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Home My WebLink AboutApplication and WC i � , } .` pF��4,,� � � .- _ � ��a TOWN OF YARMOUTH Boardof „ - _�}� Health � -- � `� 1146 ROUTE 28, SOUTH YARMOUTH,MASSACHUSETTS 02664-24451 � �; a,� � ^�� '� Telephone(508)398-2231 ext. 1241 Health T r��µE�. ' D1V1S1011 Fax(508)760-3472 To: Yarmouth Business Establishments C�pe Co� F�n1t��( K�So�,-t- � From: Bruce G. Murphy, Director G3LSC�COb[5 op Yarmouth Health Department Utl: i 7 L014 Date: �"November 7, 2014 HEALTH DEPT. Subject: Increase in License/Permit Fees ' I 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 iss,ued 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 l, 2015. These fees will be due if you complete and ' submit the application after January l, 2015. , However, if you fully complete the application, and submit it to the Yarmouth Health Depa.rtment 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 C2-> $ l ro0.C� ; Public WhirlpooUVaporBaths $ 80.00 �� 8b.0o Tobacco Sales $ 95.00 Motels $ 55.00 S� Restaurants 0-100 Seats $ 85.00 � _R�staurants Over 1 QO Seat� - _ . $i 6E3�0 _ . ; 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: �2�s.OO 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.J ; �, BGM/maf �,�� 1ir��'�;�:� , - � 2� • � ► TOWN OF YARMOUTH BOARD OF HEALTH � � � � � � APPLICATION FOR LICENS ��T -Z�1� :;;, � �� r . a� utt; '� 7 tut� ""` * Please com plete form and attach all nece��d r`�r�s.'b�De. "' ber 1S 2014. Failure to do so will result in the ret of�o k`i�i�ap�c�.tion p ketHEALTH DEPT. ESTABLISHMENT NAME: �APF C,al,FI�}mi �� QE5r�t� TAX ID: LOCATION ADDRESS:��Z /1'lr4in/ �t• W�ST y�Qmo�+� _ l�r4 oz�l�3TEL.#: 50�- 7°�/-v l�i/ MAILING ADDRESS: PO l�ox 4[S! GU, ��c�c��, I1'►�- �t�2[, �� I E-MAILADDRESS: �'o� r►-�arr'arnci �es,,,c�.i�, L�m OWNER NAME: J c►s F o h �'1'l q re,�2.�vr►;rti CORPORATION NAME (IF APPLICABLE): SgND6R� �ni4ti .��.n.�" �►vC MANAGER'S NAME: �s��h YYtA-��w�nr� TEL#• ��7�f'-3'�.S-:S�r�. MAILING ADDRESS: �� Lc� �jA-�:n��r.� �'h r�- t�Z!� 73 POOL CERTIFICATIONS: The pool supervisor must be certi�ed 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. Pa�� '�'��b��-� ��9V� �'�'b��i��-r�►-, 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 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 file at your place of business. 1. i1�4►vE (3 E�+Lkt 2. �av(��h P�s �ieie 3. r .[•�.�a�n ��9'ra�-1.c.8 4. ffrLi�s-�r�..�-•� jP�-�,�k.c.v 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. 2• PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. _ _ __ __ _ _ __ - _ 1. . _ _ 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. 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 a11 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. 2. 3. 4. _ RE��'AUR.ANT SEATING: TOTAL# _ ___ _�, OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 I MOTEL $110 ,�(��2 INN $55 CAMP $55 �SWIMMING POOL$110ea. 5` 457'. _LODGE $55 _TRAILER PARK $105 �WHIRLPOOL $110ea.i�� FOOD SERVICE: ��u�-t# Z3��" b �`> �-`� ; LICENSE REQUIRED FEE PERMIT# UIRED FEE P LICENSE REQUIRED FEE PERMIT# ' 0-100 SEATS $125 �CONTINENTAL $35 IJ— O NON-PROFIT $30 ', >100 SEATS $200 . 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 _ $ ��0.Ob � �.�� ,..