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� � _ z �,a TOWN OF YARMOUTH Boardof
� - - _� � Health �
; � -:._ .a- �' � 1146 ROUTE 28, SOUTH YARMOUTH,MASSACHLJSETTS 02664-24451 Health
�' �. �,�r v �$'� `x Telephone(508)398-2231, ext. 1241 Division
r"�"�' Fax(508)760-3472
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To: Yarmouth Business Establishments ��N kt N �oN vTS
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From: Bruce G. Murphy, Director HEALTH DEPT.
Yarmouth Health Department
Date: November 7,2014
Subject: Increase in License/Permit Fees
, 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 issued through the Yarmouth
Health Department, effective January 1, 2015.
Attached is the Yarxnouth Business License/Permit Application 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 l, 2015.
However, if you fully complete the application, and submit it to the Yarmouth Health
Department with a11 required certifications and worker's compensation coverage information
(certificate of insurance OR completed �davit) prior 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 Whirlpool/Vapor Baths $ 80.00
Tobacco Sa1es $ 95.00
Motels $ 55.00
Restaurants 0-100 Seats $ 85.00 5.00
__ ----_
__ ._ R�staurants Gver 1�i6�eats _ _ _ $1�0�06 __
-- - --
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.Co Cm�r�oN V�c .
� Total fees owed for your establishment: 5_o�
i
� NOTE: To be entitled to pay the current 2014 rates listed above, your
i 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
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� � TOWN OF YARMOUTH BOARD OF HEALT�I, '���Od��°
� APPLICATION FOR LICENSE/PERMI'T'�20 � DEC C�
�o���;��� _.� 5 2014
! `°� * Please complete form and attach all necessary doc�umef����bx.,Dec�Be �'S 2014.
� Failure to do so will result in the return of yoiir application packe . HEA�TH DEPT.
'; ESTABLISHMENT NAME: � ti h TAX ID: ' � /
� LOCATION ADDRESS: t"Cs fii�� /� �'t C s. /A�pJ(�TEL.#: Sd � � I'Oe�
MAILING ADDRESS: �1 t�. � ✓ ` r�► Jhc. M �LGG
E-MAIL ADDRESS: h �, a f e
OWNER NAME: �
CORPORATION NAME (IF PPLICAB ): fi � �,/ 0�n✓� I,C�C_•
MANAGER'S NAME: __ jC�✓�,�, Sa n,� T L.#: S��� 3�!� - 800)
� MAILING ADDRESS: �I 3h g '� �"�t-h'on �9 ✓tn v r �i��/ e.r l�i _ M����4
� 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, 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. 2.
3. 4.
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. k�r�n �o�►� 2.
PERSON iN CHARGE:
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
- _ _. __ _ _ _ _ __ _ _ _ _ -- --
1. 2.
I 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. C���rh� 1�. {�nG�, 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-choking procedures below and
attach copies of employee certifications to this form. The Health Department will not use past years' reeords.
You must provide new copies and maintain a�le at your place of business.
;
; l. l�-�1,f t,n �b N�� 2. b u f l' 12.
3. q,.
RESTAURANT SEATING: TOTAL# �10
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
II�1N $55 CABIN $55 _MOTEL $110
C�1MP $55 SWIMMING POOL$110ea.
_LODGE $55 _TRAILER PARK $105 _WHIRLPOOL $i l0ea. '
FOOD SERVICE:
L CENSE 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
RETAIL SERVICE: —RESID.KITCHEN $80 �
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FE$ PERMIT# LICENSE REQUIRED FEE PERMIT# I
<50 sq.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 i
=<25,OOOsq.ft. $150 _FROZENDESSERT $40 _TOBACCO $110
NAME CHANGE: $15 AMOLTNT DUE _ $ ���-�j���
*****PLEASE TURN OVER ANB_COM�T-T.,Q'I'.�IER,SID���F FORM*****'�C-���'C��� i
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ADMINISTRATION
Under Chapter 152, Section 25C,Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal
of any �icense or permit to operate a business if a person or company does not have a Certificate of Worker's r
Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR
CERT. OF INSURANCE ATTACHED �
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth taxes and liens must be paid pri r to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES NO
MOTELS AND OTHER LODGING ESTABLISHMENTS ��
TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy sha11 be
limited to the temporary and short term occupancy,ordinarily 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
elsewhere.Transient occupancy shall generally refer to continuous occupancy of not more than thirly(30)days,and
an aggregate of not more than ninety(90)days within any six(6)month period. Use of a guest unit as a residence or
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 have 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.
