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Home My WebLink AboutApplication and WC �--.__ ��°��'�c TOWN OF YARMOUTH Boazdof Health � � � � `3 1146 ROUTE 28, SOUTH YARMOUTH, MASSACHLJSETTS 02664-24451 - H �''r^c Xf�s�' � Telephone(508)398-2231, ext. 1241 Div si n Fa�c(508) 760-3472 To: Yannouth Business Establishments I4-ratLy o N From: Bruce G. Mtuphy, Director � ��v �_ 0 ZUl4 Yarmouth Health Department� HEALTH DEPT. Date: November 7, 2014 Subject: Increase in License/Permit Fees Please be aware that the Yarmouth Boazd of Health, under the direction of the Yarmouth Boazd of Selectmen, has raised a number of license and permit fees issued through the Yarmouth Health Deparhnent, effective January 1, 2015. Attached is the Yannouth Business License/Permit ApplicaUon 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 Yatmouttt Health Department with all required certifications and worker's compensation coverage information (certificate of insurance OR completed �davit) ariar 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 ��O.00 Public WhirlpooUVapor Baths $ 80.00 Tobacco Sales $ 95.00 Motels $ 55.00 Food Service 0-100 Seats $ 85.00 Food 3ervice 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: Total fees owed for your establishment $�p,b0 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 andlor pool certifications prior to opening, however, you must note "Will provide in the springprior to opening" on the application.J BGM/maf ,_ . — H�A�C�{ON . � TOWN OF YARMOUTH BOARD OF HEAL'FH � � APPLICATION FOR LICENSE/PERMI'F+,2��(�j� tt:;V __ O P014 `'" * Please complete form and attach all necessary docwYieni y ecemb r 1 Failure to do so will result in the return of your applicahon pac � DEPT. ESTABLISHMENT NAME: b ' TAX ID: LOCATION ADDRESS: � � TEL.#: �`t2 - � � MAILING ADDRESS: 0� E-MAIL ADDRESS: �ral�nsl o�F�. ��QSS�7 p 1�l.� � OWNER NAIvIE: CORPORATION NAME1F APPLICABLE): MANAGER'S NAME: vol-i 1. `M` '(aJ 0�/ TEL.#: _ MAILING ADDRESS: 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. �C�,'ia�>5 1 O�, \ c� O l 5 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 provide new copies and maintain a file at your place of business. i.�» > �fY1�C�� v 2.VJ �l m ic�p�lc� 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. 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Chazge (PIC) on site during hours of operation. 1. 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. L 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-chokmg procedures below and attach copies of employee certifications to this form. The Health Deparhnent 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 $t10 INN $55 CAMP $55 �SWIMMINGPOOL$110ea�j� LODGE $55 _1'RAILER PARK $105 _WH[RLPOOL $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 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,OOOsq.ft. $150 —FROZENDESSERT $40 _TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE _ $ 1'l�.00 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** �c(� � � O. OO �� 15��,� �i 'i9 ��`� ADMINISTRATIt}N Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmauth is now required to hold issuance or rencwal of any license or permit to operate a business if a person ar company daes not have a Certificate of Worker's Compensation Insurat�ce. THE ATTACHED STATE WORKER'S CQMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR C�RT. QF iNSURt�NCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AN17 A'I"TACHED 7'own of Yannouth taxes and lians must be paid prior to renewal or issuance ofyour permits. PLEASE CHECK �PPROPRIATELY IF PAID: � J YES Y NC} __ MOTFLS AND OTHER LODGING ES'TABLISHMENTS TRANSIENT OCCUPAI�CY: For putposes ofthe limitations ofMotel or Hotel use,Transient occupancy shall be lamited to the temporary and short term occupancy,ordinarily and customariIy associated with motel and hotel use. Transient occupants must have and be able to demonstrate fhat they maintain a principal place of residence elsewhere.Transicnt occupancy shall generally refer ta continuous accupancy of not more than thiriy(30)days,and an aggregate of not more than ninety(90)days within any six(6)montt�period. Use of a�uest unit as a residence or dwelling unit shall not be considered transient. 4ecupancy that is subject to the coliection of Raom dcoupancy Excise,as defined in M.G,T.. c. 64G or 830 CMR 64G,as amended, shall generally be considered Transient. POOLS POOL QPEIYIPIG:AIl swimming,wading and whir]pools which have been ciosed for the seasan must be iraspected by the Health Department prior to opening. Contact the F�ealth Departrneiat to schedule the inspectipn tbree(3) days priae ta opening. PLEASE NOTE: PeogIe are NOT allowed to sit in the pool area unril the poo] has been inspected and opened. POOL WATER TESTING: The water must be tested!or pseudomonas,total coliform and standard plate count by a State certified lab, and snbmitted to the Health Department three (3} days prior to opening, and quarterly thereafter. POpL CLQSING: Every outdoor in ground swimming paol must be drained ar covered within saven{7}days of closing. --______�._-----_..______._.._.___ - _ ____--�t30�SF,RVIG� - ,__ SEASONAL FOOD SERVICE OPENING: All food service establishments must be inspected by the Health Department prior ta opening. Alease contact the Health DepazCrnent to schedule the inspectian three{3)days prior to apening. CATERTNG P4LICY. Anyone who caters within the Town of Yaamouth rnust notify the Yannouth Health Department by filing the required Tempo Faad Service Applicatian form 72 hours prior to tha catered event. These forms can be obtained at the H�th Departrnent,or from the Town's website at www.yarmouth.ma.us under Health Department, Do�mloadahle Fotms. FROZEN DESSEI2TS: Frozen desserGs must be tested by a State certified lab prior to opening and�rnonthly hereafter,with sample results submitted to the Health Departrnent. Failure to do sa wilI result in the suspension or revocation of your Frazen Desscrt Pezmit until the above terms haue been met. C}UTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval frorn the Board of Health. OUTDOOR COOHING: Outdaor eooking,prepazation,oc dispIay of any faod product by a retaii or food service establishment is prahibited. NOTICE;Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE C{7�PLETED RENEWAL APPLICATION(S}ANI3 REQI7IRF.I}FEE(S}BY DECEMBER 15, 2014. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR PQOL (i.e., PAINTING, NEW EQUIPMENT, ETC.}j MUST BE REPC}RTED"1'O AND APPROVET}BY THE B(?AItD OF HEALTH PRTOB TO COMMENCEMENT. RENOVATIONS MAY REQU E A SITE PLAN. � DATB: � SIGNATURE: PRINT NAMB &TITLE: � �, Rev. llf431t4 � � � The Commonwea[th ofMassachusetts Department of Industrial Accidents O�ce oflnvestigations I Congress Street, Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legiblv �1' Business/Organization Name: Address: 3 O D � �l� City/State/Zip: 0 lo Phone#: ��—`Z'�]��`.�� Are you an employer? Check the appropriate bos: Business Type(required): 1.� I am a employer with —� employees (full and/ 5. ❑ Retail ___ or part-time�*_ _ ___ _ . 6. f] RestauranUBaz/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 exemprion per c. 152, §I(4), and we have 10.� Manufacturing no employees. [No workers' comp. insurance required]* 4.❑ We are a non-profit organization, staffed by volunteers, I 1.0 Health Caze , with no employees. (No workers' comp. insurance req.] 12.�Other �'.p t�'Dt1�cY� 11�'l��)m *Any applicant that checks box#I must also fill ou[the section below showing the'u workers'compensation policy informatioa. "•If the corporate officers have exempted themselves,but the corporation has other employees,a workeis'compensation policy is required and such an organization should check box#1. I am an employer that isproviding wnrkers'compensation insurance for my employees. Below is thepolicy information. Insurance Company Name: � C' �_��jl C 1'1T� �� w - • � - / � Insurer's Address: �'�3< l� f^11,71�OVCo N R�_ .,, �.��'�� ' City/State/Zip: F1�6a{L�A 9 �_�� 'LO� 1 Policy# or Self-ins.Lic.# �9� �9�v�-"f�� l 1 � �-�� Expiration Date: '�� T' �.�� Attach a copy of the workers' compensation policy declaration page(showing the policy uumber and eapirarion date). Failure te secure ceverage as required under Section 25A of MGL a 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 verification. I do hereby eeRify,u der thepains andpenalries of rjurpthat the information provided above is true and eorrect. Si ature: Date: � Phone#•��, I� �"" �� Official use only. Do not write in this area,to be comp[eted by city or town officiaL City or Town: Permit/License# Lssuing 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 � • VDAC 0. ' acegroup WORKERS COMPENSATION ANU EMPLOYERS LIABILITY POLICY TYPE AR INFORMATION PAGE WC 00 00 01 � A) POIICY NUMBER: (6S62U6-4477P70-6-14) RENEWAI OF (6S62U8-4477P70-6-13) INSURER: ACE AMERICAN INSURANCE COMPANV NCCI CO CODE: 12165 1. INSURED: PRODUCER: ` HORSE POND CORP DBA HALCVON - MILLER MCCRRTIN INC CODDOMINIUMS 973 IYANNDUGH ROAD, 2PD FL 300 Bl1CK ISLArD RD PO BOX 1990 WEST YARMOUTH MA 02673-2590 HYANN2S MA 02601 InsU�9d is A CORPQ2ATION Other work placea and identlfication numbers are ahown in the schedule(s) ettached. 2. The policy perlod Is from 02-14-14 ta 02-14-15 12:01 A.M. et the Insured's mafling address. 3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applles[o the Workere Compensation Law of the state(s) Ilsted here: MA � = B. EMPLOYERS LIABILITY INSURANCE: Pert Two of the pollcy applles to work In each state I{sted in — ttem 3.A. The Iimks of our Ilabilky under Part Two ere: � = BodNy In�ury byACCident: S , 1000000 EaCh ACCIdeM � Bodlly Injury by Dieease: S �00000o policy Limit c Bodtly In�ury by Dlsease: 3 1000000 Each Employee a= ,= C. OTHER STATES INSURANC6: Part Three of the policy applles to the states, If any, Ilsted here: += COVERAGE REPLACED BY ENDORSEA£NT WC 20 03 06A � ._ � � .� � D. This pollcy includes these endorsemeMs end schedulea: �— = SEE LISTING OF ErDORSEMENTS - EXTENSION OF INFO PAGE o� � o� — a. The premium for this policy will be determined by our Manuals of Rules, Classificatlons, Rates and Rating � Plans. All requlred Informatbn Is subJ�ct to verHfcatlon and change by audk to be made ANduALLv. DATE OF ISSUE: 02-27-14 WC ST ASSIGN: MA OFFICE: ORLANDO DA ACE 24M PRODUCER: MILLER MCCARTIN INC 73M2Y o»oae