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Home My WebLink AboutApplication and WC � � . / _ TOWN OF YARMOUTH BOARD OF HEALTH �P�IN FG12WS I��SE . � � � � Captain Farris House B&B ��MIT -2016 �� 308 Old Main Street ydocumentsbyDecemberlS. 2015 °:�� of your application packet. +� Zy� : — South Yarmouth MA 02664 ` TAX ID: ,� � % ESTABI . � LOCAT Michael & Nancy Lumia TEL.#: e �o p MAILIT N i ht Contact 508-760-2818 E-MAII g -� .-� owNE, Alarm Company: CCA co�o Extinguisher Co: Ralph J Perry TEL.#: ' MANAi MAILIl` 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. , __ _ --- -- __ _ _1 --- -- - Pool operators must list a minimum of two employees currently certified in 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 form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. L 2• 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. � � K� L�w��rP 2. AJ�./�c�" �t��,Q__ PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. ' -- 1. /� �C`� �,�� 2. ALLERGEN CERTIFICATIONS: i 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 capies 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. /h ��.��` ��,� ,� - -- 2. N � N�� -�.rM �n 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# _ (1F�I�'� �I.�T-�N�Y --- - - — --- __ ---- _ -- _ _-- - LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $110 INN $55 CAMP $55 SWIMMING POOL$1 l0ea. �LODGE $55 �� _TRA[LER PARK $105 _WHIRLPOOL $110ea. FOOD SERVICE: �L CENSE REQUIRED FEE P RMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PE�T# 0-100 SEATS $125 ��1IZ CONTINENTAL $35 NON-PROFIT $30 ' _>100 SEATS $200 �COMMON VIC. $60 � g WHOLESALE $80 —RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICEN3E REQUIRED FEE PERMIT# <50 sq.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 =<25,000 sq.ft. $I50 _FROZEN DESSERT $40 _TOBACCO $110 NAME CHANGE: $is AMOUNT DUE _ $ Z�O,OO *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** � � . � i � � � . � 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 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 i 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 Department 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 I thereafter. I 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: I 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. I CATERING POLICY: i Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the I 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.varmouth.ma.us under Health Department, I, Downloadable Forms. ' i FROZEN DESSERTS: �I 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 I 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. _ - -- - _ __ _ _ __ V. _ ---�� 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, 2015. 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 COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: SIGNATURE: PRINT NAME& TITLE: Rev. 10/O1lIS i _ , � � � � The Commonwealth ofMassachusetts �� 1 Department of Industrial Accidents � � Office of Investigations ' ' I Congress Street, Suite l00 _ Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Le�iblv Busi.ness/Organization Name: ; Address: City/State/Zip: Phone#: Are you an employer?Check the appropriate boz: Business Type(required): 1.❑ I am a employer with employees(full and/ 5. ❑Retail or part-time).* 6. ❑RestaurantJBaz/Eating Esta.blishment - _ -- - — - — — -- 2. I am a soTe propriefor or parZriershi`p an�na��o '-- - , 7. ❑Office andlor�a�es�`mcl.real estate,auto,e�c.) employees working for me in any capacrty. [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.Q Manufacturing no employees. [No workers' comp. insurance required]* 4.❑ We are a non-profit organization,staffed by volunteers, 11.�Health Caze with no employees. [No workers' comp. insurance req.] 12.0 Other , *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#L ' I am an employer that is providing workers'compensation insurance or my employees Below is the policy information. Insurance Company Name: �� i Insurer's Address: L I�` � � U �/v� City/State/Zip: t� � �� /v � � �� j � Policy#or Self-ins. Lic.# ��C ��d '-" �(��Expih�ation ate: �� Attach a copy of the workers' compensation policy declaration page(showing the policy number and ezpiration date). � i Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ' � _...-'__ � • • • • RTl1TV 1111T ,] �. ine up to 1,� .0 an or one-yearimpns�o��t, . �'�--�r.