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HomeMy WebLinkAboutApplication and WC 4 • 'YA4ti ., TOWN OF YARMOUTH Board of Health op It kta { 3 _. 1146 ROUTE 28, SOUTH YARMOUTH, MASSACHUSETTS 02664-24451�, Health Telephone (508) 398-2231, ext. 1241 Division 4 't4 c µt* Fax (508) 760-3472 To: Yarmouth Business Establishments )o4 Les aesmuczAt.rr- 4 t ice, ` 14 From: Bruce G. Murphy, Director - - - Yarmouth Health Department V --- -- 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 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 1-00- Seats $160.00 _ $i o o_ _ _ 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: 4 (CO. 00 cokKoN Total fees owed for your establishment: 4 22o4.00 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 w i i - YARMOUTH BOARD OF HEALTH .� TOWN OF _ .�� LICENSE/PERMT;201:5 '� . � j�� '� � Z014• • APPLICATION FOR LICENS :: 4 . i' . . 4 c., it •-' 't X * attach all necessary t,yDeceri� 1 er 1S 2014Please form and ry , . •completereturn of your a licatiOn pa. et. c t L __ _ x:.::- i Failure to do so will result in the r y pp . AX ID: ®� LOCATION ADDRESS: ?..)t og kTEL.#: %0 IMO' MAILING ADDRESS: $ 6f.,..*h \taArcNovieh im 4A E-MAIL ADDRESS: OV'JNER NAME: ti-5-1W------anS� CORPORATION NAME IF A PLICABLE): Z be) MANAGER'S NAME: q\i L TEL r1'1 4-- � Id --533(p MAILING ADDRESS: .2.g..5")0 3rc* 4 POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator, as required by State law. Please list the designated p Pool Operator(s) and attach a copy of the certification to this form. 1 . 2. list a minimum of two employees currently certified in basic water safety, standard First Aid Pool operators must , Community Cardiopulmonary Resuscitation (CPR), having one certified employee on premises at all times. and Co ty p rY Please list the employees below and attach copies of their certifications to this form. The Health Department will p yees usepastyears' records. You must provide new copies and maintain a file at your place of business. not 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.lication. The Health Department will not use past years' records. p You must provide new copies and maintain a file at your establishment. 1 . 0_ _ ,_„/"0 1' 01 * PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1i) tki\k,vn- -- - -- - 9 1 /liccitevitetclin ALLERGEN CERTIFICATIONS: service establishments are required to have at least one full-time employee who has Allergen certification, All food q as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.009(G)(3)(a). Please attach pp copies of certification to this application. The Health Department will not use past years' records. You must p provide new copies and maintain a file at your establishment. :r/7\ 1 . AG L2) HEIMLICH CERTIFICATIONS:: O - s EXP' P EP (Errs , All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich thepremises at all times. Please list your employees trained in anti-choking procedures below and Maneuver on attach copiesemployee of certifications to this form. The Health Department will not use past years' records. You mustp rovide new copies and maintain a file at your place of business. ii,li, , INI i :►IT, . i4, ' 2. '4 Alk 3. V ' g i t, , ► • i,, 4. RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT # B&B $55 CABIN $55MOTEL $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 , _r_ $35 NON-PROFIT $30 >100 SEATS $2004I -OO2---' I COMMON VIC. $60 TR s– WHOLESALE $80 RESID. KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT # 25,000000 sq.ft. $150 —$50 >25,000 sq.ft. $285 VENDING FOOD $25 <50 FROZEN ESSERT $40 TOBACCO $110 25 NAME CHANGE: $15 AMOUNT DUE = $ ZGO .OG *****PLEASECOMPLETE OTHER SIDE OF FORM***** 124,Ctia, 4 z o 00 TURN - K14101 cifrik ( 55-7 1 OVER AND 4 L 3 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 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 generallyrefer to continuous occupancy of not more than thirty (30) days, and p y 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. 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: who caters within the Town of Yarmouth must notifythe Yarmouth Health Department byfiling the Anyone p Application form 72 hours prior to the catered event. These forms can be required Temporary Food Service pp 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: - --_ or di s ay of-any food product a - . ' • see ice establish ent ' . ed _ - 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 • - EALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: 11 114I NATURE: PRINT NAME & TITLE: t, /A t A e / Rev. 11/03/14 • The Commonwealth of Massachusetts ,.,.! Department of Industrial Accidents =7/0,=, Office of Investigations = ` Lro. 1 Congress Street, Suite 100 • i Boston, MA 02114-2017 _ '" www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Do3Us Address. 4k- City/S tate/Zi hone #:p an employer? Check theappropriate box: Business Type required): Are you 1 . ❑ I am a employer with employees (full and/ 5. 0 Re __f/órparttime).* -- - estaurant/B ar/Eating Establishment 2. LO 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. 8. ❑ Non-profit [No workers' insurance nsurance required] 3. 0 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 .0 Health Care 4. [..] We are a non-profit organization, staffed by volunteers, to [No workerscom . insurance re .with no empees. 'yp req.] 12.❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. such an policyis required and **If the corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation q organization should check box #1. I am an employer that is providingworkers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: ON C�. (e- ,0a_43r- (15 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 number and expiration date). Failyr urs coverage der n-2 lead to the-imposition..of criminal penalties of 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 penaltie e 'ury that the information provided above is true and correct. • gnature: /*,) tLio Date: Ak, - lit - ( L4 • tccO� � Phone #. 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 Client#: 16383 2DOYLESREI A CORDTM CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 11/17/2014 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 an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Dowling & O'Neil PHONE 508 775-1620 FAx 5087781218 Insurance Agency (A/C,E-MAILo, Ext): (Alc, No): ADDRESS: 973 lyannough Rd., PO Box 1990 INSURER(S) AFFORDING COVERAGE NAIC# Hyannis, MA 02601 INSURER A : Catlin Specialty Insurance Co INSURED INSURER B : The Hartford ZDOM, Inc. D/B/A Doyle's Restaurant INSURER C : Mount Vernon Fire Insurance Co NO Bisque Boy Realty Trust 1329 Route 28 INSURER D South Yarmouth, MA 02664 INSURER E INSURER F : COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT 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 MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTRINTYPE OF INSURANCE INSRL SUBR WVD POLICY NUMBER POLICY EFF POLICY EXP LIMITS (MM/DD/YYW) (MM/DD/YYYI ) A GENERAL LIABILITY 3700302539 08/01/2014 08/01/2015 EACH OCCURRENCE $1 ,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES ERENTED occu ence) $100,000 CLAIMS-MADE X OCCUR MED EXP (Any one person) $5,000 X BI/PD Ded:2,500 PERSONAL &ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 7 POLICY PRO LOC $ JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) ANY AUTO BODILY INJURY (Per person) $ ALL OWNED SCHEDULED BODILY INJURY (Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS (Per accident) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION $ $ B WORKERS COMPENSATION O8WECN L4812 06/01/2014 06/01/2015 X WORY uM TS ETH AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y/ N E.L. EACH ACCIDENT $500,000 OFFICER/MEMBER EXCLUDED? N N /A (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $500,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $500,000 C Liquor Liability CL2646230A 08/01/2014 08/01/2015 $1 ,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS/VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Operations performed by the named insured subject to policy conditions and exclusions. ' - U ? 4zul4 CERTIFICATE HOLDER CANCELLATION Town of Yarmouth SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN License Dept. ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 South Yarmouth, MA 02664 AUTHORIZED REPRESENTATIVE .�.r4 -.- © 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD #S141193/M141192 LS1