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Home My WebLink AboutApplication and WC o�'YAR �� _� a _'�� TOWN OF YARMOUTH BIo;ad,of 0 � `j 1146 ROUTE 28, SOUTH YARMOUTH,MASSACHLJSETTS 02664-24451 � �. 4� 0� :r Telephone(508)398-2231, ext. 1241 Health T�A L NEf Division Fax(508)7603472 To: Yannouth Business Establishments C.av�rniN Fae�s H-ooS� From: Bruce G. Murphy, Director � G3[�6[�OMC�DD Yazmouth Health Department� UtC 2 3 C014 Date: November 7, 2014 HEALTH DEPT. 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 Yannouth Health Department, effective January 1, 2015. Attached is the Yarxnouth Business License/Pernut Application for 2015. You will note that the fees listed are the fees effecrive 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 Yazmouth Health Department with all 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 Public Swimming Pools $ 80.00 Public WhirlpooUVapor Baths $ 80.00 Tobacco Sa1es $ 95.00 Motels $ 55.00 Food Service 0-100 Seats $ 85.00 � f55.00 Foo3 Service Over 100 Seats $160.OG " . 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: � �15_oo le 9GE �CoMFWN V,c. Total fees owed for your establishxnent: �Q.oQ 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. �'1'hose 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.J BGM/maf r � �= uAP�.PRRRIS N'DJS� ��+.,� TOWN OF YARMOUTH BOARD OF HEALTH G3IsC�f��l�7�D - �npucdT7D�TFOB�ICEr�E�I'F�x2�� Ut� 2g Z 14 Captain Farris House B&B � ` '� � �ll ne�fum��t by � ecember IS �014. 308 Old Main Street lthe �£�trt�p�ic on� }{ DEPT. South Yarmouth MA 02664 TAXID: �� Michael & Nancy Lumia TEL.#: Night Contact 508-760-2818 Alarm Company: CCA Extinguisher Co: Ralph J Perry TEL.#: 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 Cazdiopulmonary Resuscitation (CPR), having one certified employee on premises at a11 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 Tile at your place of business. 1. Z• 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 wil►not use past years' records. You must provide new copies and maintain a �le at your establishment. 1. �^t�.�P l�c��.t�� CNC L 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Chazge (PIC) on site during hours of operation. 1. 1� ll r�. LA`� 1' ;/�� :� Z: 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 for Food Service Establishments, 105 CMR 590.009(G)(3)(a). Please attach copies of certification to this application. The Health DepaMment will not use past years' records. You must provide new copies and maintain a file at your establishment. �. I.�, �� .�adv► e 2. /� �N�-� Ly� 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 Deparhnent 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 REQU[RED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $110 —INN $55 CAMP $55 SWIMMING POOL$110ea. �LODGE $55 �00 _TRAILER PARK $105 _WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �0-100 SEATS $125 1t/T/39 CONTINENTAL $35 . NON-PROFIT $30 >I00 SEATS $200 �COMMON VIC. $60 -�1-l�S _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 _Q5,000 sq.ft. $150 —FROZEN DESSERT $40 _TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE _ $ 2�F� -OL C7 **•**PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM"**** K-�i� `t 2-'��`4� ��Z�7 ��/z�� ADMINISTRATION Under Chapter 152,Section 25C,Subsection 6,the Tawn af Yarmauth is now required to hold issuance or renewal af anq license or permit ta operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. TIiE ATTACHEl3 STATE WOILKER'S COMPEIVSA`i'IOl� INSURANCE AFFXDAVIT lYfUST BE COMPLETl?.D AND SICxNED, OR CERT. OF INSURANt'E ATTACHED OR WOR.KER'S COMP. AFFIDAVIT SIGNED AND A'CTACHED Towtt of Yazmouth ta�ces and liens rnust be paid prior to renewal or issuance of your permits. PLEASE CH�CK APPROPRIATELY IF PAID: YES Nd MOTELS ANA OTIIER