HomeMy WebLinkAboutApplication and WC + I
���Y`qR
�� -�` _ �'�� TOWN OF YARMOUTH Ha�f
� :_ ` ' `3 1146 ROUTE 28, SOUTH YARMOUTH,MASSACHLJSETTS 02664-24451 -
N 4�T�ALME�`� � Telephone(508)398-2231, ext. 1241 Divsi n
Faac(508) 760-3472
To: Yazmouth Business Establishments To�a,v � CodN�a2y Mat�f� LODCrE
(�/V� GG�;S��v'��D
From: Bruce G. Murphy, Director v
Yarmouth Health Department� FEd 0 9 2pt5
Date: November 7, 2014 HEALTH DEPT
Subject: Increase in License/Permit Fees
Please be awaze that the Yannouth Boazd of Health, under the direction of the Yarmouth Boazd
of Selectmen, has raised a number of license and pernut fees issued through the Yarmouth
Health Department, effective January 1, 2015.
Attached is the Yarmouth Business License/Permit ApplicaUon 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 applicarion, and submit it to the Yarmouth Health ,
Department with a11 required certifications and worker's compensation coverage information
(certificate of insurance OR completed affidavit) nrior to December 31. 2014, you will be
allowed to pay the 2014 rates for the following licenses:
Current 2014 Fee QR�� AG� �•31
Public Swimming Pools $ 80.00 (�{� �32D•o0 owEs y 1zo
Public WhirlpooUVapor Baths $ 80.00 �i� � g0.00 o�s � 30
Tobacco Sales $ 95.00
Motels $ 55.00 (I) SS.CX� oW es � 55
Food Service 0-100 Seats $ 85.00 '
- - _ - — Food Service Over I00�eafs " _ $166.Da - — — -.__ - - - ;
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:
._--- '
Tota1 fees owed for your establishment: ��{55•Od o�t��zo5 �L ',
NOTE: To be entitled to pay the current 2014 rates listed above, your ',
business application, food and/or pool certificafions, 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 certifacations prior to opening, however, you must note
"Will provide in the spring prior to opening" on the application.J
BGM/maf
�
I
j
, , T„r,�+couN-r2
a TOWN OF YARMOUTH BOARD OF HEALTH G �,��;,'Ji�DD
��� APPLICATION FOR LICENSE/PERMIT-2015
` * Please complete form and attach all necessary documents by Decem r I�E�o�� 2015
Failure to do so will result in the return of your applicahon pac et. HEALTH DEPT
ESTABLISHMENT NAME: TAX ID: � —
LOCATIONADDRESS: 452Mainstreet TEL.#: �'`���7/—O /z
MAILING ADDRESS: '� e�00 , i
E-MAIL ADDRESS: 3Z ` :
OWNER NAME: �P « �� '
CORPORATION NAME (IF APPLICABLE):
MANAGER'S NAME: � �- �r^� TEL.#: ' 6 y— �
MAILING ADDRESS: i/ P/� . �i /PN �r�/
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 cop of the certification to this form.
�� / �
.
- - --- „1 � _
—
- -- --- --- _ __
1. 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. �:� �� 1 L✓ �'� ''�'�Sf z. �"�l/�/ti/� 4`N�� I
3. 4• I
FOOD PROTECTION MANAGERS - CERTIFICATIONS: II
All food service establishments are required to have at least one fixll-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. 2•
PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge (PIC) on site during hows of operation.
- '
- - — - - - I
1. - - _ - _z_ _ __ _ _
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 applicaUon. The Health Department will not use past years' records. You must
provide new copies and maintain a file at your establishment. I
1. 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-chokmg 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#
OFFICE USE ONLY '
LODGING: '��
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# '..
B&B $55 CABIN $SS MOTEL $ll0 ..�1� OZ�S ��
INN $55 CAMP $55 �SW[MMINGPOOL$IlOea..tt1—,S-�` S�'��o�'
_LODGE $55 _TRAILERPARK $105 �WHIRLPOOL $110ea.��t.n2�) ��gl
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 COMMON VIC. $60 WHOLESALE $80 �i
— — —RESID.KITCHEN $80 '�..
RETAIL SERVICE: I
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED PERMIT# .
