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Home My WebLink AboutApplication and WC , TOWN OF YARMOUTH Board of -- tiff Health `; 1146 ROUTE 28, SOUTH YARMOUTH,MASSACHUSETTS 02664-24451 - '. e a,T y 49/ Telephone(508)398-2231, ext. 1241 Health • Fax(508)760-3472 Fax To: Yarmouth Business Establishments 0LiVER-5 t PtANc..K s I AvSlz-N From: Bruce G. Murphy, Director G'3NCOWCDD Yarmouth Health Department DEC 2 3 2014 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: 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 Restaurants Over 100 Seats $160.00 $I�,p,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: $ ,o.00 cor,.roN J K. Total fees owed for your establishment: 22.0.pd 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 odEuv��° (f ) APPLICATION FOR LICENSE/PERMIT -2015 ULU 23 2014 * Please complete form and attach all necessar u ntS y De—eeffsber 15, 2014. Failure to do so will result in the retail aye ' •pficatlorrpt ket.HEALTH DEPT. ' Y' 10413 ESTABLISHMENT NAME: O/_ /V i23 t l"'LAire-/-S /qbre 24 TAX ID: LOCATION ADDRESS: 'CO PA iN ST-. yA►2Hoark{ TEL.#: 52)6'-3,c2 6C54z MAILING ADDRESS: 5A-m E { E-MAIL ADDRESS: o,V9 on1 . OL,v ',5 @ /\Ic OWNER NAME: . y 2-i O 2W o` kr CORPORATION NAME (IF PPLICABLE): 1 Lr VL i O i`tl o'v /AJ c, MANAGER'S NAME: A iq LE 01(46/L./ TEL.#: ,fO 3G2-606 MAILING ADDRESS: 119 644146-Lo j2c1 . B, (Z6W 171=12; / A- 42-6'3 I 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. o 1. {'1!0K 1-i i -Gl-r,A 1-6 2. �cJ ftLL' Ot tt-t Det/ PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. ACZY 2. 2G_ QR1"iDAL 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. '14ti-E A11,01.) 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 $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 _CONTINENTAL $35 NON-PROFIT $30 >100 SEATS $200 -a-i—Ok.(2 1 COMMON VIC. $60 6.. 03 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 _ $ 2.60,00 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** iet t 2.2cCO thA3ot-I3 1 z/Z3/tL( 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 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 REQU S E PLAN. DATE: %2-2)—11( SIGNATURE: PRINT NAME &TITLE: P/ oN Rev.11/03/14 s NOTICE .,. NOTICE ha, I O .::..aUMW..piTs.iipt TO i114 . ,mow�. EMPLOYEES , EMPLOYEES ' '". tyy wr The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston, Massachusetts 02111 617-727-4900 - http://www.mass.gov/dia As required by Massachusetts General Law, Chapter 152, Sections 21,22 & 30, this will give you notice that I (we) have provided for payment to our injured employees under the above-mentioned chapter by insuring with: MA Retail Merchants WC Group Inc. NAME OF INSURANCE COMPANY PO Box 859222-9222 Braintree, MA 01285 ADDRESS OF INSURANCE COMPANY 014000502163113 1/01/2013 - 1/01/2014 POLICY NUMBER EFFECTIVE DATES Rogers & Gray Insurance Agency 434 Route 134 South Dennis, MA 02660 NAME OF INSURANCE AGENT ADDRESS PHONE# Oliver Ormon, Inc. 6 Bray Farm Road Yarmouthport, MA 02675 EMPLOYER ADDRESS • EMPLOYERk'S WORKERS' COMPENSATION OFFICER(IF ANY) 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 Workers' 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 reasonable 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 TO ,BE POSTED BY EMPLOYER From:Rogetx&Gray InsuraFax:(ST�8162756 To:r750839&6836 Fer: +75U83S8oeS6 Page 2 0(? 