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Home My WebLink AboutApplication and WC • • f'� •PYA - ,,► Board of Health JO ` • 1146 ROUTE 28, SOUTH YARMOUTH, MASSACHUSETTS 02664-24451 Health +4 �' Telephone (508) 398-2231, ext. 1241 • Fax E Division 4 cot' Fax (508) 760-3472 To: Yarmouth Business Establishments G Pre- ‘o-0 5 FAtAiL•ige-5-f-Auf_A-W- From: Bruce G. Murphy,, Director Yarmouth Health Department NOV 2 4 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, 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 - - t 60 .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: coo .00 o CKc*vte • Total fees owed for your establishment: o.oo 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 to December 31, 2014. [Those establishments which open in the spring will be prior 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 i---).„" " TOWN OF YARMOUTH BOARD OF HEALTH 4/3:; G�` 'al94- 4 ' APPLICATION FOR LICENSE/P i1 �� h�V � 4 2U14 %k ', r � i ��Q , �r 15 2014. jilPlease complete form and attach all necessary c�um�itsy Failure to do so will result in the return atyouriappltaion pac et. HEALTH DEPT. ESTABLISHMENT NAME: &14it cim"0 =r7-.f�1� lky5fir•our TAX ID: LOCATION ADDRESS: Vc /1*iv __Cr R7-. A teo W� TEL.#;�'08�r�S�D� fl1flMAILINGa ADDRESS: � a -ri. ��' .2/ y J. @ /Id Z 1 0/1 E-MAIL ADDRESS: OWNER NAME: Gi 4/4 Of iv 0 L.0 / 1/Iy e 7-0'9024out CORPORATION NAME (IF APPLICABLE): ,4/ 41/e MANAGER'S NAME: 72s/f G-, 44 nvç TEL.#: • MAILING ADDRESS: oxy01 4/4' l.F ..rr- /2/ di 't 't iiimoyttf 01 evdG 72 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 . re, Al - i --A,l'Aid 2. - In: 6;47-4- 4WD PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. .., - 'r"--S#g--Cfvt't0,A.;'e"°"'''° —1 . --rff-Ai -----61-45112.igi-A0-O— - -------- — . - 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 59V.Q09(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 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 . 704" ,9, 6/44 VA/ D 2. --- -.1* 6-/ i9A A/4/ e 3. 4. RESTAURANT SEATING: TOTAL # AA. 40 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 $125CONTINENTAL $35 NON-PROFIT $30 T>100 SEATS $200 1}'/$-017 ( COMMON VIC. $60 # f - OI � WHOLESALE $80 —RESID. KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT # q >25,000 sq.ft. $285 VENDING - FOOD $25 —<25,000 sq.ft. $150 — FROZEN DESSERT $40 _TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE = $ 2-C:,0 . 00 . 0 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** Rd $ ooO t. ADMINISTRATION A i• 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 p AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED of Yarmouth taxes and liens must bepaid prior to renewal or issuance of your permits. PLEASE CHECK Town APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LODGING ESTABLISHMENTS _ _ _ . _.�- -_,,.r'.-=.r�_�. -_--_.- -_.__. -_�.-._�w�_._._.__ TRANSIENT OCCUPANCY: For purposes of the limitations ofMotel-of Hotel-use; raps enrocoupancy-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 generallyrefer to continuous occupancy of not more than thirty (30) days, and p Y an aggregate e ate 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 bythe Health Department prior to opening. Contact the Health Department to schedule the inspection three (3) p in thepool area until the pool has been days prior to opening. PLEASE NOTE: People are NOT allowed to sit inspected and opened. POOL WATER TESTING: The water must be tested for pseudomonas, total coliform and standard plate count certified lab, and submitted to the Health by a State Department three (3) days prior to opening, and quarterly thereafter. Everyoutdoor inground swimmingpool must be drained or covered within seven (7) days of POOL CLOSING: 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 required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be 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 SITE PLAN. DATE: /, .