N LOCATIONADDRESS: f_'3 i4�,�.cNtiJ ST • TEL.#: C'CDg1 395+-'�}6L� MAILINGADDRESS: �n,L�'- `zg� �urtt��H�/�C�LL, lYlh -02664 E-MAIL ADDRESS: OWNER NAME:� � �oLa— C'� CORPORATION NAM (IF APPLICABLE): �-�7��a-RI ��2,�L� C�P . MANAGER'S NAME:_}�L.�� —�=L TEL.#: C S� ��14�40� MAILING ADDRESS: r �►y» e_ — 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. i.�I v t>s-i-� Q��=r-�-c—r a. Tlr.�� I— Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cazdiopulmonary Resuscitation(CPR),having one certified employee on premises at a116mes. Please list the employees below and attach copies of their certifications to this form. The Health DepaMment will not use past years' records. You must provide new copies and maintain a file at your place of business. l.�� V-S� � �L 2. �T�p�� 3.�,�-p n�1 1=_ R 1 c c� 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 Protecfion 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 tile at your establishment. 1. J��/.� 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. _ _ 1. D�//'f— 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 Department will not use past years' records. You must provide new copies and maintain a file at your establishment. 1. /`�/� 2. 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. �(4/� 2. 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 1 MOTEL $55 �iy-cz5 INN $55 —CAMP $55 �SWIMMING POOL $80ea �y -Cys _LODGE $55 =TRAILER PARK $105 LWFIIRLPOOL $80ea ��z,� FOOD SERVICE: � LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100SEATS $85 �CONTINENTAL $35 ��-I:J4 NON-PROFIT $30 >100 SEATS $160 _COMMON VIC. $60 WHOLESALE $80 —RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# � LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq.ft. $50 >25,000 sq.ft. $225 VENDING-FOOD $25 =<25,000 sq.ft. $80 _FROZEN DESSERT $40 —TOBACCO $95 NAME CHANGE: $15 AMOUNT DUE _ $ 33C.G� *•***'pLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*•*** " � �\ -� . ADMINISTRATION �3 Under Chapter 152, Section 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 AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED 1 OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth t�es 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 temparary 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 tliirty(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 Dapartment 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 Department prior to opening. Please contact the Health Departrnent 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 obtained at the Health Department, or from the Town's website at www.yarmouth.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 Deparfinent. 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 Health. 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 YQUR RESPONSIBILIT'I'TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 13, 2013. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW E(2UIPMENT, ETC.),MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF EALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SIT AN ��j � _ DATEc SIGNATURE: PRINT NAME&TITLE: Gi�c� - Rev. ]0/08/13 ` � The Commonwealth ofMassachusetts ' Department oflndustrialAccidents Office ojinvestigations ' ' d 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Apnlicant Information Please Print Le¢iblv Business/Organization Name: �{�►a I I�jL�-�Sf}'�� 12 I �Il� � �l) I�"� Address: ��j� �i , ��I�A�rt��,L�(�1�•. � City/State/Zip:�•l ��' � Phone #:�, ��^�� 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. ❑ RestauranUBar/Eating Establishment 2.❑ 1 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 officers have exercised 9. ❑ Entertainment 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 nomprofit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.�Other 'Any applicant[hat checks box#1 mus[also fill out the sec[ion below showing Iheir workers'wmpensa[ion policy informa[ion. **If the corporate officers have exemp[ed[hemselves,but the corpontion has other employees,a workers'compensation policy is required and such an organization should check box#I. I am an emp[oyer that is providing workers'compensation insurance jor my employees. Below is the policy information. Insurance Company Name: �/��L-SC' U �NS U !�/-I�A.1C � ��7Y)')(�L�-/�)�/ Insurer's Address: ��La � �/�f��(=12 �r�i S O ��(_ ' �, � � / l \ City/State/Zip: ��.:1/�� , �(� �f�q ��--- Policy#or Self-ins. Lic. # (aI �� ('�� Expiration Date: � 8� �i Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration 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 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 violatoc Be advised that a copy of this statement may be forwazded to the O�ce of Investigations of the DIA for insurance coverage verification. I do hereby certify, nder he ai yxtl penalties ofperjury that the information provided above is lrue and correcG Si nature: � � Date: � 3 Phone#: � t'S � Official use only. Do nat write in this area,to be completed by city or town official. Ciry or Town: yA2Mou�a4 PermiULicense # Iss ' (circle one): .Board of He h 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's O�ce 6. Other Contact Person: Phone#: 6bg-34B-a331 J(/2Y� www.mass.gov/dia Wesco Insurance Company � A Stock Insurance Company . • • 874 Walker Rd,Suite C Dover, DE 19904 WORKERS COMPENSATION AND EMP�OYERS LIABILITY WC 99 00 01 B INSURANCE POLICY 1 of 4 _ - - --- --_ _-_._ -------- INFORMATIONPAGE -- --- Ncci Code: 26135 �h �p A. t �� C^ ' /'„ �� /�_Q- n_1_� 1. Insured: 1 V �d Y �l'oZ �eit u�C �,�r,� Policy Number: WWC3p5�916 Gaytri Krupa Corp. ., � p` DBA: Ambassador Inn & Suites � � �`3 `� 7 Individual Partnership 1314 Route 28 X Corporation South Yarmouth MA 02664 Federat Ta,c ID: Other workplaces not shown above: Risk Id: See Extension of Informarion Page Renewal of: W WC3032260 . Producer: AmTrust North America,Inc. c/o GH Dunn Insurance Agency,Inc. , P.O.Box 497 Mattapoisett MA 02739 .- _ - - - - - 2. The policy period is fro 3/9/2013 to 3/9/2014 12:01 a.m.at the insured's mailing addcess. -- �� 3. A. Workers Compensation tnsmaxee, �e policy applies ro[he Workets Compensa6on Law of the states listed here: Massachusetts B. Employers Liability Insurance: Par[Two of the policy applies to work in each stated listed in item 3.A. The limits of our]iability under Part Two are: S[ace Bodily Injury by Acciden[ Bodity Injury by Disease Bodily Injury by Disease _ __._ ---- _ _ _ _ _ . ___ ME+ $ 500,000 each accident $ 500,000 po]icy limit $ 500,000 each employee C. Other States Insurance: Part Three of the policy applies to the states,if any,listed here: All states except ND, OH,WA,WY and State(s) Designated in Item 3A. D. This policy includes these endorsements and schedules: WC 00 00 00 B, WC 99 00 Ot B,WC 00 01 13A,WC 00 03 08,WC 00 04 14, WC 20 01 01,WC 20 03 01, WC 20 03 02,WC 20 03 03C,WC 20 04 01,WC 20 04 O5,WC 20 O6 01A,WC 20 O6 04 _ _ _ _ - _ -- -- --------- - .. 4. The premium for this policy will be determined by our Manuals of Rules,Classifica6ons,Rates and Rating Plans. All information required below is subject to verification and change by audi[. See Extension of Information Page TOTAL ESTIMA7'ED ANN[JAL pgEMI[JM STATE ASSESSMENT �8 TOTAL ES1'IMATE�COST � 864 Minimum Premium „ � Deposi[Premium ' / 395 Issue Date: 1/24/2013 �� i t,�r� 864 Countersigned by: � ��" � [premverl_12/11/2012 -- -- - - ' Autho d Representa6ve � F