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HomeMy WebLinkAboutApplication and WC TOWN OF YARMOUTH Board of 5� Health -'1 �, 1146 ROUTE 28, SOUTH YARMOUTH,MASSACHUSETTS 02664-24451 Health ,�r�c+.E� •- Telephone(508)398-2231,ext. 1241 Division Fax(508) 760-3472 To: Yarmouth Business Establishments CLcQ-t0N INN ElIA:15:2:7:1D14T. From: Bruce G. Murphy, Director Yarmouth Health Department Date: November 7, 2014 1 Subject: Increase in License/Permit Fees `' _ f Please be aware that the Yarmouth Board of Health, under the direction of the Yarmouth Board of Selectmen, has raised a number of license and permit fees issued through the Yarmouth Health Department, effective January 1, 2015. Attached is the Yarmouth Business License/Permit Application for 2015. You will note that the fees listed are the fees effective January 1, 2015. These fees will be due if you complete and submit the application after January 1, 2015. However, if you fully complete the application, and submit it to the Yarmouth Health Department with all required certifications and worker's compensation coverage information (certificate of insurance OR completed affidavit) prior to December 31, 2014, you will be allowed to pay the 2014 rates for the following licenses: Current 2014 Fee Public Swimming Pools $ 80.00 (2) $ t 00.00 Public Whirlpool/Vapor Baths $ 80.00 t 80.00 Tobacco Sales $ 95.00 Motels $ 55.00 $ S5.00 Restaurants 0-100 Seats $ 85.00 $ 8S.00 Restaurants Over 100 Seats $160.00 Retail Food Service <25,000 sq. ft. $ 80.00 Retail Food Service>25,000 sq. ft. $225.00 Other fees owed but not listed above: (00.00 Comm-oN\JtC. Total fees owed for your establishment: $140,00 NOTE: To be entitled to pay the current 2014 rates listed above, your business application, food and/or pool certifications, along with worker's compensation information must be received, or mailed (postmarked) on or prior to December 31, 2014. [Those establishments which open in the spring will be allowed to provide food and/or pool certifications prior to opening, however, you must note "Will provide in the spring prior to opening" on the application.] BGM/maf -1 ,..- i.,1!..) TOWN OF YARMOUTH BOARD OF HEALTH E. ►� APPLICATION FOR LICENSE/PERMIT -2015 O c,,,t2.40l,) (NUJCom7-,---..---m17- rcD * Please complete form and attach all necessary documgig ny Deceml er 15bj ll'(.2 ,• l a Failure to do so will result in the return of your application packet. ESTABLISHMENT NAME: G I 1 _LA vl TAX ID: ( LOCATION ADDRESS: 1V MM a.g S ' 1m4 144 62.4,4,4- TEL.#: 50S3-gq 4 74,00 MAILING ADDRESS: 5ov•-•-e- E-MAIL ADDRESS: cy-G(0 e*G2 el 0.4 t t aCa -CoC)n ' CdvA OWNER NAME: G9z d vc c)1 4 CORPORATION NAME (IF APPLICABLE): 4., •_u • o 4 V • I • _9 MANAGER'S NAME: G e0vf_ A . io-(4 TE'.#: .57)g OS/S MAILING ADDRESS: l7(`) \O G a Gab t,-(-�.i,�n M 0 Z0270 POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operatorr(s) anttacch�a copy of the certification to this form. 1. `c�.10�,.(�,� (-J ok.1.L 2. Pool operators must list a minimum of two employees currently certified in basic water safety, 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. 1. G - 'cJrz- A(6L40-t42. C t t. cv'�‘,4.0 ,./ 3. 1'V)a_:c cep UQ.,(P_%-k 4- I c Q 4. NAzQ VL Go L,Ack_ 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. r 00. 5v. e,A.5 2. PERSON INC RGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. q Dv U J e.,•A_ 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. �hov j S v'uj c> 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. Qo .ems—�6r0� 2. v, `'� cbl 3. ' h0.) e.2 i tc4 v� 4. MCS J0 Lida\per.4-1 k..Q RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 j_MOTEL $110 4•15V005 INN $55 CAMP $55 j SWIMMING POOL$110ea. LODGE $55 TRAILER PARK $105 1 WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 1 0-100 SEATS $125 015-03` _CONTINENTAL $35 _NON-PROFIT $30 > - 100 SEATS $200 _LCOMMON VIC. $60 •l5o3(p 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. $285 VENDING-FOOD $25 <25,000 sq.ft. $150 _FROZEN DESSERT $40 TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE = $ 425.00 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** at `d I 3 14 i'1.7616.00 pl`a114 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 it/ OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED 1/ Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: `� / YES V 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 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 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 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 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 Permit until the above terms have been met. OUTSIDE CAFÉS: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. OUTDOOR COOKING: 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, 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 COMMENCEMENT. RENOVATIONS MAY RE RE A SITE PLAN. DATE: 2 • t 10 I SIGNATURE: ( k- r) att - PRINT NAME &TITLE: GC'a� -� Afya� 1(fL:7<( Rev.11/03/14 The Commonwealth of Massachusetts Department of Industrial Accidents t■= Office of Investigations = t- � 1 Congress Street, Suite 100 Tail= Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly 4111 Business/Organization Name: �, ��r , ,, • .