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Home My WebLink AboutApplication and WC • -alla *Ye : TOWN OF YARMOUTH Board 4:#‘',W I. Health E .2*1 1146 ROUTE 28, SOUTH YARMOUTH, MASSACHUSETTS 02664-24451 �'� Health • ,� r t �, • •: Telephone (508) 398-2231 , ext. 1241 Division 4C 4 Fax (508) 760-3472 To: Yarmouth Business Establishments 019 caes-ntw + Po * 20050 From: Bruce G. Murphy, Director • Yarmouth Health Department . E:r.L;EL ‘, u- L.)/d Utt; . 5 2014 Date: November 7, 2014 HEALTH DEPT. 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 Yarmouth 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 1 , 2015. However, if you fully complete the application, and submit it to the Yarmouth Health Department with all required certifications 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: Current 2014 Fee Public Swimming Pools $ 80.00 Public Whirlpool/Vapor Baths $ 80.00 Tobacco Sales $ 95.00 Motels $ 55.00 Restaurants 0-100 Seats $ 85.00 Restaurants Over 100 Seats $ 160.00 4160 . 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: ck. 60.00 co M o N \+ c Total fees owed for your establishment: 2_2-0 .00 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.] BGM/maf s . TOWN OF YARMOUTH BOARD OF HEALTH E7g3[IUMED - '_ ,..„ , APPLICATION FOR LICENSE/PEa. I - r: -, �1t� 2O4 * Please complete form and attach all necessary documents byDecember 15, 2014. Failure to do so will result in the return of your application packetH EALTH DEPT. E S TAB LI S HMENT NAME: Ci ii2?j � - � -) ' LC - , i TAX ID: � , , • 'LOCATION ADDRESS: i(-i \'- �� e c ` TEL.#: s-:- -- 5-1.477_,-'7 7 .� MAILING ADDRESS: ^ : _�, � , :� i, `�i'_ � �-.. �`�,-�,_ . w13/7: #::d E-MAIL ADDRESS:1 `r:. ��: 1 -< ' k,(k _. . (._:: ^i-,, OWNER NAME: 1 9ii(Jr'? e LI CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: tit4•Akt „k...)\,,•-\1,c,\L''N ,...,,,_..,,- TEL•#: ? , :- MAILING ADDRESS: ti _-- j { ,F k. .)E1 POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator, as required by State law. Please list the designated Pool Operators) and attach a copy of the certification to this form. 1 . 01 /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 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 • 01A 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 . LL:),LA, Lt.” i .. lAc\-7,1-)\-k.,.): ,'--A2 `�- J ,1►r _I - 11--_ _ _ _ PER CH _ . __ Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1 . 1 " : , _ \' _ - ` ; r '''. ` 2• 0:..\\-) �\ ,4 .::o t'1: -\ --C'‘t_\. ' -4" I '' 2 CA-k . * ALLERGEN CERTIFICATIONS: , 7 A....,‘ ' \ IA LA."- civ--\ , 2-,:s A 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 . LU( 4J2. 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' records. You must provide new copies and maintain a file at your place of business. 1 { 7:3\ 1-N--tI- 2. -- _ , \ �NZA—.`� ie:_' 1. J -. 2....10LA.t; (i.A °� RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LODGING: LICENSE REQUIRED 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 TRAILER PARK $105 WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT # 0-100 SEATS $125 CONTINENTAL $35NON-PROFIT $30 -1—>100 SEATS $200 IL5 - 00 I COMMON VIC. $60 4 /S -C ZS 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 = $ 2-60 - 00 /2- c., (c.-1 41 o2•2-04 0 0 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** 49776S Jd/OsjfL( ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6, the Town of Yarmouth is now required to hold issuance or renewal of any licenseor 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 CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior 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 shall 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 thirty (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) prior s 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. POOL CLOSING: Every outdoor in ground swimming 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 