HomeMy WebLinkAboutApplication and WC / � � TOWN OF YARMOUTH BOARD OF HEALTH �
f��� APPLICATION FOR LICENS�/P, -c�l � r s�
r^r, 14 2012 �
* Please complete form and attach all nece s� d b r
Failure to do so will result in the ret�of c i ' �
ESTABLISHMENT NAME:�M P�/�SS I��c�K���1'1��['AX ID• �� ���� ��'
LOCATION ADDRESS: �3��- ���� ���(TT1i T mmw411t TEL.#: c ,`�rT� -��q/�- -,L'1y�,j
MAILING ADDRESS: F E
OWNER NAME: �'r h+ n)V A-N S
CORPORATION NAME (IF APPLICABLE):
MANAGER'S NAME: TEL.#:
MAILING ADDRESS: Y�'10
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator,as required by 5tate law. Please list the designated
Pe�l Operator(s) and at[ach a copy of the certification Yo this form.
1.�1/1��" �$,�� 1 L• _ _ - —I—�—
Pool operators must list a minimum of two employees currently certified i basic water safety, standard First Aid
and Community Cardiopulmonary 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 file at your place of business.
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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 59p.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.
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. ;�R�:;3�F;�3�:P.�r: . - __ _ _ _ _ _
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
1. 2•
HEIMLICH CERTIFICATIONS:
All food service establishments with 25 seats or more must have at least one employze trained in the Heimlich
Maneuver on the premises at a11 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 �le at your place of business.
1. 2.
3. 4.
RESTAURANT SEATING: TOTAL#
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT# L[CEiVSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
__B&B $55 CABIN $55 I MOTEL $55 -�"�5
INN $55 _CAMP $55 2 SW'IMMING POO� $SOea.�1�—n 4�
LODGE $55 _TRAILER PARK $105 �WHIRLPOOL $80ea�I�v�(12�
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# L[CENSE REQUIRED FEE PERMIT#
0-100 SEATS $85 �CONTINENTAL $35 . 13�10� _NON-PROFIT $30 _
>]00 SEATS $160 COMMON VIC. $60 _WHOLESALE $80
RETAIL SERVICE: —RESID.KITCHEN $80
L[CENSE REQUIRED FEE PERMIT# L[CENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERD4IT#
_<50 sq.ft. $50 _>25,000 sq.ft. $225 _VENDING-FOOD S25 __
_<25,000 sq.ft. $80 � _FROZEN DESSERT $40 _TOBACCO $95
NAME CHANGE: $15 � AMOUNT DUE _ $ 3�✓O .O O
*****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 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 yow permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES_� NO
MOTELS AND ATHER LtkDGING ESTABLISAMENTS —> _ - -
TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be
limited to the temporary and short term occupancy,ordinazily 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, shail 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 De�artment to schedule the inspection three(3)days
prior to opening. PLEASE NOTE:People aze NOT allowed to sit m 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 priar 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 Department to schedule the inspection three (3) days prior to opening.
CATERING POLICY:
Anyone who caters witttin the Town of Yannouth must notify the Yannouth 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.vannouth.ma.us under Health Department,
Downloadable Forms.
FROZEN DESSERTS:
Frozen desserts must be tested by a State certified lab prior 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 Pernvt until the above terms have been met.
OUTSIDE CAFES:
___ '_ ' 'ng�ith wraiterLw�tces.�servi�e�,musthave prior a�aaroyal from tl�e Bpard of H�alfli` _ _
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 RETURN
THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 15, 2012.
ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY I BOARD F HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE A
DATE: I2 � SIGNATURE: � . �
PRINT NAME & TITLE:
Rev. 10/09/12
. � The Commonwealth ofMassachusetts
Department of Industrial Accidents
Offace oflnvestigations
I Congress Street, Suite 100
Boston, MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Leablv
Business/Organization Name: �-`j'y)�G71��'.Q�.�OI� l'Yl'3� �l �L%(�
Address:��2./���/� �p'`�, ��e•��
City/State/Zip: SZ • u �+� /Y�- Phone#: � �'S 3� � CT�1�
Are�ou an employer?Ckeck aPP�F�'�tQ Fwz; .. ' ;Busisess TYLx�e4y���,: _
1.❑ I am a employer with employees(full and/ 5. � Retail
or part-time).* 6. ❑RestaurantBaz/Eating Establishment
2.❑ I am a sole proprietor ox partriership and have no �. � 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 are 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.O�ealth Caze
4.❑ We are a non-profit organization,staffed by volunteers, / „�
with no employees. [No workers' comp. insurance req.] 12.��Other �_.0
*My applicant[ha[checks box#1 must also fill out the section below showing thev workers'compensation policy information.