<50 sq.ft. $50 >25,000 sq ft. $285 VENDING- $25 �� '�
=<25,OOOsq.ft. $I50 —FROZENDESSERT $40 _TOBA $110 —�
�
NAMECHANGE: $15 AMOUNTD = $ /��o�.(1C) �
�
***""PLEASE TURN OVER AND COMPLETE OTHER SIDE OE FOR **•*" ��D ySS•U��1 �:
� � OS.00 �ul�' ;
�-- _ I
ADMINISTRA'TION
Under Chapter 152,Section 25C,Subsection 6,the Town of Yarmouth is naw required to hold issuance or renewal
af any license or permit to operate a business if a person or company does qot have a Certificate of Worker's
Compensation 7nsurance. TIiE ATTACAED STATE WOItKEit'S Ct7MPENSATION INSURANCE i
AFFTDAVIT MUST BE COMPLETF.,D AND SIGNED, OR �
CERT. 4P iNSt3IZANCE ATTACHED
OR
WORKER'S COMP. AFFiDAVIT SIGNED AND ATTA�HED
Torvn of Yazmouth ta�ces and liens rnust be paid p ' r to renewal or issuance of your permits. PLEASE CHECK
APPROPRIA'T'ELY IF PAID:
YES NO
i
MOTELS AND OTHER LODGING ESTA.BLISHMENTS
TRANSIENT OCCLTPANCY: For purposes ofthe limitatians of Motel or Hotei use,Transient occupancy shall be
limited tn the temparary and short term occupancy,ordinarily and custornarity associated with matel and hotel use. �
Transient occupants must have and be able to demonstrate that they mainta3n a principal place of residence �
elsewhere.Transient occugancy sha11 generally r�fer to continuous accupancy of not more than thirty(30)days,and
an aggregate of not more than ninety(90)days wiChin any six(6)month period. Use pf a�uest unit as a residence or
dwelling unit shall not be considered transient. 4ecupancy that is subject to the collection of Room Qeeupancy
Excise,as defined in M.G,I�. c. 64G or$30 CMR 64G,as amended, shall generally be considered Transient.
raoz,s
POOL OPENI1�iG:All swimming,wading and whirlpools wbich have been closed for the season must be inspected
by the Health DeparUnent prior to opening. Contact the FIealth Department to schedule the inspection three(3) �
days priar to apening. FLEASE N4TE: People are NOT allowed to sit zn the paol area until the poal has been i
inspected and opened.
POOL WATER TES'�'ING: The water must be tested far pseudomonas,total coliform and standard plate caunt
by a State certified Iab, and submitted to the Health Department three (3} days prior to opening, and quarterly j
thereafter.
POOL CLOSING: Every outdaor in graunc3 swimming pool must be drained or cavered within seven(7)days of �
closing. ',
FO011 SERV[CE
SEASONAL FOCID SERVICE OPENING:
All foad service establishments must be inspected by the FIealth Department priar to opening. Please contact the C
Health DepartmenY to schedule the inspection three(3) days prior to opening. ,
CATERiI!'G POLICY: '
Anyone who caters within the Town of Yannouth rnust notify the Yarmouth Health Department by filing the
required Temporary Food Service Application farm 72 hours priar to the catered event. Thesa forms can be
obtained at the Health Department,or fram the Town's website at www_yarrnouth.ma.us under Haalth Deparhnent,
Downloadable Forms.
1
FBOZEN DESSERTS: ,
Frozen desserts must be tested by a State certified lab prior to opening and monthly thereafter,with sarnple results '
submitted to the Health Deparkment. FaiIure to do so will result in the suspension or revocation of your Frozen
Dessert Permit untii the above terms have been met.
tlUTSIDE CA�'ES;
Qutside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval frorn the Board of Health.
OUTDOOR COOHING: '
Outdoor cooking,pzepazation,or display of any food product by a retail or food service establishment is prohibited.
- - -. _ _.. -.._---
_ _ __ _.—.-----
- ------ i
NOTICE:Permits run annixally from January I to December 3 L IT IS YOLTR RESPONSIBILITY TO RETURN I
THE COMPLETEI7 RENEWAL APPLICATION{S}ANI}REQUIRE.D F�E{S}BY I}ECEMBET2 I5,2014.
ALL RENOVATIONS Td ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT,ETC.},MUST BE REPC}RTED Td AND APPROVED BY THE BC}r�ItI}{7F HEALTH PRIOR
TO COMMENCEMENT. RENOVATI4NS MAY R I A SITF,PLt1N.
DATE: �SIGNATU _ _„/' ��__�.="�'°°�
PRiNT NAME& TITLE:�T�P��".f_��_ u Gt� �''`-- �
Rev. 11f031]4 I
' � t� The Commonwealth ofMassachuset[s
Department of Industrial Accidents
Office of Investigations
' I Congress Street, Suite 100
Boston, MA 02114-20U
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Auulicant Information Please Print Leeiblv
Business/OrganizationName:�d�/N � ( �/" 1��
Address: ��Z /`�G�f /✓ "� �• ���/� � / " I
City/State/Zip: , / Phone#: 5 dY 7��—"dZ� �
Are you an employer? Check the appropriate box: Business Type(required):
t.�I am a employer with�employees(full and/ 5. ❑ Retaii
or part-tim�.* _ 6. ❑ RestaurantJBaz/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 aze 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]*
4.❑ We aze a non-profit organization, staffed by volunteers, �1.� Health Care
with no employees. [No workers' comp. insurance req.] 12.❑ Other
*Any applicant thaz checks box#1 must also fill out the section below showing their workers'compensation policy in£olma[ioa.