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 y • form 72 hours prior to the catered event. These forms can be required Temporary Food Service Application 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 CAFÉS: Outside cafes (i.e., outdoor seating with waiter/waitress service), must have prior approval from the Board of Health. OUTDOOR COOKING: Outdoor cooking, preparation, or display of any food product by a retail or food service establishment is prohibited. NOTICE: Permits run annually from January 1 to December 31 . IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 15, 2014. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MA QUIRESIIPLAN/ i • I 1 / iNATUREDATE: $ SIG - U PRINT NAME & TITLE _ \ - j"-- c. Rev. 11/03/14 The Commonwealth of Massachusetts —=.*; Department of Industrial Accidents 6 1i___ , Office of Investigations —" —' 1 Congress Street, Suite 100 It VIII- ` Boston, MA 02114-2017 Arm www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: 99 Restaurant Address: 14 Berry Ave City/State/Zip: Yarmouth, MA 02673 Phone #: 508-862-9990 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. ❑■ Restaurant/Bar/Eating Establishment 2. ❑ I am a sole proprietor or partnership and have no 7, 0 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.❑ 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.] 12.0 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: American Zurich Insurance Company Insurer's Address: do Willis Insurance Services of Georgia, P 0 Box 305191 City/State/Zip: Nashville, TN 37230.5191 Policy# or Self-ins. Lic. # WC 3878538-02 Expiration Date: 08/01/15 Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure 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. I do hereby certify, under the pains and penalties of perjury that the information provided above is true and correct Signature: Date: 11/19/14 Phone #:615-744-3625 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 Contact Person: Phone #: www.mass.gov/dia COMMERCIAL GENERAL LIABILITY COVERAGE PART DECLARATIONS Policy Number: GLO 3878540- 02 ZURICH AMERICAN INSURANCE COMPANY Named Insured ABRH , LLC Policy Period: Coverage begins 08- 01 -2014 at 12:01 A.M.; Coverage ends 08-01 -2015 at 12:01 A.M. Producer Name: WILLIS INSURANCE SERVICES OF GA Producer No. 09814- 000 Item 1. Business Description: HOLDING COMPANY Item 2. Limits of Insurance GENERAL AGGREGATE LIMIT $ 401000 , 000 PRODUCTS-COMPLETED OPERATIONS AGGREGATE LIMIT $ 2 , 0001000 EACH OCCURRENCE LIMIT $ 1 , 00 0 , 00 0 DAMAGE TO PREMISES RENTED TO YOU LIMIT $ 1 , 0 0 0 , 000 Any one premises MEDICAL EXPENSE LIMIT N/A Any one person PERSONAL AND ADVERTISING INJURY LIMIT $ 1 , 0 0 0 , 000 Any one person or organization Item 3. Retroactive Date (CG 00 02 ONLY) This insurance does not apply to "bodily injury", "property damage" or "personal and advertising injury" offense which occurs before the Retroactive Date, if any, shown here: NONE • (Enter Date or "None' if no Retroactive Date applies) Item 4. Form of Business and Location Premises Form of Business: LIMITED L IAB I L I TY COMPANY Location of All Premises You Own, Rent or Occupy: See Schedule of Locations Item 5. Schedule of Forms and Endorsements Form(s) and Endorsement(s) made a part of this Policy at time of issue: See Schedule of Forms aid Endorsements Item 6. Premiums Coverage Part Premium: Other Premium: Total Premium: U-GL-D-1115-B CW(9104) PoYcy Nunter GLO 3878540-02 ENDORSEMENT ZURICH AMERICAN INSURANCE COMPANY Named Insured ABRH , LLC Effective Date: 08 -01 -14 12:01 A.M., Standard Time Agent Name WILLIS INSURANCE SERVICES OF GA Agent No. 09814-000 BROAD FORM NAMED INSURED ABRH, LLC . , AND ANY SUBSIDIARY COMPANY AS NOW FORMED OR CONSTITUTED, AND ANY OTHER COMPANY OVER WHICH THE NAMED INSURED HAS ACTIVE CONTROL SO LONG AS THE NAMED INSURED OR ANY SUBSIDIARY COMPANY HAS AN OWNERSHIP INTEREST OF MORE THAN 50% OF SUCH COMPANY . U-GL-1114,A CW (10/0