HomeMy WebLinkAboutApplication and WC .Y1IA; -•
TOWN OF YARMOUTH
. - .., .\ 0 Board of
�..�,. ,t ��- Health
`' 1146 ROUTE 28, SOUTH YARMOUTH, MASSACHUSETTS -
S TTS 02664-24451
.� Telephone (508) 398-2231, ext. 1241 Health
4.4 c Division
Fax (508) 760-3472
To: Yarmouth Business Establishments C l rf e- Co) 1 R S H vt t.,c.AGE
From: Bruce G. Murphy, Director
Yarmouth Health Department
Date: November 7, 2014
an4
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 ifyou complete and
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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, ou will be
allowed y
o ed to pay the 2014 rates for the following licenses:
Current 2014 Fee
Public Swimming Pools $ 80.00 (Z) $ t ( 0 00
Public Whirlpool/Vapor Baths $ 80.00 ( t) $ 80. QO
Tobacco Sales $ 95.00
Motels $ 55.00 * 55- 00
Restaurants 0-100 Seats $ 85.00 $ B5 . 00
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: $ (00.0o coµMoN v►c .
Total fees owed for your establishment: 440 .04
NOTE: To be entitled to paythe 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
p 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 ap lication.
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CtTOWN OF YARMOUTH BOARl?,�.?F HEALTH - ,--,.
APPLICATION FOR LICENSE/PERMIT,-,- 2015 ��°i
* Please complete form and attach all necessary dc��l en���Oy December 1:1:'z0141.2014 '-U 1 4
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Failure to do so will result in the return of your application packet: ;- ,.:_ . .,
ESTABLISHMENT NAME: _R(S4 U! LLA6 F Re-877 F /Z ESoRT TAX ID:
LOCATION ADDRESS: $22 i►'lR •SIJ 5-r. So. yA /flhoJ?'t4 Al 4 0245tEL.#: ( 57 1? 7 7/ - O/ob
MAILING ADDRESS: CS 4'vi 6)
E-MAIL ADDRESS: Ctiqcvc ( 0 �i + / • �%o �
OWNER NAME: CI�I�1S7oPtfiC2 �y14C4-{
CORPORATION NAME (IF APPLICABLE): /R (SIf Vii.L4& � E5O T, LL-C
MANAGER'S NAME: cN,eISZ k(-�2 � NGN TEL.#: q721 q?o ' a/41 6
MAILING ADDRESS: gi-z- 4IN S 50. yAwntririf i nm d 266 `f
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.
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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.
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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.
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PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
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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.
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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.
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RESTAURANT SEATING: TOTAL #
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT #
B&B $55 CABIN $55 I MOTEL $110 I s/
INN $55 CAMP $55SWIMMING POOL $110ea. .J1. � ( bpy
_LODGE $55 TRAILER PARK $105 WHIRLPOOL $110ea. ..
FOOD SERVICE:
LICENSE REQUIRED FEE ERMIT # LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT #
0-100 SEATS $125 ! — 01 CONTINENTAL $35 NON-PROFIT $30
>100 SEATS $200 COMMON VIC. $60 if<Lc-007 _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 = $ (0 25 . 00
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** kej $ 44O OO
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
CERT. OF INSURANCE ATTACHED
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth taxes and liens must be paid pri r 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
an aggregate 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
by the Health Department prior to opening. Contact the Health Department to schedule the inspection three (3)
days prior to opening. PLEASE NOTE: People are NOT allowed to sit in the pool area until the pool has been
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: Every outdoor in ground 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
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 APPLICATIONS) 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 A S PLAN.
DATE: j 17/ 7/i c", SIGNATURE: i���(/ —
PRINT NAME & TITLE: ret...STifice CyNC!et ei&d.i/ve�
Rev. 11/03/14
i •
The Commonwealth of Massachusetts
Department of Industrial Accidents
LOffice of Investigations
s ; _ �, 1 Congress Street, Suite 100
Boston, AM 02114-2017
a,,, www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name: Z.gi 31-( VI UJI 6 E / u/??A/r &SO/ T
22 MA (A)
Address:
• . Ea / 2 O2 /66Phone #: 56 71 / - O/O0
C1 /State/Z1 /��'���� �
City/State/Zip:
Are yo an employer? Check the appropriate box: Business Type (required):
1 . I am a employer with 30 employees (full and/ 5. El Retail
or part-time).* 6. estaurant/Bar/Eating Establishment
2. ❑ I am a sole proprietor or partnership and have no 7. 0 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. ❑ Entertainment
their right of exemption per c. 152, §1(4), and we have 10.❑ Manufacturing
no employees. [No workers' comp. insurance required]**
11 .0 Health Care
4. ❑ We are a non-profit organization, staffed by volunteers,
with no [Nocomp.em to eesworkers' . insurance req.] 12.❑ Other
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*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 providing workers' compensation insurance for my employees. Below is the policy information.
Insurance /'9 66-Lt.-AName:Com anyA45 . �/� .
Company
Insurer's Address: fI 00 CAOWN Cotc.11l /)12i V Q ul 'vatr �4 O 2-/i, ?
City/State/Zip:
Policy # or Self-ins. Lic. # 4q/ J5- 70S / 1/ Expiration Date: -?//
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure as coverage 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 upg to $250.00 a dayagainst 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 cer • ,�- der e : ains and penalties ofperjurythat the information provided above is true and correct.
Signature: Date: ////7 7
Phone #: ° 77 / 0100
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
_ __ , ,�� = NOTICE
NOTICE - ...
T�. , TO
TO ...
01%, EMPLOYEES
J
._
EMPLOYEES �^ � ` �,�
i
The Commonwealth of•
Massachusetts
OF IND�TSTP�IAL ACCIDENTS
DEPARTMENT
600 Washington Street, Boston, Massachusetts 02111
617-727-4900-http:/Iw'ww•mass-gov/din
Chapter 152, Sections 21, 22 & 30, this will give you notice
As required by Massachusetts General Law,
that I (we) have provided for payment to our injured employees under the above mentioned chapter by
insuring with:
Arbella Protection Insurance Com I an
` NAME OF INSURANCE COMPANY
1100 Crown Colon Drive, li l ' i. " MA. 02169
ADDRESS OF INSURANCE COMPANY
3/13/14 — 3/13/15
#9125370314 EFFECTWE DATES
POLICY NUMBER
243 MainStreet Buzzards Bay, MA 02532
Hart Insurance Agency Inc.
NAME OF INSURANCE AGENT ADDRESS
MacLyn LLC & 822 Route 28 S. Yarmouth, MA 02664
Irish Village Restaurant & Resort LLCADDRESSEMPLOYER
EMPLOYER'S WORKERS COMPENSATION OFFICER(IF ANS
DATE
MEDICAL TREATMENT
The above named insurer is required in cases of personal injuries arising out of and in the course of
employment to furnish adequate and reasonable hospital and medical services in accordance with the
provisions of the Worker's Compensation Act A copy of the First Report of Injury must be given to the
injured employee. The employee may select his or her own physician. The rens°nab1e cost of the ser-
vices provided by the treating physician will be paid by the insurer, if the treatment is necessary and
reasonably connected to the work related injury. In cases requiring hospital attention, employees are
hereby notified that the insurer has arranged for such attention at the
Name of Hospital Address
TQ BE POSTED BY EMPLOYER