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HomeMy WebLinkAboutApplication and WC 1 '41 ._ ‘C, TOWNOF YARMOUTH Board of 4000 � ,.r Health C ' ; �"'' 'O `'3F 1146 ROUTE 28, SOUTH YARMOUTH, MASSACHUSETTS 02664-24451 ��1� �, w �� 4.: Telephone (508) 398-2231, ext. 1241 ''" c"E� Fax (508) 760-3472 G;32©EilY61,� U1.tU ' Lfl4 To: Yarmouth Business Establishments kk-AMPll► It`lN MES HEALTH DEPT. 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, 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 4 Ro 0 v o 0 Public WhirlpooUVaporBaths $ 80.00 $ 90 .00 Tobacco Sales $ 95.00 Motels $ 55.00 55 -00 Restaurants 0-100 Seats $ 85.00 4? 5 op 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: $ it 0 . 00 co►^KoN `itc-• (t,ET1Pdl. PoopL5054.Pr, Total fees owed for your establishment: 444-(10 .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 appZication.] BGM/maf ' RECEIVED I � ' TOWN OF YARMOUTH BOARD OF HEALTH iii°4" APPLICATION FOR LICENSE/P `. - 201 ���y- UEI: � 1 ZO14 � * Please complete form and attach all necessa • • • � �e is b be bier 151 0 Failure to do so will result in the return of your application packet. DEPT.4 ESTABLISHMENT NAME: i-IuMfiUn Min 4 SuhA TAX ID: OUGIMLOCATION ADDRESS: �c1 I'''1u; n S� �,�e X 1.JP.�rt YGrr►IBJ`�"� I`IQ TEL.#: lFf� 89�- 3&��� MAILING ADDRESS: I or F ) ! ��ver , yeS " r in A 037"71 • E-MAIL ADDRESS: �r1� n �eia'(7te/r+ e cpn,cas�• rtp �'OWNER NAME: Dc►rl►h �ve16 CArtp � � c-i►� flirklj r�c CORPORATION NAME APPLICABLE): FE1) i-loier Trô1o,itiej LLC MANAGER'S NAME: )a S' ,) Ihvan TEL.#: ( i ) S)41 )..aLpi MAILING ADDRESS: Ilan Si' `0e act \A1f )lom / P)1\ O73 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 . ��i11l1Pk c�U ) I I 1/LtA 2. 1O1Dt(f tOr/ 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 . isferinCi Sp IliVes4N 2. 410/)Zet lelOrl 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 . cmaRreAn4 Liliv" 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1 . S�rtt no- �+�'t v6. ++ — 2. - 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 . ICU 1 A SUI11/"K 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 . lientlA c�v 1 I r vu n a. .rik � �)6 fy 3. 4. RESTAURANT SEATING: TOTAL # I. OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE P RMIT # B&B $55 CABIN $55 I MOTEL $110 ;, —INN $55 CAMP $55 SWIMMING POOL $110ea. % <b �d0 Otd LODGE $55 _TRAILER PARK $105 1 WHIRLPOOL $110ea. , _ , , . FOOD SERVICE: LICENSE REQUIRED FEE P RMIT # LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT # 1 0-100 SEATS $125 �Zq CONTINENTAL $35NON-PROFIT $30 >100 SEATS $200 ,COMMON VIC. $60 */5 -O2.7 WHOLESALE $80 —RESID. KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT # _j_<50 sq.ft. $50 ' IMS-0l0 >25,000 sq.ft. $285 VENDING - FOOD $25 <25,000 sq.ft. $150 — FROZEN DESSERT $40 _TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE = $ 675 . 00 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** ReG u i " `Q• 00 0l4131 11404 ....r.- .+..rr.....wa.....y... ». ........ .r s . s ADMINISTRATION ' Town of Yarmouth is now required to hold issuance or renewal U ��.� apt�r*152, �ection 25C, Subsection 6, the q cif any l iceiise-or-p eImit 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 Yarmouth taxes and liens must bepaid prior to renewal or issuance of your permits. PLEASE CHECK Town of 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 the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel use. limited to p ry p Transient occupants must have and be able to demonstrate that they maintain a principal place of residence Transient occupancy shall generallyrefer to continuous occupancy of not more than thirty (30) days, and elsewhere. p y an aggregate days within any six (6) month period. Use of a guest unit as a residence or gg gate of not more than ninet y 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 POO L OPENING: All swimming, wadingand whirlpools which have been closed for the season must be inspected prior the Health Departmentto opening. Contact the Health Department to schedule the inspection three (3) by p p until