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.
M
POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of
closing.
FOOD SElaVICE
SEASONAL FOOD SERVICE OPENING: "
All food service esta.blishments 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.
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
obtained 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: ,
' ata,tion,�r display Q�anYfQod�roduct��retail or_food service_establishment is prohibited. _,
�utdnnr co�lcin nr .n - __
NOTICE:Permits run a.nnually from January 1 to DecAND RE UIRED FEE(�B Y E BMB R 150, 0 4�
T H E C O M P L E T E D R E N E W A L A P P L I C A T I O N(S) Q
ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT,ETC.),MUST BE REPORTED TO ANDjAP�PRA SITE P AN E BOARD OF HEALTH PRIOR
T O C O M M E N C E M E N T. R E N O V A T I O N S M A Y R E Q
I! DATE: 1'Z-I � i N SIGNATURE: �� �
I /,+,. . �r�tn�t'
pR1NT NAME&TITLE:
Rev.l l/03/14
, _.� _ _ =
� � �� 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: �Un 1�in �on� r-� _
Address: � 6 S �'cc-f�i t,� �9J en d�/
City/State/Zip: yPhone #: ��& ' 3`l'� �'��/
Ar�e yo an employer? Check the a propriate boz: Business Type(required):
1.Cl I am a employer with Z� employees(full and/ 5. ❑ Retail
or part-time).* 6. ,�'kestaurantlBar/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 are a corporation and its officers have exercised 9. ❑ Entertainment
their right of exemption per c. 152, §1(4),and we have 10.0 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
*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#1.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information.
Insurance Company Name:� i,(-t,,,l �1'►F,�'c�a l� w� G�a�o �, _ _
Insurer's Address: �(j,L $�y �-i2 - l Z27
City/State/Zip: 1�-�s�w t� /'ti-� �'LA. O�'Lsr�
�
� Policy#or Self-ins. Lic.# Pl(��56 3 �- b 6 �! t ! �l Expiration Date: i� �S�
Attach a copy of the workers' compensation policy declaration page(showing the policy number an ezpiration date).
_ Failnre tQs�cur�coverage as required under Section 25A of MGL c. 152 can_lead to the imposition of criminal penalties 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.
1
� I do hereby certify,under the pains and penalties of perjury that the information provided above is true and correct.
I
� Si�nature: �G A- C.�" �t/ Date: !
� �l�� `�
Phone#: SOk � �7 k �S '� �f U� 1
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 Health 2. Building Department 3. City/Town Clerk 4.Licensing Board 5. Selectmen's Office
6.Other �.,� �., � � z s ��.
��:��.°..�� �:a� ���'
Contact Person: Phone#:
wwwmass.gov/dia
�
�RKERS C01+4PENSATION AND EMpLOyERS LIABILITY INSITRl�NCE CERTIE'ICATE
__
! INEORMATION PAGE
( RENEWAI, AG1-ZEEMENT
� Reta31 1�Ierchants WC Group Inc. �'roducer: Agent�'� 542 '
! Box 559222-9222 Rogers & Gray Tnsurance Agency, In
aintree, MA 01285 ' �434 Route 134
sr_r1er Code: 34355) South Dennis, MA 02b60
Cer�ificate ��: 014005032604114
Prior Cerzificate ��: Q140050326Q4113
'I'.he Employer: `L �7onut Company, Inc.
Mailing .Address: 436B Station Ave
South Yarmouth, M1� 02664 .
Othe� t,;orkplaces not sho�-n above: Fein:
SEE �;CHEDULE OF OL'FRATIONS TYpe of Business: Gorporation
Risk ID: �
T`112 cer�ificate period is irom 12:01 a.m. on_ 1/Ol/201�
1/01/2015 a� tlie insured's ma7ling address, t� �"2'�1 a'm' °n
i .
A. Workers Compensation Coverage: Part One of �he certificate appl7es �o t
Workers Co�iperls.st�.on La�,r oi the s�ates listed her_e: he
MA �
8- EmplojTers Liability Coverage: Part 'I'cwo oi the certificate applies to werk 1n
each state Iisted in :Item 3.A. 'rhe lirnits or our li.ability under Part T�o are:
Bodily r��j;�rY' bY Accid�ni
�3odily lnjury b= D.'.� $ 1 000 OOQ 2ach accid2ht
� �.�ezse
�'�(�_i�0� r�
Bodily In�url �Y Disease $ 1 000 000 certillcate limi,_
each employe�
' �. 0�.he� Sta�es Cov�raae:
� ' .