12/01l2014 71:59 ,,,�� OCIVORM-0t CNELSOPf ��`�A CEFLTIFICATE OF LtABIUTY il+{SURANCE ��`�'�`�' 3?t412014 . 7HIS CERTIFICATE IS ISSUED�AS A MATTER OF JNFORMATION ONLY AND CONF�RS NO WGHTS UPON THE CERTIF)CATE HOLDER.THIS , CERTiFICATE DOES N4T AFflRMRTIVELY OR P7EGA71VELY AA§END, IXTEtip 8R ALTER THE COVERAGE AFFORDED BYTHEPOLICIES 6ELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSi1TU1E A CONTRACT BEfWEEN THE ISSUING INSURER(5�,AUTHORIZE� REPRESEMTATIVE OR PRODUCER,kPID TNE CERTIFlCATE HOLDER. IMPORTANT: If the ceKificate holder is an ADDITIQNAL INSUftED,the policy�ies)must be endorsed. If SUBROGATION IS WpIVEO,subJect to the tenns and con�tione nf the poiicy,ce[t�n pflticies may require an endorsement. A statemeN on tNs certi8c�a does not coMer rights to fhe aertificate halder in lieu of such endorsement�s. PRODlC62 NAME{ Rogers&Grey Insurance Agency,Inc. A°� � 1ac Nor(677)816-2156 434 Rte 13G —' South Denr�s,MA 02650 n��ss: INSUPER(S)AFFOFAIN6COVERAC+B NNCA iNs�an:�.Retail Merchants WC Grou Ina. wsua�n irsu�s: � Oliver Ormon Inc wsurs�c: . OliveYs Eating&Orlr�cing �NS�a�ERo: 6 Bray Fartn ftoad . YarrtwukhpoR,MA Q2675 i"Su�RE: ... INSURER F: COVERAGES CERTIPICATE NUMBER: REVISlQN NUMSER: THIS IS TO CERTIFY iHAT THE POLICIES OF INSURANCE LISTED BELOWHAVEBEENISSUEDTOTHEINSUREDNAMEDABOVEFORiHEPOLICYPERIOD INDICATED. NONN7HSTANDING ANY REpIJIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER QOCUMENT WfTH RESPECTTONk11CHTH15 CERTIFICATE PAAY BE tSSUED OR MAY PERTRM, iHE iNStfftANCE AFFORDEp BY TH£ POI.ICIES DESCRIBED HEftEtN ISSUBJECTTOAttINETEftRES, E7(CLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMRS SHOWN MAYHAVE BEEN REOUCED BY PAID CLAIMS. �' ixatis LlR TYPEOPMSURANCE POUCYNLfidBER NJ6O MIM . COMMERCIALGEf�RALLIA611.fiY EACHOCdJRftENCE S DA&1AG}7;'6HEt� .... CLAIMSMADE ❑OCCUR pREMI$FS(Eaottvnen'e s MEDEXP{My ona person) S �PERSONAL&ADVINJURY 5 -6cMl.A6GREGAiE i.iMiT APPLIES PER: GEHERAI AG6REGATE S FOLILY❑ gCT �LOC � PROWCTS.CpMPIOP AGG $ S OTNER: OMBIN 9N LELIMI AlJIOMOBILELIABILITY Eeaccitlan[ $ PNV pUTO BODILY iNJURY(Perpersonj �$ ALL OWNED SCHEbUL� �gODILY INJIIRY(Perac<itlenq �5 AUTOS AU70S -- - NON-OWNm ft�OPF� D� AMA�E $ HIRm AIROS AUTOS Fer ac i en[ S �e�-�`� OCCUR EMCHOCCURRENCE $ Ot�SSUA$ q.AiMSMADE RGGREGATE S OED REfEMION S $ WflRNERSCdtdPBJS0.ilON $j'ATUT R ANO EMPLOVERS'LIABILRY p. ANYPROPRIEFORlPARTNER�QJTIVEYIN 0740005U2163114 01/01l2414 01lOtl20M1S E.I.EAfkIACGDENT S ..�� Q.Q� OG�ICERrTAeN�R EYCLU�D'+ Y N t A . " """ �y��eryjpy{) E.L.DISEA56EAENF40YE ,$ SUO�O It yes,dascnbe untler �� $QQ OESCRIPTIONOFOPERATI0�5babw E.t.DtSEASE-?OLtCYlib9T 5 r OESCRIPT70NOFOPERpTONSILOCAiiDNSIVEWCLE3(ACORU101,Atld4m�RemukeSClMduk,mrybeklachedllmon6peceisrequire� � Glenn Ortnon and Dale Ortnon are included in Workers Compensation coverage. CERTIFlGATE HOLDER CANCELLA710N SHOULD ANY OF THE ABOVE DL°SCRIBED Pd.IqE3 BE CANCELIFD BEFORE 1HE EXPIRATON D117E THL°REOF, NO'i10E WILL BE D@.NERED M � TOva�of Yarma6h pCCORDRNCE W171i TiiE POLICY PRQVfSiONS. 1146 Raute 28 � SpuSh Yarmot#h,MA 02666 AUTnHORIZ�RE'RESBii'A'IIVE 1./"`^�' ��'I O 1968-2014 ACORD CORPORA116N. Aii rights r�erved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD