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HomeMy WebLinkAboutApplication and WC •YA4ri - . � -, o . TOWN O F YARMOUTH Board of Health •0 :..-`_ "` WO 1'3 1146 ROUTE 28, SOUTH YARMOUTH, MASSACHUSETTS 02664-24451 kAt " ^ 4`� Ag! Telephone (508) 398-2231, ext. 1241 Health P r 4 °"E** • Fax (508) 760-3472 Division To: Yarmouth Business Establishments ANTIta �s CurtnnA4uIp INrJ From: Bruce G. Murphy, Director Ga©IROMED Yarmouth Health Department NOV 2 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 - - ___ _ -L .--��:6� � ____ - --- _ __ Restaurants 0-100 Seats $ 85.00 Restaurants Over 100 Seats $160.00 $ l b0 .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: 3, 115. 00 INN COI-04014%C . Total fees owed for your establishment: $ 25 .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 REgfA s """r- -_ TOWN OF YARMOUTH BOARD OF HEALTH -- :_ - Nov 252014 ... . APPLICATION FOR LICENSE/PERMIT2015 * Please complete form and attach all necessary documents by Dece er DEPT. Failure to do so will result in the return of your application pa. - . ESTABLISHMENT NAME: I n+hOn S ' n►m V d h TnC. TAX ID: � LOCATION ADDRESS: g ma; n I t (aA Liatipinvik TEL.#:SO 3ta a -951) ) MAILING ADDRESS: i9gq Salem Si. 5LoamiNtic oil, iv?A 0/9 07 E-MAIL ADDRESS: 042e 4 p;er y L/ • CCS''} OWNER NAME: M!ø Mol 'Afit4 co c� NAME (IF APPLICABLE : 4,, tai o �'� �►e¢. c'iCORPORATION ) y MANAGER'S NAME: f/k.h / li1/ai a*► TEL.# cf'J4'2 MAILING ADDRESS: 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 . 2. PERSON IN C-HARGE: 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 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 . 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 $55 MOTEL $110 SINN $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 $35 NON-PROFIT $30 T>100 SEATS $200 1 COMMON VIC. $60 WHOLESALE $ 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 CO FOOD <25,000 sq.ft. $150 FROZEN DESSERT $40 NAME CHANGE: $15 AMOUNT DUE — $ 315 .00 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** d/Ct 81 f j ADMINISTRATION Under Chapter-. 152, Section 25C, Subsection 6,, the Town of Yarmouth is now required to hold issuance or renewal of anylicense orpermit to operate a business if a person or company does not have a Certificate of Worker's p 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 OCCUPANCY: For purposes of the limitations of Motel or Hotel use, Transient occupancy shall be TRANSIENT limitedtemporary to the tem or and short term occupancy, ordinarily and customarily associated with motel and hotel use. Transientp occupants must have and be able to demonstrate that they maintain a principal place of residence Transient occupancy shall generallyrefer to continuous occupancy of not more than thirty (30) days; and elsewhere. p y • period. Use of a guest unit as a residence or sixmonthwithin an an aggregate of not more than ninety (90) days y 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 OL OPENIN G. All swimming, wading and whirlpoolsools which have beenclosed for the season must ust be inspectedected bythe Health Department prior to opening.. Contact the Health Department to schedule the inspection three (3) days prior toopening. 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. Every inground swimmingpool must be drained or covered within seven (7) days of POOL CLOSING: outdoor closing. FOOD SERVICE SEASONAL FOOD SERVICE OPENING: p 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 required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be req . p ary pp , obtained at the Health Department, or from the Towns website at www.yarmouth.ma.us under Health Department, p 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 p 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: or display of anyfood product bya retail or food service establishment is prohibited. Outdoor cooking, preparation, p y run annuallyfrom January1 to December 31 . IT IS YOUR RESPONSIBILITY TO RETURN NOTICE: Permits 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 ETC.), MUST BE REPORTED TO A APPROVE : Y THE BOARD OF HEALTH PRIOR EQUIPMENT, TO COMMENCEMENT. RENOVATIONS MAY ' ' Q IRE A SI A ,• LAN. DATE: UH 1 SIGNATURE: Wo " vviegieeitil� �. ts0 PRINT NAME & TITLE: Rev. 11/03/14 12/ 08/ 2014 11 : 22 17815956061 HBS PAGE 01 / 04 04 thony's Hawthorne bytheSea Sea 153 Humphrey Street Swampscott, MA 01907 Phone: (781) 595-5735 Fax: (781 ) 595-6061. Fax Er0111:_ /1/dr__ /1-45 Fax; "- • �,, ages: (including Cover Sheet) Phone: Date: Re; C_C: Confidentiality Notice: his page and any accompanying documents are confidential. and protected by law. If you are not the recipient stated above., please destroy aft)/ pages you.may r,ece1ve and contact the sender at the phone number listed above. Your cooperation, is greatly appreciated. Comments: . E 12/ 08/ 2014 11 : 22 17815956061 HBS PAGE 02/ 04 •� DATE (MMJO�IYYYYy, ACORaw OF IABILI`TY S TRANCE11/28/2014 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is On ADDITIONAL INSURED, the pollcy(Ies) must be endorsed. It SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate doe: not confer rights to the certificate holder In lieu of such endorsement(s). - --- - -..W —� - Pr ODUOEa CONTACT KIRKILES & ASSOCIATES _- . ......_. _...._ a. . . 1-659-3300 F , . , 1 -659-3366 utie COMMERCIAL INSURANCE BROKERAGE LLC 273 RIVER STREET ----------- INSUR (F )AFFORDING COVERAGE ~...._..--•--.. I_ . NAP X NORWELL. MA 02061 2209 INSURER A; MASS RETAIL MERCHANTS . .. . -----..... __._ .. -• ----- _.._.. _ . ... ... INSURED INSURER B: ANTHONY'S CUMMAQUID INN, INC. INB,u E&C;___ . , , . . ... __..._..._. .. . . .._. ._. _ ... . .. . RT. 6A INSURER b; . - YARMOUTHPORT, MA 02675 INSURERE;. ._ • ------_-.. . . . .. . -- . ..... . INSURER F. — COVERAGES CERTIFICATE NUMBER: 102063 REVISION NUMBER' THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE FN:)URRED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RE`3PECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. iN RkADDL - vim' ------ ----... --- PaLrCEf=F pOtIRExp - ----. .... ....__~_ • LTR TYPE OF INSURANCE • I,NEIR ik -�• POLICY NUMBER (MMIOD YY!'y JMMUD TYIJ LIMITS GENERAL LIABILITY EACH OCCURRENCI S COMMERCIAL GENERAL LIABILITY ` . E IIP . T . • - NTED CO . -,_-- - S 9 oCCuri4nc,n) $ CLAIMS-MADE ri OCCUR MED EXP (Any cm pr�rnon) ...__...... .. ,PERSONAL S. AM( IN WRY 5 ----— — --.-.., . .. -_. I .._...-- ----- -- — GENERAL AGGREGATE —_... .' GEN'L AOORE Ate LIMIT APPLIES PER: PROOUCTa - COMP;�.)P /TGG l• _....----1POLICY1HLQC . . ......._ __._ ~ . ...----- --.... .. - ... _..---..._ -;� . _. ....._......... . ... AUTOMOBILE: LIABILITY . T 1 la MU 1 IMIT (Era 0-. •onl? ---- ---_ $ . ,.. _..._.._._ . . ANY AUTO __ BODILY INJURY (Per I)9�nn) ---- AL.LOVuNED �r tJI.I:G -------..._..._..._...--- ---._..._. . , , . . .. --_- AU'fv;� —_ xt 8BODILY INJURY (PNS acr,IrInnl) $ N�N WNED r PROPERTY DAFAA•Cr,'—".._.. . .. . . HINIAI AUTOS AUT (Pr accidar.I) $ UMBRELLA LIAB ----- OCCUR EpCH•OCGURRENCt. ---._...._ g EXCESS LIA9 CLAIMS-MADE AGGREGATE $ • .. ..,.... ..._— DEO L RETENTION g ......—._.... • -- -------- _ _~~. .__ ._ — ._..... .. .. . ----- -........ _ . .. . ...... WORKERS CONIPEN9ATION 0140050310081014 1/1/2014 1/1,2?_015 x.TORY. IM�TS,1. _-,.L ER- A OND EMPLOYERS' LIABILITY YIN " " . ANY PROPRIETORJPARTNER/EXECUTIV E.L.FFICER/MEBER EXCLUDED? '` I NIA EACH �4CC{bI=N i 500,000( endatory In NH) E,L, DISEASE - EA FNAPLOYEE 5 500,000 E38. C198Crkbnr t i�qr _---' Ib SCRIPTION OF OPERATIONS belcwv _-- ELDISEASE=POLIr:Y I,IM... . 500,000 DESCRIPTION OF OPFRATIONH I LOCATIONS I VEHICLES (Attach ACM) 101. Additional Remnrka Schedule. It more opoco b re Tod) CERTIFICATE HOLDERCANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TOWN OF YARMOUTH THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN HEALTH INSPECTOR ACCORDANCE WITH THE Policy PROv/SION3_ 99 BUCK ISLAND ROAD W. YARMOUTH, MA 02673 AUTHORIZED REPRE9ENTATh tE FAX: 508-760-3472 _ af. I _ ' � @ 1968-2010 A-CORD CORPORATION_ alt eights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD c • . cq health license OLP'\i‘Y''''(/1 r Anthon 's Pier 4 Restaurants Check Request Credit 11/25/14 Must pay by date: Amount:$ — 315.00 Vendor #• 1006 . ;fi ` A Payee: Town of Yarmouth 1 :: s 5' Address not on file): `� r '��`�H ` ' Z ` Ery �t !0d�x a ;d - �4;;A$ c � y». t.kps_-- __ ,,,,..4.V ...'rt6 y is ,..`,14';?.....,:,, - x In Payment of invoice #('s) Date('s): or � t - -- h sf �,. s .`r � • vCQ 2015 > .a � Health License • • Ug y S 1 I^' 3c! Distribute the amount as follows: � � .sy4 � fs� x G$ Co. acct # Description Debit ` �` s M53 x s. Y 051 8121 Licenses 315.00 a -- -- i _ _ . Totals 315.00 315.00 Submitted by: JA --- -- ----- - 11 /25/14 4 Approved by: Date: Special Handling/Comments: Page 1