L011GING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the�imitarions of Motel or Hatei use,Transient vecupancy shall be limited to the temporary and shart term occu�aancy,ordinazily and customar'rly associated with motel and hotel use. Transient occupants rnust have and be able fo demonstrate that #hey maintain a principal place of residence elsewhere.Transient accupancy shall generaily refer to continuaus occupancy of not more than thirty{30)days,and an aggregate of not more than ninety(90)days within any six(fi)montta period. Use of a guest unit as a residence or dwelling unit shatl not be considered transient. Occupancy that is subject to the collection of Room Occupancy Excise,as defined in M.G.L. c. b4G ar 834 CMR 64G,as amended, shail generaily be cansidered Transient. POOLS Pt}CiL GIPENING:All swimming,wading and whirlpools tivhich have been closed for the season must be inspected by the Health llepartment prior to opening. Contact the EIealkh Departmet�t to schedule the inspection three(3) days priar to opening. PLEASE NdTE: People are NOT allowed to sit in the pool area until the pool has been inspected and opened. PQOL WATER TE5TING: The water must bc tested lor pseudomonas,tota!cois£orrn and statadard plate count by a State certified lab, and submitted to the Health Department three (3) days prior to opening, and quarterly thereafter, P40L CLOSING:Every autdoor in ground swinansing 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 Fieaith Department ta schedule the inspection three{3}days priar to apening. CATERING POLICY: Anyone who caters within the Town of Yarmouth rnust noYify the Yarniouth Health Department by filing the required Temporary Food Service Applicatian form 72 hours prior to the catered event. These forms can be obtained at the Health Departrnent,or frarn the Town's website at www.yarrnouth.ma.us under Health Department, Dpwtiloadable Foans. FROZEN DESSERTS: Frozen desserts musi be tested by a State certified lab prior to opening and monthly thereafter,with sample results submitted to the Health Depazknent. Failure to do so wrll result in the suspension or revocation of your Frozen Dessert Permit until the above 2erms l�ave been met, OUTSIDE CAFES: Outside cstfes(i.e.,outdoor seating with waiterlwaitress service),must have prior approval frorn the Board ofHealth. OUTDO(7R COOKING: Outdoor cooking,preparation,or display of any food product by a retail pr food service establishment is prohibited. NOTICE:Permits run annually from January I to December 31. IT IS XOUR ItESPONSIBILITY TO RE"I'[IRN THE COMPLETEL7 RENEWAL APPLTCATIQN(S}AND R�QL7IRED FEE(S}BY DBCEMBER 15, 20T4. ALL [ZENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR PQOL (i.e., PAINTING, NEW EQUIPMENT, ETC.}, MUST BE REPORTED 1'O AND APl'ROVED BY THE B4ARD OF HEALTH PRIdR TQ CONIMEIYCEMENT. RENOVATTONS MAY R U R�.,�,�"IT AN. �,, DATE:_ L-`L��s.._} _SIC'iNATURE: �� ( � ! � f��'�.-CJU"""� PR1NT NAME&TIT"ZE:,� I G�+,q(`l ` ��l�� ,�y � c.t�Af{� —r--- Rev. llt03114 � � � � The Commonwealth ofMassachusetts Department of Industrial Accidents Office of Investigations ' I Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance AfSdavit: General Businesses Applicant Information Please Print LeEiblv Business/Organization Name: Address: City/State/Zip: Phone#: Are you an employer? Check the appropriate box: Business Type(required): 1.❑ I am a employer with employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ RestaurantlBaz/Earing 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 corporarion 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, 11.0 Health Care with no employees. [No workers' comp. insurance req.] 12.