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HomeMy WebLinkAboutApplication and WC ��.°���`�� TOWN OF YARMOUTH Bo�dof Health � —� `� 1146 ROUTE 28, SOUTH YARMOUTH,MASSACHiJSETT5 02664-24451 - �. {'rrAeM��e� � Telephone(508)398-2231,ext. 1241 Div sl n Fa�c(508)760-3472 Gj����°��DD To: Yannouth Business Establishments MA2i N� MoTo2�orX� FEB �9 2015 From: Bruce G. Murphy, Director � HEALTH DEPT. Yarmouth Health Department� Date: November 7, 2014 Subject: Increase in License/Permit Fees Please be awaze that the Yarmouth Board of Health, under the direction of the Yarmouth Boazd of Selectmen, has raised a number of license and permit fees issued through the Yazmouth Health Department, effective January 1,2015. Attached is the Yarmouth Business License/Permit Application for 2015. You will note that the , fees listed aze the fees effective January 1, 2015. These fees will be due if you complete and ', submit the application after Januazy 1,2015. However, if you fully complete the application, and submit it to the Yarmouth Health Department with all required certificafions 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: Cunent 2014 Fee PA`D pF� �`�'3f Public Swimming Pools $ 80.00 �2� � I�O.00 owEs 3 60.o0 Public WhirlpooUVapor Baths $ 80.00 �� � O.o� oWEs �30.o0 Tobacco Sales $ 95.00 Motels $ 55.00 SS.00 a,�5 �SS.oO Food Service 0-100 Seats $ 85.00 Food Service Over 100 3eats $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: 3S• c9NrN•m2c-nr�++sr Total fees owed for your establishment: �330,C1D o�5 �1�5.o0 iaCAl� NOTE: To be entitled to pay the current 2014 rates listed above, your business application, food and/or pool certificallons, along with worker's compensation information must be received, or mailed (postmarked) on or prioC to DeCember 31, 2014. [Those establishments which open in the spring widl 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.J BGM/maf � �.. . , o�--_�, � TOWN OF YARMOUTA BOARD OF HEALTH �������+� ��� APPLICATION FOR LICENSE/PERMIT -2015 Fee o s�o�5 `'` * Please complete form and attach all necessary documents by Dece ber IS 20I Failure to do so will result in the return of your application p c et�EALTH DEP7` ESTABLISHMENT NAME: r' TA D• — � LocaTiorr aDDxEss:s � n ��-I- ti/f�' `fc,��ti'rEL.#: 5G4s_77 I_7�y� �iLn•rG anD�ss: i`'ic� ;ni�v� /�1�:�_� ��sr"����t �Pt E-MAIL ADDRESS: OWNER NAME: 'SP�F/p�' � G+ Rzc' "7046 330.0� CORPORATION NAME(IF APPLICABLE : MANAGER'S NAME: �1� � V�/ TEL.#: d — 3< —G' � MAILINGADDRESS: 2 C � �' ��� POOL CERTIFICATIONS: The pool supervisor must be certi6ed as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) and a ach a copy of the certification to this form. �,/ ,,�,y�y 1 � _ , .��r,.z7� 1 2. f ��ta-t �`�icf—+�S _- __ 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 all times. Please list the employees below and attach copies of their certifications to this form.The Health Department will �I not use past years' records. You must provide new copies and maintain a file at your place of business. �. Lti o'�( 7GhN rt/ z. �°'`�C� �j/-e�1�� � 3. C�_� e�' CiS 4.�i'o�l/ Ni�il FOOD PROTECTION MANAGERS - CERTIFICATIONS: I''� All food service establishments aze 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 tile at your establishment. 1. 2• PERSON IN CI-IARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. __. 2. _ - _ __ ', _ 1_: __ _ __ - - - - - - -- ALLERGEN CERTIFICATIONS: All food service establishments aze 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 applica6on. 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 i 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�le at your place of business. 1, 2. 3. 4• ' RESTAURANT SEATING: TOTAL# OFFICE USE ONLY �I LODGING: L[CENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE P RMIT# —B&B $55 CABIN $55 �MOTEL $110 (!–QL� —INN $55 CAMP $55 WIMMING POOL$1 IOe D�F`�' � LODGE $55 _TRAILERPARK $105 LWHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PE IT# LICENSE REQUIRED FEE PERMIT# ' 0-100SEATS $125 �CONT[NENTAL $35 ���1(fo NON-PROFIT $30 ; >100 SEATS $200 COMMON VIC. $60 WHOLESALE $80 — —RESID.KITCHEN $80 ; RETAIL SERVICE: � LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE [RED FEE P IT# <50 sy.ft. $50 >25,000 sq.ft. $285 VEND G-FOOD $25 <25,OOOsq.ft. $150 —FROZENDESSERT $40 _TOB CO $I10 NAME CHANGE: $15 ,. - . . ... . . - � �-:�� AMOLTNT DU = S `t'�S.O� . �� � � aao.00 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM**** ---- � _ O� `�f 5. C�� Du)C� � -- _.