HomeMy WebLinkAboutApplication and WC s
TOWN OF YARMOUTH Board of
1146 ROUTE 28, SOUTH YARMOUTH,MASSACHUSETTS 02664-24451
�. 4.,,. *KE��r Telephone(508)398-2231, ext. 1241 Divisith
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Fax(508)760-3472
•To: Yarmouth Business Establishments
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From: Bruce G. Murphy, Director RIMMED
DI EDD
Yarmouth Health Department
ULC U12014
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:
r' Current 2014 Fee 1
Public Swimming Pools ---$ 80.00
Public WhirlpoollVapor Baths $ 80.00
Tobacco Sales $ 95.00
Motels $ 55.00
Food Service 0-100 Seats $ 85.00 Bs.o0
Food Service Over+00 Seats $164.00
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: 4 60.00 cot�rw N Ic•
Total fees owed for your establishment: $6�k5.00
NOTE: To be entitled to pay the current 2014 rates listed above, your
business application, food and/or pool certifications, along with worker's
compensation information must be received, or mailed (postmarked) on or
prior to December 31, 2014. [Those establishments which open in the spring will be
allowed to provide food and/or pool certifications prior to opening, however, you must note
"Will provide in the spring prior to opening" on the application.]
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►►, TOWN OF YARMOUTH BOARD OF HEALTH
�.. APPLICATION FOR LICENSI+/PE ' r 4�
s ut J 1 1114
* Please complete form and attach all necesocurn n December 15, 2014.
*--b
Failure to do so will result in the rets rn of your application packe
WEALTH DEPT.
ESTABLISHMENT NAME: Ni Li h . 17 AvtiwCo"z-' I TAX ID:
LOCATION ADDRESS: I0( 7 f2C Jt-t 2$ TEL.#: 52 ' 3'V 370W
MAILING ADDRESS: S *w
E-MAIL ADDRESS: R t2ca yarn,, , 2 ape (' (.r eT
OWNER NAME:
CORPORATION NAME (IF APPLICABLE):
1
MANAGER'S NAME: R.�� C'�,����I TEL.#: �Z� n��, `t`t(i
MAILING ADDRESS: SI ()?' ;c Att '2 - y�.cww:.,14,, 0,',r. WI -75
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. ' ti-ti- CaoAphe ( 1 2.
PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
1.
PFJ - CA. 6 (1 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. 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. 2.
3. 4.
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$110ea.
LODGE $55 TRAILER PARK $105 WHIRLPOOL $l l0ea.
FOOD SERVICE:
LICENSE REQUIRED FEE P RMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
1 0-100 SEATS $125, 26 _CONTINENTAL $35 NON-PROFIT $30
>100 SEATS $200 1 COMMON VIC. $60 ikf5-O2 V 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 = $ 185.00
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*****
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„�'1 RYANF-1 OP ID:WM
A - CERTIFICATE OF LIABILITY INSURANCE
DATE
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 poiicy(Ies)must be endorsed. If SUBROGATION IS WAIVED,subject to
the terms and condition 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 endorses).
McLaughlin Insurance AgencyER CONTACT
NAMEFAQ
828 Lynn Feiss Parkway Nu.Er*781-665-2775 (MC.Nok 781-665-0295
Melrose,MA 02176
William B.Marldcard,CPCU -
'
IISURHt(5)AFFORDING COVERAGE MAIC I
INSURER A:Commerce insurance Company 34754
INSURED Ryan Family Amusements,Inc. N&jRER B:Houston Casualty Company
Attn: Mike Crowley
116 Waterhouse Road INSURER C:Torus National Insurance Comp
Bourne,MA 02532-3867 DisunER D:Guard Insurance Group
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.
ItISR MAW= POLICY EFF POLICY EXP
LTR TYPE OF INSURANCE pen YAM POLICY/AMMER aNADfYYY 1 LIMITS
_GENERAL LIABI TY EACH OCCURRENCE S 1,000,000
B X COMMERCIAL Beam/tumour( 1317001074 05/0112014 05/01/2015 DAIMGE T7E,RENTED y S 100,000
CLAIMS.MADE X OCCUR MED EXP(Any one person) S Excluded
PERSONAL&ADM*WRY $ 1,000,000
X UQUORLIAB GENERAL AGGREGATE $ 2,000,000
GEN.AGGREGATE LIMIT APPLES PER PRODUCTS-COMR'OP AGG $ 2,000,00a
—1 POLICY n.Pia ri LOC ,Liquor $ 1,000,000
COMBED SINGLE
AUTOMOBILE UABIJTY (Ea accident) LIMIT $ 1,000,000
A ANYAUTO 14MMBDPRLQ 04/10/2014 04110/2015 BOORT INJURY(Pwpers n) $
ALL OWNED X scram
BODILY BURY(Per accident) $
RUTOSUED a(rrNo viNED PROPERTY DAMAGE S —
X HItEDMJIOS X ACOS (PER'COVENT)
S
x UMBREU.ALIAB X Ocan EACH OCCURRENCE $ 2,000,000
—
C EXCESS UAB CLAPAS4AADE 70320G130AU 05/01/2014 05/01/2015 AGGREGATE $ 2,000,000
DED RETENTIONS $
WORKERS COMPPISAION ORYTLpM 1 ER
AND EMPLOYERS'LIABILITY
D ANY PROPRIErowPAR E EI YN IA RYWC486346 12/31/2013 12/31/2014 EL EACH ACCmE t $ ' 500,000OFFICERIIEMBEREXCU /
(Mandatory In NH) EL DISEASE-EA EMPLOYEE S 500,000 .
IOESCeRIPTgZOFOPERATIONS below EL DISEASE.PO.JCY LIMIT $ 500,000
B Bus Personal Prop 137001074 05/01/2014 05/01/2015 BPP 240,000
DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space Is required)
Yarmouth Summer Celebration Kick Off, June 26th, 2014 at Bass River
(Smugglers) Beach, Shore Drive, Yarmouth M . General and Liquor Liability
have been extended for this event.
CERTIFICATE HOLDER CANCELLATION
YARM001
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
TOwn of Yamwuth THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
Town Hall
1146 Route 28
So.Yarmouth,MA 02664 AUTHORIZED REPRENrATIVE
®1988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25(2010/05) The ACORD name and logo are registered marts of ACORD