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Home My WebLink AboutApplication and WC , o�'Y'qR �� --�'` _\'�� TOWN OF YARMOUTH Ha�f a :_ ` x `3 1146 ROUTE 28, SOUTH YARMOUTH, MASSACHiJSETTS 02664-24451 " N �,� EEe� � Telephone(508)398-2231, ext. 1241 Divi i n "`" Fas(508) 760-3472 To: Yazmouth Business Establishments j(16B0AT5 V��T13�c1211NT From: Bruce G. Murphy, Director � G3L�Gr•�OC�II�DD Yazmouth Health Department� UEI; 1 � `1�14 Date: November 7, 2014 HEqLTH DEPT. Subject: Increase in License/Permit Fees Please be awaze that the Yarmouth Boazd of Health, under the direction of the Yarmouth Boazd of Selectmen, has raised a number of license and permit fees issued through the Yarmouth Health Department, effective January 1, 2015. Attached is the Yannouth Business License/Permit Application for 2015. You will note that the fees listed aze the fees effecuve Januazy 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 a11 required certifications and worker's compensarion coverage information (certificate of insurance OR completed affidavit) arior to December 31, 2014, you will be allowed to pay the 2014 rates for the following licenses: Current 2014 Fee Public Swimining Pools $ 80.00 Public WhirlpooUVapor Baths $ 80.00 Tobacco Sa1es $ 95.00 Motels $ 55.00 Food Service 0-100 Seats $ 85.00 Food Service Gver 100 Seats - �160A0 J�p,00 - Retail Food Service <25,000 sq. ft. $ 80.00 Retail Food Service>25,000 sq. ft. $225.00 Other fees owed but not listed above: O.Oo caMrwN ✓tc. Total fees owed for your establishment: ao2G,00 NOTE: To be entitted to pay the current 2014 rates listed above, your business application, food and/or pool certifications, along with worker's compensation information must be received, or mailed (postmarked) on or prior to DeCember 31, 2014. [Those establishments which open in the spring will be allowed to provide food andlor pool certifications prior to opening, however, you must note "Will provide in the spring prior to opening"on the appZication.J BGM/maf , , a�c�� a TOWN OF YARMOUTH BOARD OF HEALTH ,� � . UtL 7 7 '1014 APPLICATION FOR LICENSE/PE f°�-�r5 ` � � * Please complete form and attach all necessary d tzme�tfs by Derem '1 Fa'A1GtJ DEPT. Failure to do so will result in the return of ' application pac e . ESTABLISHMENT NAME: TAX ID: LOCATION ADDRESS: � I��. iv^ S"� TEL.#: J� -� S- `f�- � MAILING ADDRESS: 311 C� . . Z�S T-c�� . m R- a zs"tcu E-MAIL ADDRESS: SC�n��.be�' - �� • Z A V P P a r,n�� OWNER NAME: W� 1\�v� '�tv.mtr J r CORPORATION NAME (IF APPLICABLE):� R-S MANAGER'S NAME: SCf/� 1�"1C N e-� 1_ TEL.#: �-�) -01�$- �3'b MAILING ADDRESS: 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. . _ _ _ _ _ _ _ - _ 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standazd 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. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishxnents 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 esta6lishment. 1. � �A�v. O S C-hr�t�L�e� 2. ��J C�-�-P� PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. �tr-� 1'�'�e, hJ w� 2. W�`�� n �st)�t�E�E,V� : ALLERGEN CERTIFICATIONS: All food service establishxnents are required to have at least one full-time employee who has Allergen certification, as defined in the State Sanitary Code far 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 Tile at your establishment. i. ��..i \t� 1�-�.,t_� 2. � f� �D Sc6�nu-�rn HEIMLICH CERTIFICATIONS: All food service establishxnents 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.�� l7 SGhr�G��cr 2. W�`�ti yGn W A.Q�2r�.J 3. .CLc.4-� Mc ,.i�ll 4. ��\ \ r 3 RESTAURANT SEATING: TOTAL # 'Z� OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $110 '� I1V1V $55 CAMP $55 SWIMMINGPOOL$110ea. ��.. LODGE $55 TRAILER PARK $105 WHIRLPOOL $110ea. '�. FOOD SERVICE: � LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 CONTINENTAL $35 NON-PROFIT $30 � �>100 SEATS $200 1�— . S %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. $285 VENDING-FOOD $25 QS,OOOsq.ft. $I50 � =FROZENDESSERT $40 TOBACCO $110 � NAME CHANGE: $15 AMOUNT DUE _ $ 260.00 � *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** I�G Q ��"'`'��'Q� e�--�3bfs /�n�� f . ' � '. ADMINISTRATION : Under Chapter'152,Section 25C,Subsection 6,the Tawn of Yannoutki is naw required to hold issuance or renewal of any license or permit to