___ --I ADMINISTRAI'ION iJnder Chapter 152,Seotion 25C,Subsection 6,the Town oFYarmputh is naw required to hold issuance or renewal � of any license or pernait to operate a business if a person or company does npt haue a Certificate of Worker's Compensarion Insuranca. TFIE ATTAt"FIEl} STATE W012KEI2'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSLTRANCE ATTACHED OR i WORKER'S COMP. AFFIDAVTI' SIGNED AND ATTACHE➢ 'I'own of Yarmouth ta�ces and liens rnust be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO � MOT�LS ANA OTHER LODGING ESTABLISFIMENTS TItANSIENT OCCUPANCY: For purposes of the limitations of Motel ar Hotel use,Transient occupancy shall be limitad to the temporary and shart tetm occu�ancy,ordinarily and custamarily assooiated with matel and hotel use. � Translent ocoupants must have and be able to demonstrata that they maintain a principal place af residence elsewhere.Transient occupancy shall generally refer to continuous occupancy of not more than thirty(30)days,and ; an aggregate af not more than ninety(90)days within any six(6)month period. Use of a guest unit as a residence or ', dwelling unit shall noY be considered transient. Qccupancy that is subject to the callection of Room t}coupancy Excise,as de�ned in M.G.i�. c. 64G or 830 CMR 64G, as arnended, shall generally be considered Transient. POOLS � i P4C/L OFENING:A ll swimrning,wading and whirlpools which have been closed for the seasan must be inspected ' by the Health Department prior to apening. Contact the Health Departrnent to schedule the inspectian three(3) days prior to opetting. PLEASE AIOTE: People are NOT allowed to sit in the pool area wstil the poal has been i inspected and opened. ; POOL WATER TESTING: The water must be tested for pseudomonas,tota!coliform and standard plate count by a State certified lab, and submitted to the Health Departrnent three (3) days prior to opening, and quarterly thereafter. PO(}L CLOSING:Every autdoor 3n ground swimmsng poal mnst be drained ar covered within seven{7)days of ! closing. FOOD SERVICE SEASONAL FOOD SERVICE OPEPiING: j All food service estabtashments must be inspected by the Health Department prior to opening. Please contact the ( IIealfh Depattrnent to schedule the inspection tt�ree{3) days prior to opening. # CATERING POLICY• � Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the reqwred Temporary Foad Service Application form 72 haurs prior ta the catered event. These forms can be obtained at the Hesxlth Department,or from the Town's website at www.varmoixth.ma.us under Health Department, Downloadable Forms. FROZEN DESSFRTS: Frozen desserCs must be tested by a State certified lab priar to opening and rnonthly thereafter,with sample results submitted to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Pernut untii the above terms have been met. OI3TSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress sarvice),must have prior approval from the Boazd of Health. CIUTDOOR COQKIIVG: � Qutdoor 000king,prepazation,or dispIay of any food product by a retail or food service estabiishment is prohibited. ( _ ___ _ – _ __ --------_ . ..__. _.__...._-..,_-----_.. . . . . - f . .__..._ -I � NOTICE:Permits run annually frorn January 1 ta December 31. TT IS YOUR RE3PONSIBILITY TO RETtTRN I THE COMPLETEI}REI3EWAL APPLICATIdN(S)A�vTI7 RBQLtIREI3 FEE{S}BX DECEMBER 15, 2014. ' ALL RENOVATIONS T4 ANY FOOD ESTABLISHMENT, MO'I`EL OR POOL (i.e., PAINTING, NEW , F',QUIPMENT,ETC.}, MUST BE REP{7RTEI?TO ANL}APPROVED BY THE BOARD{7F HEALTH PRI4R � � TO COMMENCEMENT. RENOVATIONS MAY IRE A SITE PLAN. ; �..._.- --___— I7ATE.�/ ���_SIGNATU PRINT NAME& TI"TLE: ���F/�C U �t,l�f J� � i � Rev. t U43174 � I � � � � The Commonwealth ofMassachusetts Department of Industrial Accidents Office oflnvestigations I Congress Street, Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses A licant Information Please Print Le 'bl Business/Organization Name: �I I �� / � ��d/ � G � Address:�� � �/ � ���✓t��`f� C�L.�/`�l r�f/�'Li 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 art-time).* 6. ❑RestaurantBaz/Eating Establishment --- — --- - — - -- 2. I am a sole proprietor or partnership and have no 7, � Office and/or Sales (incl.real estate,auto,etc.) I employees working for me in any capacity. [No workers' comp.insurance required] 8• ❑ Non-profit 3.❑ We aze a corporarion and its officers have exercised 9. ❑ Entertaimnent their right of exemprion per c. 152, §1(4), and we have 10.0 Manufacturing no employees. [No workers' comp. insurance required]# 11.