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HomeMy WebLinkAboutApplication and WC z. 614 .astAii; -• ---t-Te7r 4i TOWN OF YARMOUTH ;, , . �- , . 0 Board of __ V - Health Olt 0 — 1146 ROUTE 28, SOUTH YARMOUTH, MASSACHUSETTS 02664-24451 � 74: " , -' _ � Health 4 r ��,' Telephone (508) 398-2231 , ext. 1241 Division r'' c ME Fax (508) 760-3472 • Business Establishmentsftc & ' N V--.ESL. Of '(A ro } To. Yarmouth From: Bruce G. Murphy, Director �' YarmouthHealth Department V 41! NUv : 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, 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 Rest-aur-ants Ove 100 Seats _________ $160,00 _ t1,,n .CCI_ Retail Food Service <25,000 sq. ft. $ 80.00 Retail Food Service >25,000 sq. ft. $225.00 Other fees owed but not listed above: ' ,p.oc c)citA kite - Total to .Total fees owed for your establishment: t 220.0 NOTE: To be entitled to pay the current 2014 rates listed above, your business application, food and/or pool certifications, along with worker's compensation information must be received, or mailed (postmarked) on or prior to December 31, 2014. [Those establishments which open in the spring will be allowed to provide food and/or pool certifications prior to opening, however, you must note "Will provide in the spring prior to opening" on the application.] BGM/maf , , 14- + K r��, TOWN OF YARMOUTH BOARD OF HEALTH iitt���� APPLICATION FOR LICENSE/PERMIT - 2015 7 rtille*Vg$ ^ A * Please complete form and attach all necessary documents by Dece ber 1 . ZO�� F� � Failure to do so will result in the return of your application pl�et. `'- ESTABLISHMENT NAME: Pit✓ i , � , � L' ,[. ' TAX ID: ~ �`��- LOCATION ADDRESS: r f � 6'i17 c TEL.#: MAILING NOV 2 .4 ZAILING ADDRESS: I/7 S�'"soY r1����"h jlifrADDRESS: ��L Cj .)- n ,(,�( ( 1-� ( v / / � COt'rl !' HEALTH DEPT. OWNER NAME: CORPORATION NAME (IF APP CABLE): � i g, / ( G /J �MANAGER'S NAME: U�/f4 ( j"k G� S.' / ' TEL.#: 01 7 Os " MAILING ADDRESS: '. q L I1'i %�'� f< {Kigi ‘. fry4i 0 001 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 . 041114rq -6(1 k S'‘ 11 2. 04va ! kr PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site durin: hours of operation. 1 . 1kJ , (fr4M 1' j(j (?E 2;_. • . . ' r — ---- 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 . lil) (Wf/ia -.4c_ hdel 2. pg 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. 11 1 . Lit 14 We, 3. 4. ) eprL�� � 5 /hi « Ili �( 61 2. 14/A 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 —INN $55 CAMP $55 _ SWIMMING POOL $I IOea. LODGE $55 TRAILER PARK $105 _WHIRLPOOL $1l0ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT # 0-100 SEATS $125 CONTINENTAL $35 NON-PROFIT $30 1-->100 SEATS $200 4/ GS-O Go 1 COMMON VIC. $60 015----01 (1 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 = $ Zfe• O .oO *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** ` . '{u $ 2-24) `O° CkWe 229 8(.W lifrtji=f r J 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 • T" 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: 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 generally refer 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 dwellingunit 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 g schedule the inspection three (3)the Health De artment to o ening. Contact the Health Department to p byp priorp area until the pool has been days prior to opening. PLEASE NOTE: People are NOT allowed to sit in the pool Y 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 ground CLOSING: Everyoutdoor in 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: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the y' Application form 72 hours prior to the catered event. These forms can be required Temporary Food Service 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 .e.�(ioutdoor 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 RE • RE A PLAN. DATE: e) SIGNATURE: PRINT NAME & TITLE: \ \*AVPkwl Rev. 11/03/14 CATAHOS-01 APELL A�c,oRop CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYVY) 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(les) 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: Rogers&Gray Insurance Agency, Inc. PHONE FAX 434 Rte 134 (A/C,No,Ext): (NC,No): (877) 816-2156 South Dennis, MA 02660 E-MAIL ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:ARBELLA PROTECTION 41360 INSURED INSURER B:Associated International Insurance Co. Catania Hospitality Group, Inc., ETAL INSURER C:MA Retail Merchants WC Group Inc. 141 Falmouth Road INSURER D: Hyannis, MA 02601 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. INSR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM DDIYYYYI (MM DCDNYYY) UMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE ri OCCUR 8500041114 10/01/2014 10/01/2015 FREM SES Eaoccurtence) $ 300,000 MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY _ $ 1,000,000 GE 'L AGGREGATE OMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY n E 0. n LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE UABIUTY COMBINED SINGLE LIMIT (Ea accident) $ 1,000,000 A _ ANY AUTO 1020004885 10/01/2014 10/01/2015 BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS XX NON-OWNED PROPERTY DAMAGE HIRED AUTOS ACOS (Per accident) $ — $ X UMBRELLA UAB X OCCUR EACH OCCURRENCE $ 10,000,000 B EXCESS UAB CLAIMS-MADE CUBW5455114 10/01/2014 10/01/2015 AGGREGATE $ 10,000,000 DED X RETENTION$ 10,000 $ WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER C ANY PROPRIETOR/PARTNER/EXECUTIVE Y!N014005032239114 01/01/2014 01/01/2015 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 UMIT $ 500,000 A Liquor Liability 8500041114 10/01/2014 10/01/2015 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS!VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Chain of Restaurants&3 Resorts: Hearth'N Kettle Restaurants of Hyannis,S.Yarmouth,Orleans, Plymouth&Weymouth.Cape Codder Resort&Spa.Dan'I Webster Inn&Spa.John Carver Inn &Spa. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE To Whom it May Concern THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. • AUTHORIZED REPRESENTATIVE Oiag/ 2/e ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD