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HomeMy WebLinkAboutApplication and WC TOWN OF YARMOUTH Board of �� .. E Health O �_-` . 1146 ROUTE 28, SOUTH YARMOUTH,MASSACHUSETTS 02664-24451 - A a • , �'� Telephone(508)398-2231,ext. 1241 Health °"E Fax(508) 760-3472 Division To: Yarmouth Business Establishments Sw i Mo -PTbG5 From: Bruce G. Murphy, Director `' - C 1014 Yarmouth Health Department HEALTH DEPT. 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 Public Whirlpool/Vapor Baths $ 80.00 Tobacco Sales $ 95.00 Motels $ 55.00 Restaurants 0-100 Seats $ 85.00 t.g5-oo Restaurants Over 100 Seats $1-60.00 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 coMttot dic. Total fees owed for your establishment: $t%.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.] BGM/maf TOWN OF YARMOUTH BOARD OF HEALTH .trq ,* e. APPLICATION FOR LICENSE/PERMIT -2015 14L,` t_Y C 614 ---4,1 * Please complete form and attach all necessary documents by Dec�mbe 15-. 114.H Failure to do so will result in the return of your application pack:i H DEPT. ESTABLISHMENT NAME: -4.4T e-fiK-` \AA4, -Tf S TAX ID: LOCATION ADDRESS: Lg\ c`--- jc., \A-c-3, TEL.#:S-9 - ( &\ MAILING ADDRESS: tr ` , E-MAIL ADDRESS: VA.,\:P-c,c cE'-L-t- C4kT \i‘npsC CO•-- OWNER NAME: \ivy etc),t\. LI ,-t-,t-- CORPORATION NAME (IF APPLICABLE): C-i Q0‘,..\c -.- . MANAGER'S NAME: -{.l n skX, TEL.#:'>-y- a3�- a f( l MAILING ADDRESS: \—)a \-koz:MAJ.sc kD01/41\t k s A c) t2,t,Q i D a t,SS 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. r . 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. \1\1\.,e Imo \ S\-tae--tic— 2. `t._cS w\ 51. t.--4.--- PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. \1\-1\.61\- \t\ 2.c- ...t7-- 2. ?(k 4l t�`i`•.� 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. `t)RSOQ"C't''°'` 2. \k-e - ( c: : -4N\Ntk--- 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. C"?--(1-P`�N vim-- ���'�CLQ�M 2. 3. .I\�C .S (N‘ 4. 1.1 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 $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 /5-• (IZO _CONTINENTAL $35 _NON-PROFIT $30 >100 SEATS $200 l COMMON VIC. $60 -01 OO`j 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. $150FROZEN DESSERT $40 TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE = $ I SS.Od *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** It 124 t 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 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 co-okingpiepaiation,or display of any foodproductby a retail or.f d 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: \\ ^ SIGNATURE: PRINT NAME& TITLE: N\Ne0,(1 \\i Y\-PJL— Rev. 11/03/14 To: 15087603472 From: 15084263068 Date: 11/24/14 Time: 7:25 AM Page: 02/02 ACORO® CERTIFICATE OF LIABILITY INSURANCE DATEIMMrDD/YYYYI 11/29/2014 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 CONTACT NAME: Germani Insurance Agency PHONE FAX 908 Main Street (A/C,No,ExtX(506)428-9199 (A/c,No(508)428-3065 E-MAIL Osterville,MA 02655 ADDRESS:certs)gerrnan(insurance.com INSURE/4131 AFFORDING COVERAGE NAIC 8 INSURER A!NGM (Na GO na l Grange Mutual) ._..._._..._ INSURED - INSURER B The Grump Inc.0/BDA Sweet Tomatoes Pizza 170 Hollingsworth Rd. INSURER C Osterville,MA 02655 INSURER D:NGM ;National Grange Mutual) 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-H15 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 trsR ......._._.. ....... . ....... A001`SUaR .._._._....._. ..... ._._..._. . .._-..._.... ..-.._._.... POLICY EFF POLICY EXP LTR TYPE OF INSURANCE (NSD NNO POLICY NUMBER (MNYDD/YYYYI 1MMlODA'YYY)- LIMITS 1 A I COMMERCIAL GENERAL LIABILITY BPT048BN 3/4/2014 3/4/2015 X I EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED CLAIMS-MADE X OCCUR PREM SES;Ea occurrence) $ MEG EXP;Any one person) S • PERSONAL.3 ADV INJURY $ GEN''-AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE 5 2,000,000 PRO- ',LIC Y JECT LOC PRODUCTS-COMP/CP AGG $ OTHER: _ AUTOMOBILELIABIUTY COMBIr4EO5INa.E LIMIT _ E a accloe n. ANY AUTO HODIL'f INJURY(Per pernoe) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OM-FED PROPERTY DAMAGE HIRED RUT DS _ AUTOS '(Per accident- -- -- $-- $ UMBRELLA LIAB _ OCCUR EACH OCCURRENCE --!EXCESS LIAB CLAIMS-MACE AGGREGATE $ CEO RETENT'.DNS $ 1) WORKERS COMPENSATION WCT09BBN 3/4/2014 3/9/2015 PER GT-I- ANDEMPLOYERS'LIABILITY YIN STATUTE ER ANY PRIJRPIETORIPAP.TNER,EXECIJTIVE E.L.EACH ACCIDENT $ 100,000 OFF c E?/MEMEEr:EXCLUDED? Y« H(A --- (Mandatory In NH) LI.L DISEASE =MMPI UYEF Y 100,000 If yes,Ae:cane LindeI ..._.. __..—._. ..._....-... —.._. ........... DESCRIPTION OF OPERATIONS below EL.DISEASE POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS i LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached it more space is required) Loc 1: 461 Station Ave.,Bass River,MA 02664-1849 Loc 2: 790 Main St.,Chatham,MA 02633-1823 {Merrill Sweet is excluded. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Yarmouth THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1146 Route 28 ACCORDANCE WITH THE POLICY PROVISIONS. South Yarmouth,MA 02664-1492 AUTHORIZED REPRESENTATIVE 1 _ ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD To: 15087603472 From: 15084283068 Date: 11/24/14 Time: 7:25 AM Page: 01/02 r" 10X a Date: Mon Nov 24 10:24 EST 2014 TO Fax Number: 15087603472 ciName: Town of Yarmouth ammi nzunmix Afqcny FROM 908 Main St, Fax Number: 15084283068 Osten/Ate. AM 02655 Name: Germani Insurance Office 508-428-9194 Fax 508-428-3068 Company: Certificate of Insurance - Sweet Subject: Tomatoes Pages: 2 Notes: Greetings, Attached please find a Certificate of liability Insurance for Sweet Tomatoes Please do not hesitate to contact our office should you have any questions or concerns. Regards, Germani Insurance Agency 908 Main Street Osterville, MA 02655 Phone: 508-428-9194 Fax: 508-428-3068