❑ Health Caze 4.❑ We aze a non-profit organization,staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.❑ Other *Any applicant that checks box#I must aLso 5ll out the section below showing the'v workecs'compensation policy infotmation. ��, "If ihe cocporate officeis have exempted themselves,but the corporation has other employees,a workers'compensation policy is requimd and such an '�,. organization should check box#1. ; I am an employer that is providing work���'arion in,s✓ur����m��oyCees. Below is the policy information. ', Insurance Company Name:��� �" / � ���,1 Insurer'sAddress: 11� r^JN��'P'P Ur�I�R City/State/Zip: ���1�/l�P ' 1 J� Policy#or Self-ins.Lic.# G I Nr/C/�� �1� � I �-Y Exp'uation Date: Y !L f d Attach a copy of the workers' compensation policy declara 'on age(showing the policy nnmber and ezpiration date). Failure to secure coverage as required under Section 25A of MGL a 152 can lead to the imposition of criminal penalties of a � - — -- - --- --- I -- - - 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 violator. Be advised that a copy of this statement may be forwazded to the Office of InvestigaUons of the DIA for insurance coverage verificafion. Ido hereby cert�,under thepains andpenal8es ofperjury that the information provided above is true and corred. ' Sienahue: � Date: � � �� Phone#: 'Z Official use on[y. Do not write in this area,to be completed by city or town officiaL � City or Town: PermitlLicense# � Issuing Authority(circle one): 1.Board of Health 2. Building Department 3.City/Town Clerk 4.Liceasing Board 5. Selectmen's Office i 6.Other Contact Person: Phone#: ; www.mass.gov/dia l', WpRKE32S C4MPENSATION AND SMPIAYERS LSABSLZTY INSURI,.NCE C:ERTIFICATE INFqRMATION PAC,E' � Praducer: Agent# 137 Mk Retail Merchants SdC Group Inc. Boynton Znsuarance Agency Inc. Po aox es9222-92z2 72 River Park St Hsaintree, MA 01285 Needham, MA 02194 (C6�YriCt Code: 34355) Certificate i�: 0140050334�9114 Prior Certificate #: NEW 1. The Employar: Dockside tiotel Group Inc taaS2ing nddreas: e�6 Main SCreet � West Yarmouth, MA 02673 Fein: � Otrier workplaces not ehown above: Type of Susiness: Corporatian SEE SCHEADLE OF OPERA2IpNS Risk ID: 2. The certificate period is from 12:01 a.m. on Sf0it2618 to 12:01 a.m. on � 1/01/2015 at the i.neured's mailing addrems. 3. A. Wozkers Compensation Cwerage: Part dne o£ the certificate applies to the Workers Compensation Law nf Che sCates 13sted here: � MA B. Emp2oyera Liabi2ity Coverage: Part Two of the certificate �applias��to work in each etate listed in Stem 3.A. The limitx of our liability under Part Two are: aodily Injury� by Accident $ � 1,Ooo�000 each accident �. Bodily Injury by Disease $ 2,OOOrOOQ certificate limit ��� Bodily Injury by Disease $ 1,000,000 each employee � C. other States Coverage: D. Thi9 certificaCe includes these endorsaments and achedules: WCOOOOpOA(p4/92) WCOOtl310(04J94) WCOp0414(07/9D) WC000422A(09/OB) WC2p03�1(04/84) WC240302{45J66) WC200303.H{6�/99) WC�60405(06j01j �%C200661t06142} 4. The contribution for Chis certificate will be determined by aur Mannals pf Rules, � '�. Cla9sification8, Rates and Rating Plana. All infarsnatioz� required below is suhject � �; to verification and change by audit. � � '. Claseifications Code Contribution Sasie �Rate Per Eetimated � � � Nq. Tota2 ESEimated $160 of kaaual ��: Annual Remuneratinn Remuneration Contributlon i '. SEE SCHEDtILE QF OPERATIONS . . � � ! � Total Eetimated Annual Contribution 12,667.Op � Minzmum Cantribution $ 346.oD Sxpense Constant $ .00 � . . . . .. . . . .. _ . _ . .. . . . . . _ . .. _ . � . WC 00 00 O1 A Zssue Aate: 2/03/2018 Counteraigned by I � I I �..._. . .. _ . . . _..-'-_ I �,.�.- . SCHEDULE OF OPERATIONS FOR: PAGE: 1 . � Dockside Hotel Group IT1c Certificate # : 014005033479114 . } 476 Main Street Fein: : � West Yarmouth, MA 02673 OTHER WORKPLACES : . Cape Point Hotel . The Faint LLC . 476 Main Street, Route 28 . West Yarmauth, MA 02673 • Fein: 043418497 . � Mariner Motor Lodge Mariner Motor Lodge . The Mariner Motor Lodge LLC . 573 Main Street, Route 26 476 Main Street, Route 28 . West Yarmauth, MA 02b73 West Yarmouttz, MA 026'73 . Fein: 043418500 � , Town 'N Cauntry Motor Lodge 2own 'N Country Motor i,odge . Cape Town & Country Motor Lodge LLC . 452 Main Street, Route 29 476 Main Street, Raute 28 . West Yarmouth, MA 02673 West Yarmouth, MA 026'73 . j Fein: D4341&494 - V ' � � i • ( � i ' ' . WC 00 44 Ql A .