HomeMy WebLinkAboutApplication and WC of•Y.yR utt; 1,5 2014
Y\ TOWN OF YARMOUTH oaro
• _ HEAL7�JI�f.
�3 1146 ROUTE 28, SOUTH YARMOUTH,MASSACHUSETTS 02664-24451 Health
a� t#c N��6� Telephone(508)398-2231,ext. 1241 Division
Fax(508) 760-3472
•
To: Yarmouth Business Establishments Sows oft N CAPE Cap
From: Bruce G. Murphy,DirectorClf\ w i Ll low-Lt��tt�LI
Yarmouth Health Department �' S ,,
thif
Date: November 7,2014 ( �'- tNI1S
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
Food Service 0-100 Seats $ 85.00
Food Service Over 100 Seats $160.00 $1,60.OG
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: $ ,o.00 Com-too vtC .
Total fees owed for your establishment: 422.0,06
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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SONS of eRtN
teti .► TOWN OF YARMOUTH BOARD OF HEALTH
,► APPLICATION FOR LICENSE *i5!- C} f 7 rt O M EE
1
* Please complete form and attach all necesqury do4innie Itfi bysDec. ber.W26142014
Failure to do so will result in the retuttf of iii`"applcation pa ket.
3.re.it .I.a1 n;:.-pi
ESTABLISHMENT NAME: S OnS (.4-rein Car Ca4, e TAX ID:
LOCATION ADDRESS: 7j�j13'1'2-SS L)L � e rvd.. , OL(.o -S TEL.#: 50S1'1Ob3g9
MAILING ADDRESS: . "PP�yC O c,ki arty m k1.2 2.G
E-MAIL ADDRESS: info € Szo s o.P 1-in C C. coe n
OWNER NAME:
CORPORATION NAME (IF APPLICABLE): on . s .e_- C.. '131 -�i Q
MANAGER'S NAME: IA i c ,r,,tL S f.
MAILING ADDRESS: CoS C.ei701-4 t j-�• TEL.#tett/t i1e-, MIA. O2.(A Z
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. OPS-----
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. Iv( IA 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 rovide new copies and maintain a file at your establishment.�/
1.
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PERSON IN CHARGE:
Each foodlestablishment must have at least one Person In Charge (PIC) on^ site during hours of operation.
1. K f..�t r ' .. t r-rs m. S
►5 2. f v fir. 1 ,SG-C_.
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
providw 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.ll
1. Cc,,n�l L I1' 2. .uC-k{ t40K4'-ex
3. 4.
RESTAURANT SEATING: TOTAL# 160
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 $125 _CONTINENTAL $35 NON-PROFIT $30
"T>100 SEATS $200 I COMMON VIC. $60 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 = $ 2Jo O.00
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** C to 0'22,0.00
C, lrpl3 /?J's(y
l 7
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 prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES V 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 APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 15, 2014.
ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PANTING, NEW
EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. -
DATE: '-I t° 11 jt SIGNATURE: 114
PRINT NAME & TITLE: M 1 d..& ' t C ti
Rev. 11/03/14
The Commonwealth of Massachusetts
Department of Industrial Accidents
+_ t Office of Investigations
1 Congress Street, Suite 100
. of "
•, _: Boston,MA 02114-2017
AO, www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name: J •A, • �I C C ' ccA JC .
Address: (013-;
City/State/Zip: 41°41-"^'-'`t I PI 0103Phone#: SOg —190_0319
Are you an employer? Check the appropriate box: Business Type(required):
1.[ I am a employer with 7.. employees(full and/ 5. ❑ Retail
or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment
2.❑ I am a sole proprietor or partnership and have no '7. ❑ Office and/or Sales(incl.real estate,auto,etc.)
employees working for me in any capacity.
[No workers' comp. insurance required] 8. Non-profit
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.❑ Health Care
4.❑ We are a non-profit organization,staffed by volunteers,
with no employees. [No workers' comp. insurance req.] 12.0 Other
*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 Company Name: IfA (-es' pt I,' C1t cGvr U"rev-AA-t.
C.
Insurer's Address:
To, � 35Sco
3z�s�TL Sb
City/State/Zip: /O�ric ,,n r'L
`` �
Policy#or Self-ins. Lic.# (Q S(i�V 7 L �1�. Ts I LI Expiration Date: u' 2-- c
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 25Aof DIOL c. 152 can lead tothe 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,under the pains and penalties of perjury that the information provided above i true and correct.
,1
Signature: 14"j4/L-L ?'flw14)1 S1)C'� Date: i 0. 1V i 4
Phone#: 50 o---lgq —91S1
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
V DAC;
ace group WORKERS COMPENSATION
AND
EMPLOYERS LIABILITY POLICY
TYPE AR INFORMATION PAGE WC 00 00 01 ( A)
POLICY NUMBER: (6562U6-4705P92-8-14)
RENEWAL OF (6S62UB-4705P92-8-13)
INSURER: ACE AMERICAN INSURANCE COMPANY
1. NCCI CO CODE: 12165
INSURED: PRODUCER:
SONS OF ERIN CAPE COD INC BRYDEN & SULLIVAN INS AG
PO BOX 403 PO BOX 1497
SOUTH YARMOUTH MA 02664 SOUTH DENNIS MA 02660
Insured is A CORPORATION
Other work places and identification numbers are shown in the schedule(s) attached.
2. The policy period is from 08-02-14 to 08-02-15 12:01 A.M. at the insured's mailing address.
3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers
Compensation Law of the state(s)listed here:
MA
AIM B. EMPLOYERS LIABIUTY INSURANCE: Part Two of the policy applies to work in each state listed in
item 3.A. The limits of our Ilabiity under Part Two are:
Bodily injury by Accident: $ 100000 Each Accident
Bodily Injury by $ 500000 Policy Limit
Bodily injury by Disease: $ 100000 Each Employee
C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here:
COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06A
mion
D. This policy includes these endorsements and schedules:
SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE
4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating
Plans. All required information is subject to verification and change by audit to be made ANNUALLY.
DATE OF ISSUE: 07-18-14 WC ST ASSIGN: MA
OFFICE: ORLANDO DA ACE 24M
•
PRODUCER: BRYDEN & SULLIVAN INS AG 75BKG
014235
VDAC
ace group WORKERS COMPENSATION
AND
EMPLOYERS LIABILITY POLICY
TYPE AR INFORMATION PAGE WC 00 00 01 ( A)
POLICY NUMBER: (6S62UB-4705P92-8-14)
CLASSIFICATION SCHEDULE:
PREMIUM BASIS
ESTIMATED RATES ESTIMATED
TOTAL ANNUAL PER $100 OF ANNUAL
CLASSIFICATIONS CODE NO REMUNERATION REMUNERATION PREMIUM
SEE EXTENSION OF INFORMATION PAGE — SCHEDULE(S)
SIC-CODE: 8641 NAI CS: 813990
STANDARD
TOTAL ESTIMATED ANNUAL STANDARD PREMIUM $ 645
PREMIUM DISCOUNT NONE
0900-20 EXPENSE CONSTANT 250
TERRORISM 20'
TOTAL ESTIMATED PREMIUM 915
TAXES AND SURCHARGES 22
DEPOSIT AMOUNT DUE 937
A/R (WCIP) #
Minimum Premium: $ 213
ST ASSIGN: MA
DATE OF ISSUE: 07-18-14 WC
OFFICE: ORLANDO DA ACE 24M
PRODUCER: BRYDEN & SULLIVAN INS AG 75BKG