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Home My WebLink AboutApplication and WC - . - - - . -614 TOWN OF YARMOUTH eo: Board of Health 4000 -4: 1146 ROUTE 28, SOUTH YARMOUTH, MASSACHUSETTS 02664-24451 Health 4 64 . Telephone (508) 398-2231, ext. 1241 r4 cos.- (508)Fax760-3472 Division To: Yarmouth Business Establishments G eR-P\R-- t s (�cF From: Bruce G. Murphy, Director 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 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, ifou fullycomplete the application, and submit it to the Yarmouth Health y p pp 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 $5 . 00 —Restaurants-Over 100 Seats— -- 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: tôoo eottos400 Vtc • Total fees owed for your establishment: t 4S.od 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 providein the spring prior to opening" on the application.] BGM/maf 1, ��, �G�P. bi's ` , C44 TOWN OF YARMOUTH BOARD OF HEALTH -��1� , k►� ftltilAPPLICATION FOR LICENSE/PE1t1��I�:- 2015# � � t � � W � D * Please complete form and attach all necessary documents by Dece ber �� 2014. Failure to do so will result in ur the return of yoapplication p cke1 5 2014 ESTABLISHMENT NAME: CI & fh2b i S Ca ft TAX ;„„. LOCATION ADDRESS: 10 2 At. 2 6 TEL.#: sog M / /// MAILING ADDRESS: q02 Al--, 76 , S . jarl'uaU�I 4461 O2.Io(D y E-MAIL ADDRESS: IL KC i4 @ {i0 TII�(ar dO141 OWNER NAME: b I 10 i c S{22 L i2i trzI i CORPORATION NAME (IF APPLICABLE): 6 (51_ f}1.4)i S Ca Fe Inc MANAGER'S NAME: � ( � 0 61er-tie& TEL.#: SA 77 0 4 G � / MAILING ADDRESS: 17 � (Li 1) LE Palk Pi . 6 re ask r, puL Q 7_ 4, 3/ 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 Heap*'- ' lartment will not use past years' records. You must provide new copies and maintain a file 9* — � business. 1 . 2. "4... GARS i 3. 4. CA4� Cpp odPe 111c NO/ ofit) / /i& 1........ ... WiLeiFOOD PROTECTION MANAGERS - CERTIFICATIONS: 917--- All food service establishments are required to have at least one full-t. ce-e0::" fry s a Food Protection Manager, as defined in the State Sanitary Code for Food Ser 90.000. Please attach copies of certification to this application. The Health Depa ecords. You must provide new copies and maintain a file at your establishme, 1 . bi e o aertircii 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC on site during hours of operation. -- __ S2(# �� i I_ ra �i � _ . -- - �i l ) � F a ---- 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 . 1) 1P90 6 _e ya trfti 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 . S4ydt 2. 3. 4. RESTAURANT SEATING: TOTAL # 53' 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 P IT # LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT # i 0-100 SEATS $125 �� CONTINENTAL $35 NON-PROFIT $30 >100 SEATS $200 I COMMON VIC. $60 .--4tib�'��G =��D. KITE $80 CHEN $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 = $ II 85 .00 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FO tM�***** � � ( � �t �� f L ADMINISTRATION r 1 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 pri to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: purposes For 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 p elsewhere. Transient occupancy shall generally refer 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 g 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 bythe Health Departmentprior to opening. Contact the Health Department to schedule the inspection three (3) p pool area until the pool has been days prior to opening. PLEASE NOTE: People are NOT allowed to sit thein p inspected and opened. p 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. CLOSING: Everyoutdoor inground swimmingpool must be drained or covered within seven (7) days of POOL 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 QUIRE , TE PL a ' . Jo. DATE: (i l i SIGNATU A` ... . , & /2/1t 1100" PRINT NAME & TITLE: Id elart ,e t,* Rev. 11/03/14 i , ,.................. _ ,.._... ...----N ��M��YYYY� Ac9RD CERTIFICATE OF LIABILITY INSURANCE �•� 11 13 14 THS CERTIFICATE IS ISSN AS A MATTER OF SFORMA?ION ONLY AND CONFERS NO RIGHTS WON THE CERTIFICATE HOLDER THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY NAM EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POUCES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURERS), AUTHORIZED TENTATIVE OR PRODUCER,AND THE CERTIRCATE HOLDER. IMPORTANT: If the certificate bolder Is en ADDt31ONM. INSURED, to polic1iis) must be endorsed. If SUBROGATION IS WANED, subject to the terms and conditions of the pollclt,certain policies may require an endorsement. A statement on this certificate does not confer rigftts to the corneal*holder in Sou of such endorsenengs). i PRODUCER T Chevonne A Pratt Pike Insurance Agency, Inc. PHONE E,D; f5081 255-7880 amiss. (508) 240.2908 8 Main Street PO Box 1659 4- INSURE a APPORDAG COVERAGE NAIC Orleans, MA 02653-241 ,MUM A:Hospital 4ty 1lutexal Insurance ,C Matin mums:hospitality Mutual Insurance C Gerardi's Cafe Inc mons* A dam Mutual Fire I 902 Main Street D: - S Yarmouth, MA 02664 nye: COVERAGES CERTIFICATE NICER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICES OF INSURANCE USTED BR.WV HAVE BEEN ISSUED TOTIE INURED NAMB)ABOVE FOR THE POLICY PERIOD INDICATED. NO1WTHSTANOING MN REQUIREMENT,TERM CR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY 8E ISSUED OR MAY PERTAN, THE R4 URANCE AFFORDED BY TIE POLO ES DESCRIBED HEREIN IS SUBJECT TO All. THE TERMS, E SS_CNS ANDCONDTICNS OF SUO1 POUt� LIMITSW S.LIMITS SHOMAY HAVE BEEN REDUCED BY PAD CLAIM LTR TYPE OP CE WAlliCSOA POUCY Ntrisot �eM r it UM" - A GENERALI.IABUTY 71100GL 5/14/14 5/14/13 EACH OCCURRENCE $ 1.000.000 X COMMERCIALGENERKLTY ,ad $ 00.000 ICIAINSMADE MI OCCUR tr+ED EXP$,voa•pw+I $ 5.000 PERSONALa pavnwRY $ 1.000.000 GENERAL AGGREGATE $ 2.000.000 GENIAGGREGATELeATAPPLR$PER PRODUCTS-cow P A0o , $ 2.000.000 X ! Pa- I 1 C3:Ef Loc $ AUTOMOBILE UMW, grIBEIFD ar ?NGLE LNtf $ ANY AUTO ODDLY INJURY ret Pte) $ ILL SCHEI AUTOS OWNED AUTDDS ED ODDLY INJURY(Par wading $ NON-OWNED $ ..__ HIRED AUTOS `... AS 'S sao DAMiIGE - $ UNeIREIJ A LM DOCUR EACH OCCURRENCE $ MESE LMB CLAIMs4AIIDE AGGREGATE $ DED RET'MIQI(t ' _$ B Women COMPENSATION!, nl1E077044A 5/19/14 5/19/15 xf �: l°MD EMPLOYER,MY R°MEMSER!EXCLUDED? , NIA EL EH/CONT 4 100.000 OFFICEMandatory!a NH) E L DISEAS'g-EAE PLOVEE, $ 100,000 if - OF• _ • •NS below • EL DIS - - • ., mlr 500 060 C liquor liability 71102LL 5/14/14 5/14/15 1,000,000 2,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VENUES fAinde ACORD tet.Addaond Restos sch«hil..I awe spew sragq rel) CERTIFICATE HOLDER CANCELLATION $11011 ' NY OF j = • ' : ,:, • • E$• SE CANCELLED BEFORE PIRA -, DALE THEREOF, • - of DELIVERED EI Town of Yarmouth ► MRDANC ` - :