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Home My WebLink AboutApplication and WC : .�°��R'�a TOWN OF YARMOUTH Boardof � = -� � xealth 0 � `� 1146 ROUTE 28, SOUTH YARMOUTH,MASSACHLISETTS 02664-24451 - � • !.� � Telephone(508)398-2231,ext. 1241 Health ''r�c HE� Division Fas(508)760-3472 � To: Yarmouth Business Establishments BL-�N41ES l cE C�P-� ' � n;,v � 0 20�4 From: Bruce G. Murphy, Director Yannouth Health Department� HEALTH DEPT. Date: November 7, 2014 Subject: Increase in License/Permit Fees Please be aware that the Yannouth Boazd of Health, under the direction of the Yannouth Boazd of Selectmen, has raised a number of license and pernut fees issued through the Yannouth Health Department, effective January 1, 2015. Attached is the Yarmouth Business License/Permit Applica6on 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 January 1, 2015. However, if you fully complete the application, and submit it to the Yarmouth Health Department with a11 required certifications and worker's compensation coverage information (certificate of insurance OR completed affidavit) nrior 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 WhirlpooUVapor Baths $ 80.00 Tobacco Sales $ 95.00 Motels $ 55.00 Food Service 0-100 Seats $ 85.00 $85.cp Food Service Over 100 Seats �160.00 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: $ !oo.ao ca.+r�oN V�c,� ��DKSEY-T Total fees owed for your establishment: �t g5.00 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. [7'hose establishments which open in the spring will be allowed to provide food andlor pool certifications prior to opening, however, you must note "Will provide in the spring prior to opening" on the application.J BGM/maf � F�t,oN�ic s - � TOWN OF YARMOUTH BOARD OF HEALTH �� APPLICATION FOR LICENSE/PERMIT -�(�,15 ��$ f•:.'� O PO14 �,��"y � � . * Please complete form and attach all necessary c�octttf'ie'�ts by cembe 15 7H DEPT. Failure to do so will result in the return of your application pac ESTABLISHMENTNAME: Cr1� EnTr2P2�sts I.�.c g 1.orro�64ScaC�t�r+fAXID• LOCATIONADDRESS: Q2� Qa�n zBBu��ou+et So.YnaMeo*+t, Maez�b�e TEL.#: SbB'-d?9- 3Gl� MAILINGADDRESS: 323 H�nrN�-r� �D SCRRS9a�E rl•Y. IosF3 E-MAILADDRESS: 7leaha� e veri on•'r�et • ,JrrCa�ial � m�ai�•Co� OWNERNAME: flMt��l A- C9HA�Y , oSr,PH � ANA�Y _ CORPORATION NAME (IF APPLICABLE): �K� �hn't�nR�sr� l.�-� MANAGER'SNAME: i�IR�iey R . C�AHe�Y osEre F �ny��r TEL.#: �`�'��" ��-f MAILINGADDRESS: 323 l�tA�F+�Tt (Z+� �SChRS7�Au= n�y ias�3 � y��r� 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, standazd 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 prov►de new copies and maintain a file at your place of business. 1. Z• 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: ��•M ei-�'S r D� All food service establishments aze 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. �ANey /� � �AHA�y 2 PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) site during hours of operation. 1. ��rLt't � ' CA t313 '-Y 2. ��SEPl4 � �/� {�f��—�f y�� ALLERGENCERTIFICATIONS:7� ��'�' �oviot �+Y �r SP2��16' '�42� ��• cranr�Gr�ons �+a� in 'r��rrc� CRra� SudP. All o�od service establishments aze 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. �AK��( A• IAHALy pStPH ��ANA�y 2. HEIMLICH CERTIFICATIONS: C L NC�os�-5�� 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-chokmg 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 �le at your place of b siness. � � c�. �ostY�H � L'1H��7 ��S�CZS �. Ar��tA ��Na�y �'-S A s 2. 3� 4. RESTAURANT SEATING: TOTAL # I.Z 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 $55 SWIMMING POOL$I l0ea. LODGE $55 _TRAILERPARK $105 _WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQIDRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �0-100SEATS $125 -t6rs-OS7 CONTINENTAL $35 NON-PROFIT $30 >100 SEATS $200 �COMMON VIC. $60 �ys _WHOLESALE $80 — —RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQIDRED FEE PERMIT 1t LICENSE REQUIRED FEE PERMIT# LICENSE REQU[RED FEE PERMIT# � <50 sq.ft. $50 >25,000 sq.ft. �Zgs =TOBAC O FOOD$$10 —Q5,000 sq.ft. $150 �FROZEN DESSERT $40 �T —�Z NAME CHANGE: $15 AMOUNT DUE _ $ Z25•Ob *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM•**** ��"f� �`�s�4 c4L#6go3 ti�is`�t� ti • ADMINISTRATION Undar Chapter t 52, Section 25C,Subsection 6,the Town of Xarmouth is now required to hold issuance or renewal aF any licanse ar percnit to aperata a business if a person or company daes not have a Certificate af Warker's Compensation Insurance. THE AT'l'ACHED S'CATE W012KER'S CCIMPENSATION INSUItANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR � CER1'. OF INSURANCB ATTACHBD OR � � WORKER'S CQ3YIP. AFFTDAVIT SIGNED AND ATTACHED 7'own of Yarmouth ta�ces and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK AFPItOPRIATELY IF PAID: YES �`� NO MOTELS AND tlTHER LQDGING ESTABLISHMENTS TRANSIF.NT OCCUPANCYt For pusposes ofthe limitations ofMotel or Hotel use,Transient occupancy shatl be limited to the temparary and shart term accupancy,azdinarily and customarily assacaated with motei and hatel use. Transient occupants must have and be able to demonstrate that they maintain a principal place of residence elsewhere.Transient occupancy shall generatly refer to continuous occupancy of not rnore than thirty(3d)days,and an aggregate af not more than ninety(44}days within any six(6}month perzad. Use of a guest unit as a residenoe or dwelling unit shall not be considered transient. Qccupancy that is subject to the collection of Roorn Occupancy Excise, as define$in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient. POQLS POOL OPENING:All swimming,wading and whirlpools wluch have been closed Far the season rnust be inspected by the Haalth Department prior to opening. Contact the Iiealth Department to schedule the inspection three(3) days prior to opening. PLEASE NOTE: People are NOT allowed to sit in the poal area until the pool has been inspected and opened. POOL WATER TESTING: 'The water must bc tested for pseudomonas,total coliforrn and standard plate count by a State certified lab, and snbmitted to tl�e Health DepartmenL thrce (3) days priar to a�rening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool musi be drained or covered within seven(7)days of closing. F'O011 SPR`'ICE SEASONAL FOOD SER'VICE OPENING: All faad service establislunents must be inspected by the FIealth Department prior to openiug. Please contact the Health Departrnent to schedute the ittspectian three (3) days prior to opening. CATERING POLICY: Anyone wha caters within the Town of Yarmouth must notify the Yannouth Health Department by filing the requared Temporary Faod Service Ap�llcation fornx 72 hours prior to the catered event. These forxns can be obtained at the Health Department,or from the Tocvn's cvebsite at www.yarmauth.ma.us under Health Department, Downloadable Forms. FROZEN DESSERTS: Frozen desserts must be tested by a State certified lab prior to apening and monthly thereafter,with sample results submitted to the Health Department. Failure to do so will result in the suspension or revocatian of your Frozen Dessert Fermit until the abave terms have been rnet. OUTSIDE CAFFS: Outside cafes{i.e.,outdoar seating with waitertwaitress service),must have prior approvai from the Board of Health. 4UT`DQOR C0t3KING: Outdaor cooking,preparation,ar display of any food product by a retail or food service estabfishment is prohibited. NQTICE:Permits run annuaily from 3anuary 1 to December 31. IT IS YOUR RESPONSIBILITY'1"O ItETURN "I`HE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 15, 2014. ALL RENOVATIONS TO AT�TY FOOD �STABLISI-�MENT, M4TEL OR POOL {i.e., PAINTING, NEW EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR Td COMMENCEMElVT. RENOVATIONS M REQTJIRE A SITE PLAN. �(� �.�11L,: Ii l �r'�i 1 ��,p /_ SIGN:ATURE: �,q' °"ts` � PRiNT NAME&TIT"LE: j�AHCY J�• p H Ac�' � � o s r e rf �' (�,�9 H A cY b w/YE�Y�s) Rev. 11/03/14 . ' � The Commonwealth ofMassachusetts Department of Industrial Accidents Offzce of Investigations ' I Congress Street, Suite Z00 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insuraace Affidavit: General Businesses A licant Information Please Print Le 'bl Business/OrganizationName: eNa ��Tt^lt�/LtSt'3 �--1-e D 8� �jLon�iik�s Tcr C2rAM Address: "1 zg" �ouT� iZ� 6ui��rrf(� � City/State/Zip: �. /A�oort� �� d2�6� Phone#: S 0�-6/9 - 3�Io Are you an employer? Check the appropriate box: Business Type(required): 1.�I�m-�e�oyer with fa " � employees(full and/ 5. ❑ R�etail �r part-rime�.* 6. [r�'1�estaurantlBazBating 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 o�cers 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.Q Health Caze with no employees. [No workers' comp. insurance req.] 12.