operate a business if a persan or cotnpany daes not have a Cerfificate of Worker's Campensation Insurance. TFiE ATTACFIED STATE WOI2KER'S CQMPENSATION INSIII2ANCE AFFIDAVIT MUST SE COMPLETF,D AND SIGNED, CiR CERT. OF INSURANCE ATTACH�I} OR � /'� WOR.KER'S COMP. AFFIDAVIT SIGIVED ANLY ATTACHED [/ Town of Yannouth taxes and liens must be paid prior to renewal ar issuance of your permits. PLEASE CHECK APPI2OPRIATELY IF PAID: ,/� YES +/ N(} MOTELS ANA OTHER LODGING F.STABLISHMENT5 TRANSIENT OCCUPANCY: Far purposes of`the limikations ofMotel or Hotel use,Transienf occupancy shall be limited to the temporary and short term occupancy,ordinarily and custamarily associated with motel and hotel use. i Transient occupants must have and be ahle to demonstrate that they maintain a principal place of residence elsewhere.Transient occupancy shall generaliy refer to continuous occupancy of not more than thirry(30)days,and an aggregate of not more than ninety(90)days within any six(6)month per'rod. Use of a guest unit as a residence or dwelling unit shall not ba considered transient. Occupaney that is subject to the collection of Raom C}eeupanay Lxcise, as defined in M.G.L. c. 54G or 834 CMR 64G,as amended, shall generally be considered Transient. PQOLS 1'OC1L 4PE1�tING:All swimming,wading and whirlpaols which have beer�ciosed far the season must be inspected by the Health Deparhnent prior to opening. Contact the Health Department to schedule the inspection three(3) days prior to opening. PLEASE NOTE: Peaple ara NOT allawed to sit in the poaI area until the pool has been inspected and opened. I POOI.WATER TESTING: The water must be tested f'or pseudomonas,total coliform and standard plate count by a State certified lab, and submitted to ihe Health Department three (3} days prior to opening, and quarterly thereafter. POOL CL4SING:Every outdoor in gzound swimming poai must be drained or covered within seven{7)days of closing.. FO011 SETtVIC� SEASONAL FOQD SERVICE OPENING: ' All food service establishments must be inspecfed by the Health Department prior to opening. Please contact the Eiealth Department to schedule the inspection three(3)days prior to opening. CATERING POLICY: Anyone who caters w'rthin the Town of Yaimouth musc notify the Yatmouth Health Department by filing the reqwred Temparary Food Service Application farm 72 hours prior to the catered event. These forms can be obtained at the Health I7epartment,or from the Town's website at www.yarmouth.ma.us under Health Department, Downloadable Forms. FROZEN DESSERTS: Prozen desserts must be tested by a State certified 1ab prior to opening and monthly thereafter,with sarnple results submitted to the Health Departrnent. Failure to do so will resnit in the suspension or revocation of your Frozen Dessert Permit until the above 2erms have been met. C}UTSIDE CAF�S: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval frorn the Board of Health. OUTAOOR COOHING: Qutdoor cookin�,pre�azation,or display of any faod product by a retail or food service establistunent is prohibited ' NOTICF.:Permits run annually from January 1 tn December 31. IT IS YOITR RESPONSIBTLITY TO RETt7RN 1'HE COMPLETF,D RENEWAL APPLICATIQN{S}A1VI}REQTJIRED FEE(S}BY DECEMBER l5,2014. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MO' OR POOL (i.e., PAINTING, NEW EQLIIPNSBNT, ETC.},ME3S1'BE REPC?RTED TO AND PRt?V BX THE BOARD OF HEALTH PRI4R "1'O COMMENC�MENT. RENOVATIONS MAY IRE TE . L7A"1'E: SIGNATLTRE: �� PRTNT NAME b': TITLE: Rev_11f031(4 � �� I ' � The Commonwealth ofMassachusetts � Deparrinent of Industrial Accidents Offzce oflnvestigations ' I Congress Street, Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legiblv Business/Organization Name:' • �� Address:� r-/,��_��_¢� — City/State/Zip: G'.iL • - �C�� Phone#: � >�l- 7�j-�o Are you an employer. heck the appropriate bos: Business Type(required): 1.❑ I am a employer with�`� employees(full and/ 5. ❑ Retail __ _or part-rime)* 6. [,].RgstaurantBaz/Eating Establishment - - - -- --- — ---- - _ _- 2.❑ I am a sole proprietor or partnership 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 aze a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4), and we have �0.❑ Manufacturing no employees. [No workers' comp. insurance required�* 11.� Health Caze 4.