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Home My WebLink AboutApplication and WC l } Yit OV • Ji6 TOWN OF YARMOUTH . _ .�,. Board of , � � • Health � ,-4-- j-7 � 1146 ROUTE 28, SOUTH YARMOUTH, MASSACHUSETTS 02664-24451 a- ; y �� ;�. Health 4 r Telephone (508) 398-2231, ext. 1241 r4040* Fax (508) 760-3472 Division To: Yarmouth Business Establishments R:)(3(2.- SES5oNS TR-PAlt R4P From: Bruce G. Murphy, Director • Yarmouth Health Department ' Z1114 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 85.06 Restaurants Over 100 Seats - $-160.00 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: 6O.o o coM.Mota 'Itc Total fees owed for your establishment: ' t'5.o O 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 .�, TOWN OF YARMOUTH BOARD OF HEALTH APPLICATION FOR LICENSE/PERMIT - 2015 �, . Pr , , ia.�4 * Please complete form and attach all necessary doctll itsby Dece -1 ''r 15, 2014. Failure to do so will result in the return ;of your application pac ! -t. DEPTJ ESTABLISHMENT NAME: I Obt3 Tr��r � � TAX ID: LOCATION ADDRESS: j0 77 f'ogdz, Ae TEL.#: -�760 - 646'00 MAILING ADDRESS: So 11 �J-'Et r M oa 4 k E-MAIL ADDRESS: reckla#1 o%P2-e(3/se)i1-oC * cin OWNER NAME: CORPORATION NAME SIF APPLICABLE): 7-in# .req' S on l` Trq etfn MANAGER'S NAME: ptU iS � rKCZ TEL.#: 774f - - 2a3 MAILING ADDRESS: ( ? e �a Pool trigQ ff n i f /nom 02 60 l 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 . G<<S ThcicIez 2. /i' ju, t iF . PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1 . F1etilue '-r �r'1q'rLQ1C2 2. I(7 rySde2 -- — 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 . Ma/we.L'. &rtart-dez, 2. ALT HEIMLICH CERTIFICATIONS: JOsc- CALtpLeg-m-D esu25 E VI* -• (Alll�. PP-�1ItDEAll food service establishments with 25 seats or more must have at least oyee 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 # /if 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 EIWIIT # LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT # 1 0-100 SEATS $125 -DO CONTINENTAL $35 NON-PROFIT $30 >100 SEATS $200 I COMMON VIC. $60 If15�0/ 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 = $ t 85 .00 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** Verial\i I ADMINISTRATION • of Yarmouth is now required to hold issuance or renewal Under Chapter 152, Section 25C, Subsection 6, the Town , p ' person or company does not have a Certificate of Worker's of anylicense or permit to operate a business if a p y 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 prior Town of Yarmouth taxes and liens must be paid 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 • short term occupancy, ordinarilyand customarily associated with motel and hotel use. limited to the temporary and p y� 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 an aggregate of not more than ninety (90) da s within six (6) month period. Use of a guest unit as a residence or y any 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 swimming, wadingand whirlpools which have been closed for the season must be inspected POOL OPENING: All p inspection three (3)to opening. Contact the Health Department to schedule thep by the Health Department prior LEASE NOTE: Peo le are NOT allowed to sit n the pool area until the pool has been days prior to opening. P p i 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: ground Everyoutdoor in swimming pool must be drained or covered within seven (7) days of closing. FOOD SERVICE SEASONAL FOOD SERVICE OPENING: All foodp 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: An one who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the y ' required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be p 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 MAY REQUIRE A S PL , N. XDATE• 1(7/3(20 / SIGNATURE: fr�ri . LimiLp PRINT NAME & TITLE: ey IF • a__ pw o e Y fr(ocQY Rev. 11/03/14 The Commonwealth of Massachusetts tt . Department of Industrial Accidents arh •=i Office of Investigations — misogamist. 1 Congress Street, Suite 100 #,1, ' Boston, MA 02114-2017 , .,"74•7www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Se-41,5-643,s Address: City/State/Zip: Phone #: Are you an employer? Check the appropriate box: Business Type (required): 1 . ❑ I am a employer with (full em to ees and/ 5. ❑ Retail p Y – time).* 6. L] Restaurant/Bar/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. workers' com . insurance required] 8• ❑ Non-profit [No p 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 *My 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: Insurer's Address: 46C- City/State/Zip: tON9C' vx,/p(A. Policy # or Self-ins. Lic. # Expiration Date: 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 c. 152—can—lead—to . .on-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 cert , un ' • '' p i s and penalties of perjury that the information provided above s true and correct. Signature: ,Or- & Date: (3 dr20 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 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE CERTIFICATE INFORMATION PAGE RENEWAL AGREEMENT • Producer : Agent# 928 MA Retail Merchants WC Group Inc . James E Sullivan Insurance PO Box 859222- 9222 885 Main St . Braintree , MA 01285 Tewksbury , MA 01876 (Carrier Code : 34355 ) Certificate It : 014005033240114 Prior Certificate If : 014005033240113 1 . The Employer : Four Seasons Trattoria Inc Mailing Address : 1077 Rte 28 S Yarmouth , MA 02664 Fein : Other workplaces not shown above : Type of Business : Corporation NO OTHER WORKPLACES FOR THIS POLICY Risk ID : 2 . The certificate period is from 12 : 01 a .m . on 1/01 /2014 to 12 : 01 a .m. on 1/01 /2015 at the Insured ' s mailing address . 3 . A . Workers Compensation Coverage : Part One of the certificate applies to the Workers Compensation Law of the states listed here : MA B . Employers Liability Coverage : Part Two of the certificate applies to work in each state listed in Item 3 .A . The limits of our liability under Part Two are : Bodily Injury by Accident $ 100 . 000 each accident Bodily Injury by Disease $ 500 , 000 certificate limit Bodily Injury by Disease $ 100 . 000 each employee C . Other States Coverage : D . This certificate includes these endorsements and schedules : WC000000A(04/92 ) WC000310 (04/84) WC000414 (07/90) WC000422A(09/08) WC200301 (04/84) WC200302 (05/86) WC200303B (07/99) WC200405 (06/01 ) WC200601 (06/92) 4 . The contribution for this certificate will be determined by our Manuals of Rules , Classifications , Rates and Rating Plans . All information required below is subject to verification and change byaudit . Classifications Code Contribution Basis Rate Per Estimated No . Total Estimated $100 of Annual Annual Remuneration Remuneration Contribution SEE SCHEDULE OF OPERATIONS Total Estimated Annual Contribution 827 . 00 Minimum. Contribution $ 216 . 00 Expense Constant $ . 00 n #\ • I dee- fl 1 IN \ Issue 00 00 01 A I ue Date : 1/30/ 2014 Countersigned by 1 l , • SCHEDULE OF OPERATIONS FOR : PAGE : 1 * * * * * CERTIFICATE INFORMATION FOR MA * * * * * Four Seasons Trattoria Inc Certificate # : 014005033240114 1077 Rte 28 Fein : S Yarmouth, MA 02664 Code Classification Payroll Rate Contribution 9079 RESTAURANT NCC 88 , 000 . 00 1 . 07 942 . 00 Manual Contribution 942 . 00 Rate Deviation 15 . 00% 141 . 00 Standard Contribution 801 . 00 Normal Contribution 801 . 00 Expense Constant Foreign Terrorism 26 . 00 Annual Contribution 827 . 00 DIA Assessment ( 00930 ) 1 . 1000% / 1 . 1000% 10 . 00 WC 00 00 01 A