the pool has been daysprior to opening. PLEASE NOTE: People are NOT allowed to sit in the pool area Y p 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: ct the All food service establishments must be inspected bythe Health Department prior to opening. Please conta • •p p • 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 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: I1a/14SIGNATURE: PRINT NAME & TITLE: \1 C ( .,k t Lat Rev. 11/03/14 The Commonwealth of Massachusetts Department of Industrial Accidents =- =` - Office Investigations ff of f _ 1 Congress Street, Suite 100 1%1:1=14 mowlyn4 minim- Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly c. Business/Organization Name: )-16-f-al mpLa Address: qg P +� ear Ci /State/Zi Phone #: — Lity p Are you an employer? Check the appropriate box: Business Type (required): 1 . PE I am a employer with employees and/ 5. ElRetail or part-time).* 6. 1:1 Restaurant/Bar/Eating Establishment 2. ❑ I am a sole proprietor or partnership and have no �• Office and/or Sales incl. real estate, auto, etc.) employees working for me in any capacity. workers' comp. insurance required] 8• ❑ Non-profit [Nop 3. ❑ We are a corporation and its officers have exercised 9. 0 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. insurancereq.] 12. 11 Other 0 *Any 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 provi' 'ng workers' com 'a ation ins rance fD.r..wy employees. Below is the policy information. Insurance Company Name: A ! a V J G ' .► Insurer's Address: 5S-4-1- CO 1 Q EC1S'ti C,t 1\\ OW.13 City/State/Zip: <--PC-6(12O1 Policy # or Self ins. Lic. # CYiOO Expiration Date: sisik- 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 25A of MGL c. 152 can lead to the imposition 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 certify, un ' er t ' p# . and penalties of perjury that the information provided above is true and correct. /,° Signature: // Date: I I /2‘ //11 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 ,.-••••• DARLDEV-01 CADI DATE (MM/DDIYYW) A CPRCERTIFICATE OF LIABILITY INSURANCE10/31/2014 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 (508) 676-0309 CONTACT Diane Carvalho Viveiros Insurance Agency, Inc. . f/UPo, 5086892711 la/c,Ext): No): 375 Airport Road ADDRESS:L Fall River, MA 02720 SS: dcarvaiho °�viveirosinsurance.com INSURERS)AFFORDING COVERAGE NAIC# INSURER A :American Alternative Insurance Corp 31879 INSURED Darling Development Corp MA187 INSURER B : 940 Fall River Ave INSURER C : Seekonk, MA 02771 INSURER D : 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. INSRADSL SUBR POLICY EFF POLICY EXP OMITS LTR TYPE OF INSURANCE W INSR VD POLICY NUMBER (MM/DD/YYYY) JMM/DD/YYYY) GENERAL UABiLITY EACH OCCURRENCE $ DAMAGE TO RENTED COMMERCIAL GENERAL LIABILITY PREMISES (Ea occurrence) $ CLAIMS-MADE OCCUR MED EXP (Any one person) _$ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS -COMP/OP AGG $ $ POLICY ECT LOC COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY (Ea accident) $ ANY AUTO BODILY INJURY (Per person) $ — • — ALL OWNED SCHEDULED BODILY INJURY (Per accident) $ AUTOS AUTOS PROPERTY DAMAGE NON-OWNED (PER ACCIDENT) $ HIRED AUTOS AUTOS $ UMBRELLA UAB OCCUR _EACH OCCURRENCE $ EXCESS LIABCLAIMS-MADE AGGREGATE $ DED L. RETENTION $ $ WORKERS COMPENSATION WC STATU- OTH- TORY LIMITS ER AND EMPLOYERS' LIABIUTY A ANY PROPRIETOR/PARTNER/EXECUTIVE YIN W2A2WC0000932-00 3/31/2014 3/31/2015 E.L. EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? N I A 1�Q�Q�QQQ (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS/ LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule, if more space is required) RE: Hampton Inn & Sutes of Cape Cod, 99 Main St., W. Yarmouth, MA CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE f Yarmouth THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN TOWn O ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 South Yarmouth, MA 02664- AUTHORIZED REPRESENTATIVE &...earelo1/4.,, NG.4,44L11..":4)--olk.... • C. t.0 , © 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD