HomeMy WebLinkAboutApplication and WC Y
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�� -�` _ �`�o TOWN OF YARMOUTH Ha�f
� —,... �- }"3 1146 ROUTE 28, SOUTH YARMOUTH,MASSACHLISETTS 02664-24451 -
� `,���CNE�'6% � Telephone(508)398-2231, ext. 1241 D v si n
Fas(508) 760-3472
To: YazmouthBusinessEstablishments -rnkis P�zzA
� N�� 'Z-� [U14
From: Bruce G. Murphy, Director HEALTH DEPT.
Yarmouth Health Depaztment�
Date: November 7, 2014
Subject: Increase in License/Permit Fees
Please be awaze that the Yazmouth Board of Health, under the direction of the Yazmouth Board
of Selectmen, has raised a number of license and permit fees issued through the Yannouth
Health Department, effective January 1, 2015.
Attached is the Yazmouth 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 January 1, 2015.
However, if you fully complete the application, and submit it to the Yannouth Health
Department with all required certifications and worker's compensation coverage information
(certificate of insurance OR completed �davit) 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 Sa1es $ 95.00
Motels $ 55.00
Food Service 0-100 Seats $ 85.00 SS.00
Food Service-Over 100 Seats $�(�0-,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: $ �p.po con.MON v�c
Total fees owed for your establishment: .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 springprior to opening" on the application.J
BGNVmaf
_ -rnt�ts--
� TOWN OF YARMOUTH BOARD OF HEALTH
��� APPLICATION FOR LICENSE/PERNIIT -20�b,`��' � n�'V � (U 14
�"°' * Please com plete form and attach all necess a r y'docut�en y De� m er IS 2019.
Failure to do so will result in the return of your applicahon pac et. HEALTH DEPT.
ESTABLISI-IMENT NAME: i�K i S La i Z219 TAX ID: �
LOCATION ADDRESS: vrtt�7 A')!9 LCl9 S� W �f•�i2rhdu��. �h�7�TEL#�uY- �7�-3 33�
MAILING ADDRESS: ti ' � '
E-MAILADDRESS: � �y�,u/�i ir`pc�.fC� bj pTMCt�
OWNERNAME: �TPi�f' 1� Ve4✓Pr� t9oC
CORPORATION NAME (IF APPLICABLE):
MANAGER'S NAME: 1�P�}P�' EJ� LV l t�7 VCl✓� L MT1( TEL#• 5-D�� 7��3� /
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.
-- - -- -
L - - - _ _ 2•
Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid
and Community Cazdiopulmonary 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.
1. �7�VY �� U s�lY�"1 i—c l�-r _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 establishxnents 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° � , UCl✓��I��-( f3f 2. t. V�� V�✓�'1 1�(�
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 Department will not use past years' records.
You must provide new copies and maintain a file at your place of business.
1. �P i f' ��v���"� E-t n S 2. l,'✓b � vygv��i 1-[l9-S
3. Q�� �« � GL✓P � lt�tl�s 4.
RESTAURANT SEATING: TOTAL# 2 �
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
B&B $55 CABIN $55 MOTEL $1l0
—INN $55 CAMP $55 SWIMMING POOL$I l0ea
LODGE $55 TRAILERPARK $105 _WHIRLPOOL $IlOea
FOOD SERVICE:
LICENSE REQUIRED FEE P RMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
�0-100SEATS $]25 / . CONT[NENTAL $35 NON-PROFIT $30
>100 SEATS $200 LCOMMON VIC. $60 �L�6p-1 _WHOLESALE $80
— —AESID.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 $I10
NAME CHANGE: $15 AMOUNT DUE _ $ ISS�OO
•****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*"*** ��-'u �bT �
��-!�t3 ii/zl 1 r�
ADMINISTRA,TIpN
Under Chapter 152,Sectian 25C,Subsection 6,the Town of Yarmouth is now required Yo hold issuance or renewal
nf any license or permit to operate a business if a persan or company daes not have a Certifrcate of Worker's
Compensatian Insurance. THE ATTACHED STATE W412KER'S CCtMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR
C�RT. OF INSURANCE ATTACHED
OR �
WORKER'S COMP. APFIDAVIT SIGNED AND A'CTACHED
Town of Yannouth taz;es and liens rnust be paid prior to renewal or issuance of your permits. PLEASE CHLCK
APPROPRIATELY IF PAID: � >
YES V I�IO
MOTELS ANA OTHER LODGING ESTABLIS$MENTS
TRANSYEN'T OCCUPANCX: For purposes of the limitations of Motel ar Hotei use,Transient occupancy shall be
limited to the temporary and short term occupancy,ordinarily and austornarily associated with motel and hotel use.
Transient occupants must have and ba able to demanstrate 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 af not mote than ninety(90)days within any rtix(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 ar 834 CMR 64G,as amended, shall generally be considered Transient.
PdOL5
POOL QPENING:All swimmzng,wading and whirlpools tuhich have been closed forthe seasan must be insgected
by the Health Departrnent prior to opening. Coutact the Health Department to schedule the inspection three(3)
days priar to opening. PLEASE NdTE: People are NOT allowed to sit in the pool area until the poal has been
inspected and opened.
POOL WATER TESTING: The water must be tesled for pseudomonas,total colifonn and standard plate count
by a State certified lab, and submitted to the Health Department three (3) days pxior to opening, and quarterly
thereafter.
POOL CLOSING:Every autdaar in ground swimming paol must be drained or covered within seven(7)days of
closing.
F40D SF',RVICE
SEASONAL FOOD SERVICE QPENING:
.�,.II food service establishments must be inspected by the Health Department prior to opening. Fiease contact the
I'Iealth Departrnent to schedule the inspectian three(3}days prior to opening.
CAT�RIIYG POLICY:
Anyone who caters within the Town of Yarmouth rnust notify the Yarmouth Health Department by filing the
requzred Temporary Food Servace Appticatian form 72 haurs prior to the catered event. These forms can be
obtained at the Health Deparlment,ar from the Town's website at www.yarmouth.ma.us under Health Depar6ment,
Do�vnlaadable Forms.
FROZEN DESSERTS:
Frozen desserts must be tested by a State certified lab prior to opening and rnonthly therea8er,with sample results
submitted to the Health Departsnent. Failure to do so will result in the suspension or revocation of your Frozen
Dessert Permit until the above terms have been met.
OUTSIDE CAFES:
Qutside cafes(i.e.,outdoor seating with waiter/waitress service),must have prioz approval frorn the Boazd of Health.
OUTDOOR COOHING:
Outdoor cooking,preparatian,or display of any food product by a retail pr food service establishment is prohibited.
NOTICE: Permits run annually from January 1 ta December 3 L IT IS XOLTR ItESPONSIBILITY Td RETURN
THE C4MPLETF,D RENEWAL APPLICATION(S}AND REQUIRED FEE(8}BY DECEMBER 1S,2014.
ALL RENOVAfiIONS TO ANY FOOD ESTf1BLISHMENT, MOTEL OR POdl (i.e., PAINTING, NEW
BQUIPMENT,ETC.}, MUST BE REFORTED TO AND APPROVED BY THE Bt1ARD OF HEALTH PRIOR
TO COMMENCETvIENT. RENOVATTONS MAY REQUIRE A SITE PLAN.
DATE: � � '" �C� = �`� SIGNATURE� �,�,,� � ���,���c.._.,
PRINT lYAME& TITLE:. S��UP� �Ltf��7 ti-i(.�l �Gt�.C.��DZ
Rev. 11f03t(4
' ' � The Commonwealth ofMassachusetts
Department of Indu.rtrial Accidents
Office of Investigations
I Congress Street, Suite I00
Boston, MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Annlicant Information Please Print Le�iblv
Business/Organization Name: �"�K I S 'f 622►�
Address: �i 4,7 UVI ►91 41 ��'
City/State/Zip: , �9►'!1'YIOc99"t] fYl � � 7 Phone#: �'O�'-T11- 3�?j�
Are you an employer? Check the appropriate box: Business Type(required):
1.❑ I am a employer with 2 employees(full and/ 5. ❑ Retail
_ or art-time).* 6. �estauranUBaz/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 capaciry.