**If the coxpomte officeis have exempted themselves,but ihe corporation has other employ�s,a wocicers'compensation policy is required md such an
organization should check box#1. � . �
I am an empinyer that isproviding w rkers'compensation insuMrance far my employees. Below rs thepo[icy information.
Insurance Company Name: � �� '� �� � / �������� f
Insurer's Address: �)�G�I/✓�/[_ D d���� -Q �/�i/✓#/��P f �T v ��vS
City/State/Zip:
Policy#or Self-ins.Lic. # A ��-I(/J/����� -1 U 11�_Expiration Date:V Z.dI
Attach a copy of the worke�s compensation policy declar�ah'�a page(showing the policy number and expiration date).
- -- --Failaxefo suureroverage_as rec}uired under Section24A-of N1�'iL�. 152 can_lead to the imposirio_n of criminal penalries 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 fine '
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwazded to the Office of
Invesrigations of the D r insurance coverage verification.
I do hereby certi , n ains and penalties of tion provided above is true and correct.
Si ature: Date: � '
Phone#: —
O�cial use only. Do not write in this area,to be comp[eted by city or town officiaL
�
City or Town: PermitlLicense# �
Issuing Authority(circle one):
1.Board of Health 2. Building Department 3. City/Town Clerk 4.Licensing Board 5. Selectmen's OfSce
6.Other i
i
Contact Person: Phone#: I
www.mass.gov/dia l
i
W6RKERS CpMPENSAT20N AND EMPLAYERS LIABILZTY INSUAANC& CERTIFICASE
�
�
SHFQRNfATEflN PAGE - .
� Producer: Agent# 137
', MA Retsil Merohants WC Group Inc. Bpyntqn Insuaxanca Agency Ina.
� PO Box 859222-9222 72 RivEr Park SC
BraintXee, MA 01285 Needham, MA D2194
(Carrier CoBe: 34355} Certificate #: oi400S433479124
Prior Certificake #: NEW
i. 7'he Employer: Dockside Hotel Group Inc
Mailing Addre95: 476 Main Street
West Yarmoukh, Fm 02673
Fein:
Otber workplaces not shown above; Type of Businees: Cozparation
6E£ SCHEDULE OF OP$RRTIONS Risk ID:
a. 2he certifieata period ie from 12:01 a.m. on 1/O1/2014 to 12:01 a.m. on
1I01/2015 at khe ineure8's mailing addrems.
3. A. cuorkers Campensation Covorage: Part One aP the eertificate appliea to the
Workers Compensation Law of the states listed here: �
MA
H. Employers Liability Caverage: Part Two oP the certificaGe applies� ta work zn
eaeh state iiatecl in Ztem a.A. The limi.ts of our liabSlity under Fart Two are:
Bodily Fnjnry�by Rccident $ . 1,440�aaQ each accident �
Bodily Injur}+ by Diaease $ 1,000�000 certificate 11mit
Sodil}+ Injury by Disease $ 1,640,Q40 each employae
C. other States Coverage:
D. Thig certificsCe i.ncludes these endorsements and schedules:
WCOOOd00A(p4j42) WC000310(04J$Q) WC000424(07j90) WC400922A(69/OS} WC200302{Q4j84}
WC2p0302 (09/86) WC2003038(07/99) WC2004tl5(06/01} �W�200601(06/B2) ,
4. 2'he conCrik�ution for this certificate will be determined by our Manuala pf Rulae, �
ClassiEications, Rates and RaCing Plans. All information required below ia subject �
to veri£ication and change by audit. �
ClassificaCions Code Contribution Basis � RaC� Per EstimaCed �
� No. Total EatimaLed $1Q0 of 13nnual
Annual Remuneration Remuneration Concribution .
SfiE 5QiEpTJI,E OF 4P8R,ATIONS ' �
i
Total Eetimated Annaal ConCribution 12,667.00 �
Minimvm Contributiott $ 306.00 Expense Constant $ .p0
. _ i
WC 60 DO O1 A Zssue Date: 2f03j2024 Counters3gned by i
�
' I
I I�
I
(
✓' �
SCAEDULE OF OPERP,TZONS FOR: PAGE: 1 .
� Dockside Hotel Group Inc Certi£icate # : 014p05033479114 .
! 476 Main Street Fein: .
iWest Yarmouth, MA 02673 :
QTHER WORKPLACE5 : •
Cape Point HOCel -
The Point LLC -
476 Main Street, Route 28 •
West Yarmouth, A9A 026?3 •
E'ein: .
j Mariner Motor Lodge Mariner Motor Lodge .
The Mariner Motor Lodge LLC �
573 Main Street, Rbute 28 476 Main Street, Route 28 .
West Yarmputh, MA 02673 West Yarmouth, MA 02693 .
Fein: •
� Town 'N Country Motar Lodge Town 'N Country Motor Lodge .
Cape Town & Country Motor Lodge LLC •
452 Main Street, Route 28 476 Main Street, Route 28 .
West Yarmouth, MA 02673 West Yarmouth, MA 02673 .
; Feinc -
i •
� �
(
i .
WC QO QO Ql A •