� • T.�iis certificate ir�clu��� these endorsements and schedules:
WCOOOOOOA(04/92) WC000308(04/84) WC000310(pt�/g4) t��00U40GA(08/95) WCOQ0414
WC000422A{09/p8) �,�C200301(04/84) WC200302(05/86) WC20p303B(07/99) Wr2�0�05 (p6�9Q)
WG200601(Ob/9L) .. . ( /O1)
ie cuni_ribut7 on for this certifica-ce t,r-iJ 1 be det=�r
-ass-��ications, Rates and Ra-ciia P1�� �-�ed by our Manuals Of RllZ2S,
� ver3fica�ion anc�. ch�:i e b b All in�orma�ior� required belo},� 7s subject
g y audi�.
assif-i catiuns Code ' '' ' '
Con�ributio�. Basis
No. Total Estimated �a-ie Per Estimated
A-nr�ua7 R2�uneration $104 0� Annual
Remuneration Contribut,on.
SEE SCIiEDULE OF OPERATTONS
:aI Est;ma�ted A.nnu�]. Contribut,on 38,496.�0
i+�i�i�nt�s Cont:�iby.�;:iozi $ � 294.QO �'xpes�se CGIig�{��i�."L' $ ,
.00
0 01 � Issue Dat�: Y/30/2,01t� .
� Courrter'�7.a11E:d Jy ___
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� SCHEDULE `
vF OPERATIQNS FOR:
Z Donut Company, In�. P�GE: 1
436B Station Ave Certi:Cicate �: 014005Q32o04114
3outh Yarmouth, 1�A 02604 Fein:
)1^HER WORKPL.ACES:
� Donut Company, In�,
3o Station Ave
o�uth Yarmouth, M� Q2a64 .
tation Avenue Donuts, LLC
36 Station Ave
' �uth Yarmouth, MA. 02664
' �in: '
�grafos Donuts, Inc.
:e 137 ZograFos Donuts,
.rwich, MA 02645 a36B Station �Ve Inc.
;in: South Yarmoutli, MA 0266�.
' ewster �onuts, LLC
Lower Rd Brewster ponuts, LLC
' awster, MA 02631 �'36B Station Ave
; in: S°uth Yarmouth, MA 02664
inis Donuts, Inc.
� = 6A Dennis Donuts, Inc.
'th Eastham, MA p2651 �36B Station Ave
n: �outh Yarmouth �
. , MA Q2o6�
wich �7onuts, LLC �
I Rte 137 �Har-wich Donuts, LLC
��i t Har-wich, MA 02645 436B Sta�zfln AVe
�I z: �011th Yarmouth, MA
� Q2664 .
' '_fl eet �on.ta.ts, LLC
� State Highway Wellfle�� Donuts
.f�ee�, � 02667 �36B Station AT�, LLC
.: �`°llth Yarmouth, M� 02664
iot Square Donuts, LLC .
terprise Road Patriot g
h Dennis, P�tA 02660 436B Sta.tlonrAve��u�s' LLC
: Sout.h Yarmouth, M1� 02G64
aan� La%�e .�onuts, LLG
?leasant Lake �7rive � Pleasant L�ake �onuts
-ch, NIA 02646 436B Station �Ve ' LLC
South Yarnlouth, �
02664
�:, ._ r� .
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SCHEDULE OF OPERATIONS FOR;
� Donut Campany, In�. PAGE; 2
�36B Station Ave Certificate �� 014005032604114
>outh Yarmouth, MA 02664
Fein:
�THER WQRKPLACES: �
hatham �7onuts, LLC
563 Rte 28 Chatham Donuts, LLC
!�atham, MA 02669 '�36B Station Ave
�in: South Yarmouth ,-
� � Q26o4
' �grafos Donuts, Inc.
'leans Market P1_ace
.e 6A
� ��eans, NLA 02653
in:
�rafos Donuts, Inc.
L Route 28
'' =��ichport, MA 02o4F
ln:
�nis Donuts, Inc.
Route 134
' �h. �ennis, M� G2660
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