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Home My WebLink AboutApplication and WC O��Y'qf? �� -_�` _\'�a TOWN OF YARMOUTH BHa�f � :� �`r 1146 ROUTE 28, SOUTH YARMOUTH, MASSACHLJSETTS 02664-24451 � � ;��A ceEEa�j�� Telephone(508)398-2231,ext. 1241 Div si n Faac(508) 760-3472 To: Yazmouth Business Establishments 20�� Z8 piN� � ' , .:;4 � From: Bruce G. Murphy, Director � � Yarmouth Health Department� �� ----- Date: November 7, 2014 Subject: Increase in License/Permit Fees Please be awaze that the Yannouth Boazd of Health, under the direction of the Yannouth Boazd of Selectmen, has raised a number of license and permit fees issued through the Yannouth Health Department, effective January 1, 2015. Attached is the Yannouth Business License/Permit Application for 2015. You will note that the fees listed aze the fees effective January 1, 2015. These fees will be due if you complete and submit the application after Januazy 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 Pubiic Swimming Pools $ 80.00 Public WhirlpooUVapor Baths $ 80.00 Tobacco Sa1es $ 95.00 Motels $ 55.00 Food Service 0-100 Seats $ 85.00 $ g5.U0 Food Service Over 100 3eats $�60.fl0 - - — - Retail Food Service CL5,000 sq. ft. $ 80.00 Retail Food Service>25,000 sq. ft. $225.00 Other fees owed but not listed above: (�p.00 �Q��N ��c . Total fees owed for your establishment: �I�}S.oO 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.J BGM/maf 2T.23 D�ro� a . TOWN OF YARMOUTH BOARD OF HEALTH �;�°/ �� APPLICATION FOR LICENSE/PERIVIIT -�201.5 �7- �, t�p�O * Please complete form and attach all necessary docume s by December IS 2014. Failure to do so will result in the return of your application pac cet. ESTABLISHMENT NAME: ��'^�'�- T ID: " LOCATIONADDRESS: a� �a.�c- a£r S Ik.�.��-k^ TEL.#: Sor3S� •a�S� MAILING ADDRESS: .� � .75� SK- r1� E-MAILADDRESS: i�.t/,c.� r9�-�Ca.� OWNERNAME: o� /Ut� r CORPORATION NAME(IF APPLICABLE): %�oV�i. ��'r1/+� y f �-p�rrs , MANAGER'S NAME: �✓K ./�lu�s*�� TEL.#: Sv8- S>y,�Sv MAILING ADDRESS: s`�R„"c • 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 a11 Umes. 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. Z• 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 Sariitary 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. � �t/�C�'�O 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Chazge (PIC) on site during hours of operation. 1. � 1G✓cc-�vf�C[a 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. �i �4�rX � 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. /O�*'I �c.tL�.i-/� 2. �-�/'CY /!/t� 3. i o�v� /t/� 4. RESTAURANT SEATING: TOTAL# `�'S OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# C.ICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN � $55 MOTEL . $110 INN $55 CAMP $55 SWIMMING POOL$110ea. LODGE $55 1RAILERPARK $105 WHIRLPOOL $tl0ea FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# I 0-100 SEATS $125 _CONTIIVENTAL $35 NON-PROFIT $30 � >I00 SEATS $200 �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 =<Z5,000 sq.ft. $150 _FROZEN DESSERT $40 _TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE _ $ I �S ��O *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*****. �,�+ �L�✓'� v��,p�-��Zt�� nvn�mis��riaN Under Chapter 152, Section 25C,Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal af acxy license or permit to operate a business if a person or company does not ha�e a Ccrfificate of Worker's Campensation Insurance. TFIE ATTACHED STATE W012KER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CER1". QF INSURt1NCE ATTACHED OR WOKKEK'S COMP. AFFII7AViT SIGNEI7 AND A'T"I'ACH�I} 'I'oum of Yarrnouth taxes and liens must be paid priar to renewal or issuance of your pertnits. PLE�1 SE CHECK t1PPROPFtIATELY IF PAID: YES N(} MOTELS ANA OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes ofthe limitations ofMoYel or Hotel use,Transient occupancy shall be limited to the temporary and short term occupanay,ordinarily and custornarily assoaiated with motel and hotel use. Transient