�+ ,3 ' . Address: 02[,(0LI City/State/Zip: �,.4( /VIA Phone #: c7)g ;c1 Ii -76 tr u Aree yo an employer? Chec appropriate box: Business Type(required): 1.LiC I am a employer with /5--Z.0 employees(full and/ 5. ❑ Retail — 6. ❑ Restaurant/Bar/Eating Establishment 2.❑ I 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 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.❑ H lth Care 4.❑ We are a non-profit organization, staffed by volunteers, rr with no employees. [No workers' comp. insurance req.] 12. Other © e 1 *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#1. I am an employer that is providin workers'cempensatioinsur ce for my employees. Below is the policy information. Insurance Company Name: /1Q cA 1 o\, Insurer's Address: 0 v e. RGti,"-k----Cp J ' ,G Z�- City/State/Zip: 1-6,44--c---0%.r-cg--- c r ©G i S S Policy#or Self-ins.Lic. # 719 — 0(Z `-E-A Expiration Date: 2• • C 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 MGI.c.152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year 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 violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cert nder the pains '_ d p ' ties o perjury that the information provided above is true and correct. Signature: d- _ rkiDate: F Z• t(, . 1 `4 Phone#: 503�ig - 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#: www.mass.gov/dia 03, (Policy Provisions: WC 00 00 00 B) • 40 DR INFORMATION PAGE WEG WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY INSURER: TWIN CITY FIRE INSURANCE COMPANY �;q ONE HARTFORD PLAZA, HARTFORD, CONNECTICUT 06155 NCCI Company Number: 14974 THE Company Code: 7 HARTFORD Suffix LARS RENEWAL CD POLICY NUMBER: 76 WEG DR4003 02 Previous Policy Number: 76 WEG DR4003 HOUSING CODE: 76 V4' 1. Named Insured and Mailing Address: HEMEON ABBOTT MANAGEMENT CORP DBA (No., Street, Town, State, Zip Code) CLARION INN 1199 ROUTE 28 FEIN Number: SOUTH YARMOUTH, MA 02664 State Identification Number(s): UIN: The Named Insured is: CORPORATION Business of Named Insured: BUILDING OWNER Other workplaces not shown above: 1199 ROUTE 28 SOUTH YARMOUTH MA 02664 2. Policy Period: From 02/01/14 To 02/01/15 12:01 a.m., Standard time at the insured's mailing address. Producer's Name: COMPLETE BENEFIT SOLUTIONS/PAC 11001 PO BOX 33015 SAN ANTONIO, TX 78265 Producer's Code: 250837 Issuing Office: THE HARTFORD 3600 WISEMAN BLVD. SAN ANTONIO TX 78251 (877) 287-1316 Total Estimated Annual Premium: $12, 872 Deposit Premium: Policy Minimum Premium: $281 MA (INCLUDES INCREASED LIMIT MIN. PREM. ) Audit Period: ANNUAL Installment Term: The policy is not binding unless countersigned by our authorized representative. Countersigned by 12/14/13 Authorized Representative Date Form WC 00 00 01 A (1) Printed in U.S.A. Page 1 (Continued on next page) Process Date: 12/14/13 Policy Expiration Date: 02/01/15 ORIGINAL IN1ORMATION PAGE (Continued) Policy Number: 76 WEG DR4003 3. A. Workers Compensation Insurance: Part one of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits of our liability under Part Two are: Bodily injury by Accident $500, 000 each accident Bodily injury by Disease $500, 000 policy limit Bodily injury by Disease $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 STATES DESIGNATED IN ITEM 3 .A. OF THE INFORMATION PAGE. D. This policy includes these endorsements and schedule: WC 00 04 06A WC 00 04 03 WC 00 04 21C WC 00 04 22A WC 20 01 01 SEE ENDT 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Premium Basis Classifications Total Estimated Rates Per Estimated Code Number and Annual $100 of Annual Description Remuneration Remuneration Premium 8810 43,500 .09 39 CLERICAL OFFICE EMPLOYEES NOC 9052 561, 500 1.49 8,366 HOTEL: ALL OTHER EMPLOYEES & SALESPERSONS, DRIVERS INCREASED LIMITS PART TWO (9807) 1.00 PERCENT 84 TOTAL PREMIUM SUBJECT TO EXPERIENCE MODIFICATION 8,489 MA - INTRA EXPERIENCE MODIFICATION 000014437 (PRELIMINARY) 1.420 PREMIUM ADJUSTED BY APPLICATION OF EXPERIENCE MODIFICATION 12, 054 TOTAL ESTIMATED ANNUAL STANDARD PREMIUM 12, 054 PREMIUM DISCOUNT 0.9 PERCENT -108 EXPENSE CONSTANT (0900) 338 MASSACHUSETTS DIA ASSESSMENT 3 .400 PERCENT 406 TERRORISM (9740) 605, 000 .030 182 TOTAL ESTIMATED ANNUAL PREMIUM 12, 872 Total Estimated Annual Premium: $12, 872 Deposit Premium: Policy Minimum Premium: $281 MA (INCLUDES INCREASED LIMIT MIN. PREM. ) Interstate/Intrastate Identification Number: / 000014437 NAICS: Labor Contractors Policy Number: SIC: 6512 UIN: NO. OF EMP: 30 Form WC 00 00 01 A (1) Printed in U.S.A. Page 2 Process Date: 12/14/13 Policy Expiration Date: 02/01/15