❑ Other 'Any applicant that checks box#1 must also fill out the section below showuig their workeis'compensation policy information. '•If the cocporate officers have exempted tLemselves,but the corporation has other employees,a workers'compensation policy is required and such an organiza[ion should check box#1. I am an emp[oyer that is providing workers'compensation insurance for my employees. Be[ow is the policy information. Insurance Company Name: Insurer's Address: City/State/Zip: Policy#or Self-ins. Lic. # Expiration Date: Attach a copy of the workers' compensation policy declaration page(showing the policy nnmber and eapiration date). Failures9 secur�s��cage aar�quir�d under Section 25A of_M�rL c._152 can_lead to the imposition of criminal�enalties of a_ fine up to $1,500.00 and/or one-year imprisonment, as well as civil penal6es 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 Investigations of the DIA for insurance covemge verification. I do hereby certify,y,n,�lgr th� penalries ofperjury that the information provided above is true and correct. Y� f- � �! s��,�e: �/'Y l J Date: I L' � � / Phone#: Official use on[y. Do not write in this area,to be comp[eted 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 ___ - _ -- - -_.-. - -. _ --- _ - __.__ . . Assxfated Employere Insurence Company _�.. _—._ —__ �_ —__. —._ __—. --�_.�_ _ —_ _—_ _ Insurad: 5007559 Protlucer: 04971-001-197 Captai�Farris Hospitality LLC Ragers&Gray Insuraoce Agency Inc 308 Okl Main Street 434 Rotrte t34 South Yarmouth,MA 02864 South pennis,MA 02660 Insured FEIN: ='" Issue Date: 0�/18/2014 Poiicy P7umber. WCC•500-5607559-2614A Endorsemant Effeciive Dai�: 09/09120td Policy Periotl: 09/09/2014�09/09/2015 Endowement Number: _ __„_J LQCATION SCHEDULE Insuretl Unit 001 Workpl9ce:001 Buskiess Typa:Llmited liaUilky Cotporation 8usiness Type: Captain Farris HoBpitaiiry LLC 308�310 M6in Street South Yarmouth,MA 62664 TAX10:030587334 Buslness Typa: gusiness Type: Business Type: Busie�9ss Type: Business Type: Business Type: Businass TYPe� 6usiness Type: Business Type: Business Type: Imured (lvrt)LocationScn -__- - - - - - , Assxiated Employers.lnsurence Company. _ _ - -- .—.. . .. - ... - �� Producer. 04971-001-197 Insured: 5007559 Captain Farris Hospilality LLC Rogers&Gray Insurence Agency Inc 308 Old Main Street 434 Route 134 South Yarmouth,MA 02664 � South Dennis,MA 02660 Insured FEIN: "' Issue Date: 07/18/2014 Policy Number. WCC-500-5007559-2014A Endorsemant Effecdve Date: 09/09/2074 Policy Period: 09/09/2014-09/09/2015 Endorsement Number: ENDORSEMENTSCHEDULE The forms listetl below are included in this policy: Fortn No. Form Deseription Applicable States Policy EHective Date -------... . ---. . _ .____---_—.. -- -�-----�---- PRIVACY Privacy Notice 09/09/20/4 Servonl Services Online InstrucGons 09/09/2014 WCRIB. WCRIB Ciroular Letters Notice MA 09/09/2014 AEICCI AEIC-ClPhoneNumbers o9/a9/2074 Lxation Location Schedule 09/09/2014 Class Code Classification Code Schedule 09/09/2014 Installment Installment Schedule 09/09/2014 Rating Summary Rating Summary by State 09/09/2014 WC 00 00 00 8 Policy Conditions 09/09/2014 WC 00 01 14 TERRORISM flISK INSURANCE PROGFiAM 09/09/2074 WC 00 03 11 A Voluntary Compensation and Employers Liebiliry 09/09/2014 WC 00 04 04 Pending Rate Change Entl. MA 09/09/2074 WC 00 04 14 Notification of Change in Ownership 09/09/2014 WC 00 04 22 A Terrorism Risk Reauthorization Disclosure 09/09/2014 '� WC 20 03 07 MA Limits of Liability Endorsement MA 09/09/2014 WC 20 03 02 A MA Assessment Charge MA 09l09/2014 WC 20 03 03 D MA Notice to Policy Holder Endorsement MA 09/09/2074 WC 20 03 O6 B MA Limited Other States Insurance Endorsement MA 09/09/2014 WC 20 04 05 MA Premium Due Date Endorsement MA 09/09/2014 WC 20 O6 Ot A MA Cancellation Endorsement MA 09/09/2014 WC 20 O6 64 MA Policy Definition Endoreement MA 09/09/2014 EMPNOTICE MA Notice to Employees MA 09l09/2014 Insured EndorsemaniSc�(OOA1)