aceupants must have and be able to demonstrate that they maintain a principai place af residence elsewhere.Transient occupancy shall generally refer to continuous occupancy of not more than thirry(30)days,and an aggregate af not more than ninety(90)days within any six(6)month period. Use of a guest uniti as a residence or dwelling unit shall not be considered transient. Occupancy that is subjact ta the collecrian af 12oam {}aeupancy Excise,as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient. POCILS POClL 4PENING:Ali swiinming,wading and whirtpoals which have been closed far the seasan must be inspected by the Health Department prior to apening. Contact the I�ealth Department to schedule the inspection three(3) days prior to opening. PLEASE NOTE: People are N4T allowed to sit in the pool area un#il the pooi has been inspected and opened. POOL WATER TESTING: The water must ba tested i''or pseudomonas,total coliform and standard plate count by a State certified lab, and submitted to the Health Department three (3) days prior to open'tng, and quarterly thereafter. POOL CLOSING: Every outdoar in graund swimming pooi must be drained or covered within seven(7)days of' closing. FOOD SERVICE SEASONAL FOpD SERVICE OPENIN(">: All food service establishments must be inspected by tfie Health Department prior to opening. Please contact the F3ealCh Departrnent to schedule the inspection Yhree(3) days prior to opening. CATERING POLICY: Anyone who caters within the Town of Yarmouth tnust notify Che Yarmouth Health Department by filing the required Tempo Faod Service Application form 72 hours prior to the catered event. These forms can be obtained at the H�th Department,or from the Town's website at www.yarrnouth.ma.us under Haalth Department, Downloadable Forms. FROZEN DESSERTS: Prozen desserts must be tested by a State certified lab prior to apening and rnonthly thereafter,with sarnple results submitted to the Health Department. Failure to do so will result in the suspension or ravocation of your Frozen Dessert Permit until the above terms have been met. OUTSID'E CAF'�S: � Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. OUTDOOR COOHING: Outdoor cooking,prepazatian,or display of any fpod pxoduct by a retail or food service establishment is prohibited. NOTICE:Permits run annually from January 1 ta December 31. IT IS YOLiR RESPONSIBILITY TO RETt7RN THE CQMPLETED RENEWAL APPLICATION(S}AND REQUIRFD FEE(S}BY DECEMBER I5,2014. ALL RENOVATIONS TO ANY FOOD GSTABLISHMENT, I�fOTEL OR POOL (i.e., PAINTING, NEW GQUIPMENT,ETC.), MIJST BE REPGRTED TC} ANI}APPIt4VED BY THE BOARD QF HEALTH PRTOR TO COMMENCEMENT. RENOVATIONS IvIAY R�EQUIR.E._,A�S.�ITE PLAN. DATE: ��y�� SIGNATURE: ,,.� ��"��/`°z- PRINT NAME& TITLE: � ��' /'Z�«,C%�c�l� Rev. 11J03fl4 � � � The Commonwealth ofMassachusetts Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite I00 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Aaalicant Information Please Print Le¢iblv Business/Organization Name: F� �� ^� Address: �a� /��`''� .�� City/State/Zip:�c�^ Y�'�� Phone #: So� 3�lFr��• Ar,�e y,/ou an employer? Check the appropriate box: Business Type(required): 1. `L�f 1 am a employer with�employees(full and/ 5. ❑ Retail or part-rime)* _ _ __ _ _ _ 6. RestauranUBaz/Eating Establishment 2.❑ I am a sole proprietor or parmership 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]* 4.❑ We aze a non-profit organization, staffed by volunteers, 1 I.� Health Caze with no employees. [No workers' comp. insurance req.] 12.❑ Other *Any applicmrt ffiaz checks box#1 must also fill out the section below showing their workers'compensalion policy information. **If the co:porate officers have exempted themselves,bu[the corporation has other employees,a workers'compensation policy is required and such an organi�ation should check box#I. . I am an employer that is providing w/orkers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: }y/�.uiL �sartA+�2 fjicup, Insurer's Address: �•a � �ax ��r� City/State/Zip: L�i ��ii. i.