[No workers' comp.insurance required] 8• ❑ Non-profit
3.❑ We are a corporarion and its officers have exercised 9. ❑ Entertainment
their right of exemprion per c. 152, §1(4),and we have 10.❑ Manufacturing
no employees. [No workers' comp. insurance required]' I 1.❑ Health Caze
4.❑ We aze a non-profit organization, stafFed by volunteers,
with no employees. [No workers' comp. insurance req.] 12.� Other
'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy iafotmation.
'•If the coiporate office�s have exempted themselves,but the corporation has other employees,a workers'compensation policy is required md such mm
organization should check box#I.
I am an employer thaf is providing workers'compensation insurance for my employees. Be[aw is the policy information.
Insurance Company Name: Z f GL-1' Y� 1 GA N ,
Insurer's Address: • (� , � �a � ��7
city/state/zip: ' �n 21��9 t11 ►J e? , �L� 3 2 g D 2�- ���-(�
Policy#or Self-ins. Lic. # , Exp'uation Date:
Attach a copy of the workers' compensation policy declaration page(showing the policy nnmber and expiration date).
Failwe 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-year imprisonment,as well as civil penal6es 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 cert�,under the pains and penalties ofperjury that the information provided above is true and correct
Signature: �i� �� //eo� Date: /L— Zi�-1 �
Phone#:
Official use only. Do not write in this area,to be completed by city or town ojficiaL
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2. Buildiug Department 3. City/Town Clerk 4.Liceasing Board 5. Selectmen's Office
6.Other
Contact Person: Phone#:
www.mass.gov/dia
VDAG
� THIS IS A QUqTE , NOT A POLICY —
ZURtCH W4RKERS C{SMPENSATIOW
AND
EMPLOYERS LIABiLITY POUCY —'
QUpTE PROFIIE – VERSION Oi
POLICY NUMBER: (6Z2U6-0762N00-8-141
RENEWAL OF (6ZZU8-0'762N00-8-13)
INSUREp'S NAME AND ApDAESS
WORKERS COMPENSATION
VARE7IMOS, STEVE pBA INSURANCE PLAN
TAKIS PIZZA A/R (WCIP) # MA �
547 MAIN STREET ROUTE 28
WE5T YARMOUTH MA 02673
POL�CY PERIdD FRQM: 05-22-t 4 TO 05-22-15
TOTAL ESTIMATED AMJUAL STAI�ARp PREMIUM $ 654
PREMIUM QISCOUNT t�t�
0800-20 EXPENSE CONSTANT � 250
TERR�RISM 10
TOTAL ESTIMATED PREMIUM 914
TAXES Ai� SI�CHARG�ES 22
DEPOSIT AMOUNT DUE 936
Employer's Liabifity BI Limit: S 100000 Each Accident
540op0 ppiicy Limit
140000 Each Employee
INSURER: AMERICAN ZURICH INSURANCE COMIPANY
Adjustments of Premiums shait be made A�A1ltAL�Y
w:,ex+te�x�xa+nk*rwx*xx*ir*�*�tewfr*,r Deposit Amount Due: � 836 rxwx<xxw+�rr�r:re*:��*:�s,e�,r+*,e
POLICY NUMBER: (�ZZUB-0762N00-8-14)
DATE OF ISSUE:o4-t t-t 4 Mc SF ASSIGN: �a
OFFIGE: ZURICH-ORLAN 809
PRQDUCER: CHAGNORI INS A6ENGY INC ?3Gt�2