❑ We aze a non-profit organizarion,staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.❑ Other *Any applicant that checks box#I must aLso 5ll oui the section below showing the'v workecs'compensation policy infotmation. **If the cocpomte officers have exemp[ed themselves,but the coiporatioa has other employees,a workers'compensation policy is required and such an � organization should check box#L � � � I am an employer that is providing w kers'compensation insurance for my employees. Below is the policy informatiore. Insurance Company Name: �j��a DLr�Q �Pr�,�y��t��,r�'. �r-r/v.'� �i.r� Insurer'sAddress: � J �� C�� -Cl':�� City/State/Zip• r( ,, (' (�p )..-( �' �;�0 � Policy#or Self-ins. Lic.# ��/�11�}�l�r��/�/�Y Expuation Date:J-�� Attach a copy of the workers' compensafion policy declaration page(showing the poGcy nnmber and ezpiration date). - Failure to securecoverage required under Saction 25A 9fMGL c. 1�2_ Fan_ lead to the impo_siuon of criminalpenalries of a fine up to$I,SQ0.00 and/or ne-yeaz imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day agai t the violator. Be advised that a copy of this statement may be forwarded to the Office of Invesrigation o the DIA f insurance coverage verification. I do hereby ert ,u t e pains and penalties of perjury that the information provided above is true and correcx Si ature: Date: �� a � �� Phone#• �� 'a' -�� O�cial use only. Do not write in this area,to be completed by city or town ojficial City or Town: Permit/I.icense# Issuing Authority(circle one): 1.Board of Hea1tL 2. Building Department 3.City/Town Clerk 4.Licensing Board 5. Selectmen's Office 6.Other Contact Person: Phone#: www.mass.gov/dia INFpRMATION PAGE ggN�W�, q�g�p�g,� Pradacer: Agent$ �44 RetaiZ Merchaz.ts WC Group Znc. Lawrence-Carlin Insurance Agenc} Box 859222-9222 234 Jones Road Suite 3 Braintree, MA 01285 Falmouth, MA 02540 (Carrier Code: 34355) Certificate �: 024000502147114 � Prior Certi£icate U: 014000502247113 1• The Emplayer: Cponamessett Inn CINN Corg Mailing Address: 311 �if£ord Street Falmoixth, Mfi Q2544 Fein: Other workplaces not shown above: Tyge of Business: Gorporation SEE SCHEDULE OF OPERATIOFJS Risk SD: 2. The certificate periad 3s from I2:01 a.m. o� 1/O1/2014 to 12:p1 a.m. on iro1f201�. at the insnred`s mailing address. 3. A. Workers Gampensation Coverage: Part Qne o£ the certificate applies to the Workers Compensation Law of the states listed here: MA B. Employers Liability Coverage: Part Ttoo of the certificate applies ta work iq each state listed in Item 3.A. The 3imits af onr liability under Part Two are: Badily Znjury by Accident $___5�g,00i�__, each accici'�nt Bodily Injury by D3sease $i_$�0 000 certificate limit Badily 3njury by Disease $ 500 000 each emplayee C. Other States Coverage: D. This certi£icate includes these endorsements and schedules: WCOOOOOOA(04/92) lr^000308(09/84) WC000330(04/84) WC0004p6A{0&/95? WC000414(G7/90) WG004422At09j03} WC20d3d2{04184} WC2003p2{d5/867 WC2Q03p3B(07l993 WC2p040S(06/O1) WC2p0601(06/92) 4. The contribution Eor ttiis certi£ir�te will be determined by our Manuals af Rules. Classifications, Rates and Itating Plans. All information required below ic suSject to veri£ication and change by audit. Classificatians Code Contr.ibution Basis Rate Per Estimated No. Total Estimated $100 of Annual Annual Remunerati.on Remunerat3on Contribution SEE SCHEDiJLL� OP GPEP.ATTON$ Total. L�stirk�ted Annual Contr3bution 27.79J .00 Mini.mum Cpntributi.on $ 520.00 F.�spense Constant $ i1Q WC 00 00 Ol A Issue Date: 1/27/2q14 Cotuitersigned by __ �_��___ }y SCHEDULE OF OPERATIONS FOR: PAGE: 1 Cqonamessett Inn Certificate #: 014000502147114 C2NN Corp Fein: 311 Giffard Street Falmouth, MA 02540 OTHER WpRRFLACES: The Flying Bridge Restaurant The Flying Bridge Restaurant Sailar's, Inc. 220 5cranCon Avenue 311 Gifford Street Falmouth, MA 02540 Falmouth, MA 02594 Fein: Tugbo�ts Tugboats QAS 21 Arlinqton 3treet 321 Gifford Stre6t Hyannis, MA 0260i Falmouth, MA 02540 Fein: Cape Cod Restaurants Inc. Cape Cad Restaurants znc. �0 Joy Street 312 Gifford Street , Mashpee, MA Q2599 Falrnouth, MA 02540 Feia: Red Hor.se Inn Red Horse Inn RH Inn LLC 28 Falmoixth Heights Road 311 Gifford Street Falmouth, MA 0254Q Falmouth, MA 02540 Fein: � Swan River LLC Swan River LLC 8 Upper County Road 311 Giffard Street Dennis, MA 0?.638 Fal.mauth, MA 02540 Fein: .0 60 d0 O1 A