��li 2� �-�m�[' !J�� /S— Policy#or Self-ins.Lic. # �� °��3 7i6a �� Expiration Date: 7�� Attach a copy of the workers' compensafion policy declaration page(showing the policy number and eapiraHon date). Failure to secure coverage as 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-yeaz imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwazded to the Office of Investigations of the DIA for insurance coverage verificarion. I do hereby eenify,under the pains andpenalties ofperjury that the infarmation provided above is true and correct. Sienature: � l�v Date: ��( " �/�� Phone#: �� S 7�/ 7 3 �d Official use only. Do not write in this area,to be completed by city or town officiaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2. Building Department 3. City/Town Clerk 4.Licensing Board 5. Selectmen's Office 6.Other Contact Person: Phone#: www.mass.gov/dia �``�� CERTIFICATE OF LIABILITY INSURANCE ��i��iZo� ' THIS CERTIFICATE IS ISSUED AS A AMTTER OF INFORMA710N ONLY ANO CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS CERTIFICATE DOES NOT AFFIRMA7IVELY OR NEGATIVELY AMEND, EXiEND OR ALTER THE COVERAGE AFfOROED BY THE POLICIES BEIOW. THIS CERTIFICATE OF INSUR4NCE DOES NOT CONSTITUTE A CONTRACT BE7WEEN THE ISSUING INSURER�S�, AUTHORIZED REPRESENTATIVE OR PRODUCER AND THE CERTIFICATE HOLDER. IMPORTANT: If the certiNcate holder is an ADOI710NAL INSURED,the policy�les)must be entlorsed. If SUBROGATIOti IS WANEU,subJe�t to the terms and conditlons of the poliry, certain pollcias may requlre an enaorsemant A statement on this certificate dces irot confer Aghts to the certificate holder in lieu of such andorsement(s). P0.0WCER CONTRCT USI INSURANCE SERVICES LLC 5700 POST RD NAME: PO BOX 1158 PMONE �HTI�46�-27Z3 ip�-Np_SFG-$ZS-24ZM1 qo"�� . Certificate�harrover.com EAST GREENWICH,RI 02818 INSURERS AFFORUIN6COVERAGE wucs iNsu�rs n: �izers Ir�s Co of Amenca � 31534 wsuneo wsunen a�, Harwver Insirance Co ZZz9z Y TNT FAMILY ENTERPRISES - DBA ROUTE28 DINER �NSURERC: 928 ROUTE 28 INSURER D: INSURER E SOUTHYARMOUTHMA 02664 INSURERF'�� COVER4GES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY TMAT TME POLICIES OF INSURANCE LISTEO BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PER100 INDICATED. NOTMTMSTANDING 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 MEREIN IS SIIBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POUGES.lIM1T5 SHONM MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR R POLICY EFF POIJCY EXP � �— Tp TYPEOFWSUMHCE I PoUCYNUNBER MMNDMlYV MM UMITS GENERPI WBILIIV j li � EACMOCCURRBJCE 5�.00O,OOO X COMMERCNLGENERPLLIABILITY �,.,�_�r '. PREMISES a S��0� A CWM$-MAOE �OGCUR I i ZBE899851503 0'I/29Y1014 '., 01/29/2075 MEDEXP(Maiepenan) 25.0� '.... veasoruaanoviruuar s1,000,000 __ li .GENEau Ac.�RErore 3 z,000,000 GENLOGGREGAiELIMITRPPLIESPER� I PRODUCIS-CpAP/OPAGG SZ�QOO,OOO ��n�a �� - t �RUTOMO&LEtINB1UTY � � '. �Oen M L LIMI S I ANVAUTO � j BODILYINJURY�Perpcnn� S RLLCIMJEO j�SCHEOULED AIITOS uAIITOS I I BODILYINJl1RY(PoremUe�tl� 5 �HIREDM1t05 I ANON�NNE� II I�a�wC M�ANAGE S t—� i �__ S ____— � I uMBREUALInB p�UR �� i IEACHOGCURR@1GE S _ i E%CESSLIFB �CWMS-MAOE I AGGREGATE S ____..., ' ��ED REtENTIONE y IWORNERSCOMPENSATION ', NCSTATU� OT1-_, PN�EM0.0YERSlJ�BILITI , ! ANYPPOpftIEfORiPARiNEFIE%ECUTNE Y/N � I �JOO�OOO B OFFlCErMEMBEREXCLU�EDi � NIA� WFIE793716204 04/06Y2014 �; 04/O6/2015 ELEACHACCOENT . f _ n"'d�°�"^�N� �'�. i ELOISEASE-EAEMGLOYE2 5�•�0 11 yan.EmrnEe uMa '. . � ' ' ElDI5EA5E-POLICYLIMIT S�O,OOO I�� i j� I oescrsivnoN oF or�unons i�oc�noxs�v�ic�s 1nrc,cn ncorso�oi,amwo�,i n�.ms scn.awe,x mo�..pa��.�.q,a.ae� CERTIFICATE HOLDER CANCELLATION Town of Yarmouth 507 Buck Island Road `3HWLD ANY Oi THE ABOVE DESCRIBED PoLICIES BE CANCELLED BEFORE West Yarmouth, Ma 02673 THE EXPIRATION DATE THEHEOF, NOTICE N7LL BE DELIVERED IN ACCORDANCE WITH THE VOLICV PROVISIONS. •UlHdi¢EO RFPRESENiATVF 1 �� 198&2010 ACORD CORPORATION. All righfs reserved. ACORD 25(2010/OS) The ACORD name and logo are registered matks of ACORD