� � �d � 2��o� *****PLEASE TURN OVER AND C � �'I�� FORM***** �- e,P2-�27,0 3 f Z�t��i�- t �' '� , , �<; 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 k CERT. OF INSURANCE ATTACHED � F OR ' WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED v Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK i APPROPRIATELY IF PAID: v NO � YES � MOTELS AND OTHER LODGING ESTABLISHMENTS � TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy sha11 be f limited to the temporary and short term occupancy,ordinaxily 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 i elsewhere.Transient occupancy shall generally refer to continuous occupancy of not more than thirty(30)days,and j an aggregate of not more than ninety(90)days within any six(6)month period. Use of a guest unit as a residence or f 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 ha�e 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. i 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. r FOOD SE�tsJICE 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. i , 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 , obtamed 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 CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. OUTDOOR COOKING: Outdoor cooking,�reparatio_n,_or display of_any fo_od product by a retail or food service establishment is_prohibited. � RETURN � NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO , THE COMFLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 15, 2014. ; � ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW � I EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. � DATE: SIGNATURE: : PR1NT NAME& TITLE: ; Rev. l l/03/14 ' � � � { . � j , . � The Commonwealth of Massachusetts � � Department of Industrial Accidents ,' �, - Office of Investigations ` 1 Congress Street, Suite 100 Boston, MA 02I14-2017 � www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legiblv Business/Organization Name: S��i /"ha��r,.�1 n� 8��/� F9rnr� Address: �� l� Yl�,'Lu S�� City/State/Zip: (.11.,l��n�F ►�I�9 G 2�� Phone #: g`�f'-3 Z.S- —�4�02— Are you an employer? Check the appropriate boz: Business Type(required): 1.� I am a employer with �v employees(full and/ 5. ❑ Reta.il or part-time).*___ __ _ _ 6. ❑ RestaurantBar/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 capacrty. [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.� Health Care 4.❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.�'Other ��',�.[, ,��r�sz� *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#L I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: .�Gc.az.e�� Insurer's Address: /� � l�-y� 6 �5�7 9 City/State/Zip: �`� !�"''L' Policy#or Self-ins.Lic. # S�IU C �� 8"� G Expiration Date: J��/S— Attach a copy of the workers' compensation policy declaration page(showing the policy number and egpiration date). Failurein�cura�o�rerage_as requir�d undex Section2�A of_lYIS'zL�. 15�_can_leac�_to_t�_ir�position of c�min�,l�en�lties 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 certify, er the pai and alties of perjury that the information provided above is true and correct. Si ature: Date: /Z��S�� Phone#: el'7�-37S-S�G2- 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 Aealth 2. Building Department 3. City/Town Clerk 4.Licensing Board 5. Selectmen's Office 6.Other �,��'�`:� � �� Contact Person• Phone#• ! www.mass.gov/dia � , i ,� ' �� i • coRt� �E�TIFICATE OF L.IABILITY lNSURANCE ""�'�"'°°"'"'"' THS CERTIFICAZE 18 188UEA AS MATTER OF INFORMATION ONLY/WD CONFERS NO RIGHTS UPON?HE CERTIFlCATE NOLDER TMS � CERIIFICA'iE DOES NOT AFFtRAA 71VELY OR NEGATIVELY AMENp, EXTEND OR AL1ER TFlE COVERAGE AFFORt7ED BY THE ppUpES , BELaIV. THiS CERfIFlCATE OF I 8URANCE DOES NpT CONSTITUIE A CONTRACT BE7INEEN THE ISSUING INSURER�S), AUTHORIZED REPRESE(�fTATiVE OR PRODUCERJ AND 111E CERTIFlCATE HOLDER. � !M : N the cerNticate fiofd r is an ADn1710NAt INSURED,the policy(ies)must be endorsod. If SUBROGA710N IS WAIVED�subject to � tlte fem�s and conditions ofthe pol y,certain policies mey requlre an endo�sement A Sfw6emerR on tlus certificate dces not conbr righb b�1he � cerd8cabe Aolder in�ieu of such e orsamen s. ��c� NA : Brian Allaia Choice Insuranoe Ageney�� nc. v NE _ � 3,76 Summer Street � 800 649-4653 �'" N ; (9�8? 3a5-loo� b'itohburq, MA 01420 ao�Es : ballain Choiee insurariCe.com INSUf� S APFORDiNG COVERA E NAIC• --� •• "....__.__.. iNSvaEa q:Guard Insuraxaae Co �A6 UREO .... ._._ -- I WURER B: Sandbar Managam t Inc ' i ro9urtER c: Cape Cod Inflat le Park P.O. Box 481 ��R�D; ' 9�A8'C Y8i'IDOLIC}1� O2 G7� ��RER E: INSUREq F: COVERACaES C RTIFICATE N UMBER: REVISION NU�IIBER: 7HIS IS TO CERTIFY TNAT 711E Pq.l I�S OF INSURANCE USTEO BELOw HAVE gEEN ISSUED 70 THE INSUItED NAMED ABOVE FOR?HE POLICY PERIOD INDICATED. NO7WITHSTANDING AN , REQlI1REMEM,TERM OR CONOITION OF ANY CONTRACT OR OTHER DOCUMFJYT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR Y PERTAiN,THE INSURANCE AFFORDE�e�TI-E POLICIES OESC�tIBED HEREIN IS SUBJ�C7 TO ALL THE TERMS, EXCLUSIONS ANO CONDITIONS OF S�POUC�S.l INUTS SH01MV MAY HAVE BE EN REDUCED ev PAID CLAIMS. LTR IYYEOFINSURIWCE A -- P •EFX 'p�y�P. , ..._ ... .. NND POUC1f MJ1�6ER M/�K INAUpp UMTS GENEAAL UABILI7V EACH OCCURRENCE i COMNEqCl4L O�NEwql�WBILiTY II � OAMAGE TO REN7ED �...�,�.. s cu�nas�n� �occuR � �o�w�a o� Q,m� s � Peasora�s,e,�v�wurev $ ' GENERAL AGGRlW7E i i GEN'LAGGREGATELMTAAPUESPER j� PRODUCTS-OONP/Orq�G E POLICY P �� i AUTOM081LE LIA81l1TY D SINGIE CMAR � aacadlN Z �YA�� BOOIIV INJURY(Per pa�aon) i , ALLOW►�D SCHEOULEO I AUTOS AUTOS 8004YIN�URV�per eCCIOwIq t NON.OWNED(I � PROPE fRY DAJW4 . NIRED AUTOS _AUTOS i a.e�� E �' E �� V�� OOCUR � FdCMOCCURRENCE S F]fC63SUAB ��pIMS�� AGGREGqTE S DED RETENTION i � A WORKEASCOMPENyATl011 �'N 3AWC477816 30/1/3A 10/1/15 WCSTATU• X pTH. 1 AND EMPLOY6p8'LiA&UTN � ' ANYVROVR�E70wvMTNEWEXECUnvE � OfFICEAil�AE1�EREXCLWEU7 N!A E.L.EACHACGOEM 6 1,000 OOO ; (MSMabry InNN} E.l.Dt8EA9E•EA FA�p� r 1 000 000 Iryra deo�be under DES�RI�TION�OPERqTiONS babw E.L.DISEASF-P011CY IIMR 1 �� 0� I OF,SCqIP110N OF OPERAT1pW9/LOpITONb/V CLES(JNp�C�pCpq0101,AdditlonN R1mi1Me 9ChWule,N mor�sp9C�Is nqU ryd� Operstions of Insured. � II �I I� �� CERTIFlCATE HOLDER CANCELLATION I i 3HOULD ANV OF TfIH ABOVE DESCRIBEp PpLICIE9 8E CANCELLED 6EFORE Tf1E E%VIRATION DAIE TNEREOF, NOTICE WILL BE OEUVEREO IN Toar► of YarmOti ACCORDANGE W17H 7}IE POLICY PROVISIONS. Route 28 Yarmouth, D4A 02�¢64 AUTIORlZED REPRESENTAiNE �?:,- -�� .;.�� !� Brian P. Allain �1988-2010 ACORD CORPORATION. All rights reaerved. ACORb 25(2010/05) � The A�CORD namo and logo ore ragist�rcd marks oi ACORD Phone: F�c: E-Mail: q