�ar�E�t��:�--- ; of up to $250.00 a day against the violator. Be advised that a copy of this sta.tement may be forwarded to the Office of ' Investigations of the DIA for insurance coverage verification. I do hereby cert' , e ' a d nalties of pe�that the information provided above is true and correct. Si ature: Date: � ' Phone#: Official use only. Do not write in this area,to be completed 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#: i www.mass.gov/dia j I i ' � • DATE(MMIDD/YYYY) { ,4�n CERTIFICATE QF LIABILITY INSURANCE � 12/28/2015 THIS CERTIFICATE IS ISSOED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS I CERTIFICATE DOES NOT AFFIRMATIVELY OR tJECiATIVELY AMEND, EXTEND, OR ALTER THE COVERACiE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S�, AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the certifcate holder is an ADDITIONAL INSURED, the policy(ies)must be endorsed. If SUBR0C3ATION IS WAIVED,subjcct to the tcrms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate dcea not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER 04971 _001 j,��j��T April Tarr The Fairway Agency Inc Pj��E,�; p� o A/C.No.: 479 Turnpike St Umt 6 ��5��: service@ theEairwayagency.com South Easton,MA 023T6 IN AFF RAG p . Associated Employers Insurance Company + INSURED � INSURER B: j Captain Farris 8ospitaiity i.LC 308 Old 14aia Street I su South Yarmouth, l�► 02664 INSU E: COVERAGES CER7IFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NONNTHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT 1MTH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCN POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. �� TYPE OF INSURANCE �� POLICY NUMBER �� Y� LIMITS ��E��B��TM EACH OCCURRENCE $ CAMMERCIAL GENERAL LIA9ILITY DAMAGE TO RENTED $ PREMI ES Ea occurrmc CLAIMS•MADE �OCCUR MED EXP(Any ane person) $ PERSONAL 8 ADV INJURV $ GENERALAGGREGATE $ EN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ LICY EC OC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY Per accident $ , AUTOS AUTOS ( ) HIREDAUTOS NON•OWNED PROPERTYDAMAGE AUTOS Per accident $ $ UMBRELW IIAB OCCUR EACH OCCURRENCE $ EXCESB LIAB CLPJMS MADE AGGREGATE $ DED RETENTION $ $ 1C�E�R�p�S��7ps��pp�T11N.4Ef�4� X r"o��ur��'s °��'' /� OFFICER/MEIABER EXClUDE6T CUTIVE Y�N E.L.EACH ACqDENT $ SOO�OOO.00 ❑Y a�n WCC-600-6007658-2016A 8/8/2016 8/8/2016 (Mendaeory In NN) E.L.DISEASE-EA EMPLOYEE $ 600,000.00 D��CRI�`ION�F OPERATIONS below E.L.DISEASE-POLICY LIMIT $ S��O�.00 DESCRIPTION OF OPERATIONS!LOCATIONS/VEHICLES(Attaeh ACORD 101,Additlonal Remarks Schedule,if more spaee is required) "Proof of Coverage" ' Workers Compensation Coverage Applies to Massachusetts Employees Only CERTIFICATE HOLDER CANCELLATION Captain Farms Hospitality LLC 308 Old Main Street SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE South Yertnouth,MA 02664 TNE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCOROANCE WITH TNE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ��--�'�� 01888-2010 ACORD CORPORATION.Ali rights reserved. ACORD 26(2010/06) The ACORD name and logo are registered marks of ACORD � 1 ' A:I M M utua I A.I.M.Mutual Insurance Company � . . Massachusetts Employers Insurance Company � New Hampshire Employers Insurance Company , INSURANCE COMPANIES Associated Employers Insurance Company I � RENEWAL GIUOTATION WORKERS'COMPENSATION I j Insunnoe Company:Associated Employers insurance Comparry Policy N:WCC-S00-5007459 2015A 1 � Inwrod: Producer.4971—1—197 Captain Farcis Hospitality LLC Roge►s 8 Gray Insuraru�e Agency Inc � 308 Old Main Strest 434 Route 134 South Yarmouth,MA 02664 South Dennis,MA 02660 � Empbyers'Liability: Renewal EHective Date: 09/09/2015 Bodily Injury By Accident 500,000 Each AccideM Anniversary Rating Date: 09/09/2015 Bodily injury By Disease 500,000 Policy Limit Quote Date: O6/09/2015 Bodil In'u B Disease 500,000 Each Em lo ee Unit 1-Captain Fanis Hospftality LLC � From 09/09/2015 to 09/09/2016 Massachusetts Total Estimat�d Rab Per Eotlme�d Annwl s100 of Annuel ClassiNcattons Cod�No. Remunoratbn Romuneration Pnmium � MOTEL,MOTOR COURT,TOURIST COURT O R CABIN:ALL OTHER EMPLOYEES 8 S � AIESPERSONS,DRIVERS 9052 35,210 1.58 556 � � i Deviated Premium �g Excess Employers Liability 1.00°� 6 562 EEL Minimum Premium Adjustment 4q BO6 Premium Subject M Exp Mod � Merit Nbdifier 0.95 (30) 576 Standa►d Premium 57g Expense Constant 250 826 Tertorism Act Surcharge 11 837 Totsi Estimabd Pnmlum g37 DIA ASSESSMENT 5.809b 31 868 Total Estimated Pnmium�Surcharga(s) �9 54 Third Avenue•P.O.Box 4070.Burlington,MA 01803-0970•Tel:781.221.1600/800.876.27fi5•Fax:781.270.5599 BRIDGEWATER•BURLINGTON•CONCORD,NH.HOLYOKE.MARLBOROUGH sPwu�wed bYA�social�d Indus�ofM�rhusetts �