❑ Other •Any applicant that checks box#I must also fill out the sec[ion below showing their workers'compensation policy information. "If the cotporate officers have exempted themselves,but the coiporalion has other employees,a workers'compensation policy is=equired aud such an organi�ation should check box#L � I am an employer that is providing workers'compensation insurance r my emp[oyees. Bej�ow is the policy information. InsuranceCompanyName: ( R�v�=�tRg ^('�E'��'rY �/�1PArly pF /"TMt2tcA Insurer's Address: e� I�OGeR * ITRAY 1�Su2��C� �GE'DfC City/State/Zip: OU� I 3 4- So�,H � r-�r�c s �A p 2� � a Policy#or Self-ins. Lic. # l9 �'� U g — S� � 0�0�-- (� ^f� Expiration Date: �� 'Z' /S Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure covgcage as re�uire�under Section 25A9f MGL c.l��-canlsad tQ the imposition of�rim;nal 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do here ertify,u�,de e pains an enalties of per'ury that the information provided above is true and correct. � Si ature: � Q Date: l� �S ��' Phone#: E�-L -1��'��" �� ostY'It� q��{'�S"b� �R�.��/�F1/feY) Official use only. Do not write in this area,ta be completed by city or town officiaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2. Bui►ding Department 3. City/Town Clerk 4.Licensing Board 5. Selectmen's Office 6.Other Contact Person: Phone#: www.mass.gov/dia �` TRAVELERS� WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY TYPE AR INFORMATION PAGE WC 00 00 01 ( A) POLICY NUMBER: (6HU6-5690104-0-14) RENEWAL OF (6FR16-5690104-0-73) INSURER: THE TRAVELERS INDEMNITV COMPANY OF AMERICA NCCI CO CODE: 13439 1. INSURED: PRODUCER: CNJ ENTERPRISES LLC ROGERS & fRAY IN$ AGENCY 323 HEATHCOTE ROAD ROUTE 134 SCARSDALE NY 10583 SOUTH DENNIS MA 02660 Insured is A LIMITED LIABILITY COM�ANY Other work places and ident'rfication numbers are shown in the schedule(s) attached. 2. The policy perlod ts from Oa-02-�a to 04-02-15 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) Ilsted here: MA � � B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work fn each state ilsted in = item 3.A. The IImRs of our IiabHity under Part Two are: �� ,= Bodily Injury by Accident: S 500000 Each Accldent � Bodi�y In�ury by Disease: S 500000 policy l(mrt � Bodily InJury by Disease: S 500000 Each Employee m= C. OTHER STATES INSURANCE: Part Three of the policy applfes to the states, if any, listed here: � COVERA�E REPLACED BY ENDORSEMENT WC 20 03 06A e� � D. This pollcy includes these endorsements and schedules: �� o� SEE LISTING OF ENDORSEN�NTS - EXTENSION OF INFO PA6E os - 4. The premfum for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating � Plans. All required information is sub�ect to verificatlon and change by audk to be made ANNUALLv. DATE OFISSUE: 02-27-14 WC ST ASSIGN: MA OFFICE: ORLANDO INDUS AFF 161 PRODUCER: ROGERS & GRAY INS AGENCY 237XR 002617 r. � � TRAVELERS,�, WORKERS COMPENSATION �,� AND � EMPLOYERS IIABILITY POUCY '�� % TYPE AR INFORMATION PAGE WC 00 00 01 ( A) POLICYNUMBER: (6F�16-5B9o1o4-0-14) CLASSIFICATION SCHEDULE: PREMIUM BASIS ESTIMATED RATES ESTIMATED TOTA�ANNUAL PER 5700 OF qNNUAL CIASSIFICATIONS CODE NO REMUNERATION REMUNERATION pREMiUM SEE EXTENSION OP INFORMATION PA(�E - SCHEDULE(5) SIC-CODE: 5812 NAICS: 722511 ------------------------------------------------------------------------------------ STAt�ARD TOTAL ESTIMATED At�IUAL STAI�IDARD PREMIUM $ 211 PREMIUM DISCOUNT NONE 0900-20 EXPENSE CONSTANT 250 TERRORISM 5 TOTAL ESTIMATEO PREMIUM 486 TAXES At� SURCHARGES 5 DEPOSIT AMOUNT DUE 491Np A/R- (WCIP) # Minimum Premium: S 276 EMPLOVERS LIABILITY MINIMUM: $50 ST ASSIGN: MA DATE OF ISSUE: 02-27-14 wC OFFICE: ORLANDO INDUS AFF 161 PRODUCER: RO(�ERS & (�AY INS AGENCY 237XR . . � ,A. TRAVELERS J WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY k;' EXTENSION OF INFO PAGE-SCHEDULE WC 00 00 01 ( A) POLICY NUMBER: (6t�u6-5690104-0-t a) INSURER: THE TRAVELERS INDEMNITY COMPANY OF Al�RICA 13439-MA INSURED'S NAME : CNJ ENTERPRISES LLC RATE BUREAU ID: 000974767 PREMIUM BASIS ESTIMATED RATES ESTIMATED TOTAL AtdNUAL PER $100 OF ANNUAL CLASSIFICATION CODE REMUNERATION REMUt�RATION PREMIUM LOCATION 007 01 FEIN ENTITY CD 001 CNJ ENTERPRISES LLC 928 ROUTE 28 S YARI�UTH, MA 02664 SIC CODE : 5812 NAICS: 722511 RESTAURANT I�OC. 9079 15000 1 .07 161 .s LOCATION 001 O1 (CONT'D) � �_ � FEIN ENTITY CD 001 � CNJ ENTERPRISES LLC �� a 928 ROUTE 28 o� = S VARMOUTH, MA 02664 '� SIC CODE : 5812 NAICS: 722511 e� e� �� m= �Q � o� oC � m= � DATE OF ISSUE: 02-2�-1 a wc Sr aSsiGN: rea SCHEDUIE NO: t OF MORE oozs,a