"If Ihe corpornte officers have exempted themselvu,but[he corporation has other employees,a workers'compensation policy is required and such an
organization should check box#1.
I am an employer that is providing workers'compensation insurance far mny employees. B-el^ow—is the policy injormatinn.
InsuranceCompanyName: ��'�ltil,✓YG7'�C� ( PILC,�,f�".L�T
Insurer's Address: ���, l�/X��!%� C=Ii� .�o �i�U
t
City/State/Zip: ��{lP/1�- ,, �� — �C�,'�/��
___ ndiey#w. Se?cias.Lic:# ����Q�-��(�-- - _ -Expi:�sfiea Dat� �3< ��f�01� _ _
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failwe to secwe coverage as requued under Section 25A of MGL c. 152 can lead to±he imposirion of crimir.al penaltees 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 Sne
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 coverage verification.
I do hereby cernfy,under the ains d�ofperjury that the injormation provided above is true and conect
Si ature: �— Date: ���'�
Phone#: � ��
Official use on[y. Do not write in this area,to be comp[eted by ciry or town officiaL
City or Town: lA�M1J1T11�- Permit/License#
ng u o 'rcle one):
1.Board of Health 2.Building Department 3.CitylTowo Cle�k 4.Licensing Board 5.Selectmen's Office
ContactPerson: Phone#: ,rjQ'�`j `�-�Z�J � X �2-I�
. . _ � .. � � www.-m�.ss.goviHia . . . ..
. Wesco Insurance Company
' A Stock Insurance Company
874 Walker Rd,Suite C
Dover, DE 19904
WORKERS COMPENSATION WC 99 00 01 B
AND EMPLOYERS LIABILITY 1 of 4
INSURANCE POLICY INFORMATION PAGE
Ncci Codc: 26135
1. Insured: Policy Number: WWC3032260
Gaytri Krupa Corp.
DBA: Ambassador Inn& Suites _Individua] _ Partnership
1314 Route 28 X Corporation or _ _
South Yarmouth MA 02664 Federal Tax ID:
Other workplaces not shown above: Risk Id:
See Ex[ension of Informa[ion Page Renewal of: WWC3022105
Producer.
AmTrust North America, Inc.
c/o GH Dunn Insurance Agency,Inc.
55 Counry Road
Mattapoisett MA 02739
2. The policy period is from 3/9/2012 to 3/9/2013 12:01 a.m. at the insured's mailing address.
3. A. Workers Compensaaon Insurance: Part One of the policy applies to the Workers Compensation Law of
the 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 liability under Part Two aze:
State Bodily Injury by Accident Bodily Injury by Disease Bodily Injury by Disease
MA $ 500,000 each acciden[ $ 500,000 policy limit $ 500,000 each employee
C. Other States Insurance: Pan 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. Tlvs policy includes these endorsements and schedules:
W C 00 00 00 B,W C 99 00 01 B,W C 00 01 13A, W C 00 03 08,W C 00 04 14, W C 20 Oi 01, W C 20 03 01,W C
20 03 02,W C 20 03 03C,W C 20 04 01, W C 20 04 05, W C 20 06 01 A,W C 20 06 04
4. The premium for Utis policy will be determined by our Manuals of Rules,Classifications,Rates and Rating
Plans. All information required below is subject to verification aad chan�e by audit.
See Extension of Information Page
TOTAL ESTIMATED ANNUAL PREMIUM 823
STATE ASSESSMENT �
TOTAL ESTIMATED COST , 853
Minimum Premium 352
Deposit Premium s 853 �
Issue Date: 1/]0/2012 Coun[ersigned by:
A z Representaave
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