-- 1 —/ SIGNATURE: : nA4,/ PRINT NAME & TITLE. � � �1 1T Rev. 11/03/14 '/,/� /�/ Workers Compensation and Employers Liability Insurance Policy FOREMOST INSURANCE COMPANY GRAND RAPIDS, MI Policy Chnges Branch Policy Number Producer Code GRAND RAPIDS WC 04239283 04 19722768 THIS ENDORSEMENT CHANCESI''IIE POLICY. PLEASE READ IT CAREFULLY. Policy Effective: Policy Changes Effective: From: 08/01/2014 To: _98/01/2015 0811/2014 Named Insured: Authorized Representative: OIARDING'S TASTEE TOMER INC DOP-MILES INSURANCE AGENCY INC 242 MAIN ST, PQ BOX 1018 WEST YARMOUTH MA 02673 TAUNTON MA 02780-0957 (508) 824-8961 CHANGES CHANGED EXPERIENCE MODIFICATION FOR MASSACHUS ,. TO .0% CHANGED MERIT RATING FACTOR FOR MASSACHUSETTS TO 5.0% PR.EMIUM EFFECT OF THIS TRANSACTION: $ 158.00- i 58.t0-i Countersigned by Au /zed Representative Date Issue Date: 07116/2014 INSURED COPY WC 99 00 07 (Ed. 10.99) PAGE 1 OF 1 ALJG-26-2014 10: 16 DCS'' N I LES 880 2734P. 01/01 T GIARD4 OP ID: Al. A4CCPREr rim pomoorevyr 4........,-. CERTiFICATE O LIABILITY 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 COVEMACIE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF iNsURANCE DOES NOT COMMUTE A CONTRACT BETWEEN THE ISSUING INSURERS), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT; If t #ifl r Is an Jai' ONAL I w INSURED, t e po ) m I �' ust be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain poles may require an endorsement A statement on this ciertificate does not confer rights to the certificate holder In lieu of such nt(s). _ Ake ACT �... w PRQD(P , R _ Gordon G. AAseck DGP-Miles Insurance Agency,Ir 3 School Street P. ►. c 10 8 7°7. .-4., 508-82441961 ,W$-Y$V-'6 S � T Taunton. MA 027804957 ilatia , Gordon G. Mack -.-�.. INE R�tE�Rt .' D NOD CovERAGE rim e . —. SERA!Ca ' A =I Indern iii Gore , I INGURED Glardino's Tam Tower Inc ouRER D: - Eddie Giardino 242 Main SL N� c west Yarmouth, IIIA OM INSURER D: MUM!E: INSURER F COVERAGES w CERTEICATE NUMBER: NUMMI: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW NAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POSY 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, T1-IE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEEREIhi IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POUCIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE^RAE POLICY NUMBER ......4CLNERA4 UA81L1T1t f &WYWYI (MMAIR'$ -1 co.,......7 Wen&L IUrY IMAGETuREFITto PRBUI= - .- . -r . . – $ IIIIIIIIMIINWofform CLAVAS-MADE 1.11 OCCUR MED'Ma VoyatIe :, $ PERSONAL a ADV WAY $ GENII RAL AOGREGATR a GENIIAGGREGATE milt APPLIES ISR; PRO DU r c MP/OP NIG $ 4.911•111% ----j POLICY II_I_ j_ I_I_wc - «,•-- ara Ll ANY AUTO BOD/ILY KIM(NW ) $ ALL OWNED SCHEDULED �- againal - AUTCS AUTOS BOo Y Num r t art s WNED NSW AUTOS AIMSp - . ..' . - }r7TT $ ICER $ U�t�1 �• „i-' GGA VACtii OCCURRENCE _ $ . .�.. . MESSLu*B CIALIIE•MADE G GRIEOATE ,.._. 3 DED RETENTIONS $ WORKERS COMPENSATION �— i STA7iJy • H. �. AND E�.E �' LIABILITY ' i ANYPt3PROR UTNE Y l ` �� t,r - ER .�.- OFRGERfilEMBER EXCLUDED'? N!A E.L. 1RCH ACCIDENT Mandatairy In N EL [ I�#y�,deems under EASE-PA E .QY S OESCRIPT�OF OPERATi�bel w E.L, DIMEASE-POLICY Leer A • quer Liability CP02263303FT001/2014 ! 0810/120/5 i DE 'ION OF OPERATIONS f'LOCATIONS 1 VEHIC1 (Attach ACORD 1A;,Addillonal Reemilte ISchimiele, If mem spate is reRJInb) Proof of ineurence coverage subject to actual policy toms, oond tion,a , limits, exclusions and definitions . CERTIFICATE HOLDER _i_.,. CAND LLA` ION .__.w W., TO iNYAR SHOULD ANY OF THE ABOVE DE3CRIISED POLICES BE CANCELLED BEFORE a Town EXPIRATION DATE THEREOF,,. TICE -i, BE DELIVERED IN ACCORDANCE WITH THE POLICY PROWNIION8. 528 Forest Rd. VV,. Yaxmouth, MA 02873AuTskIIIIF41i . 1.I'! 1(YtTk . . 0 19804010 ACORD CobiRPORATION. AU right roved. ACORD 2S i2fl1ninAt Ti... Ar&OWkri _....a.— _ :_ -- _ • - a - - - - • TiITAI P_ Cel 1