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Home My WebLink AboutApplication and WC ��°F=��'�a TOWN OF . YARMOUTH Boazdof Health � —... �`j 1146 ROUTE 28, SOUTH YARMOUTH,MASSACH[JSETTS 02664-24451 - � `, ,�':'r Telephone(508)398-2231, ext. 1241 Health ',�c MEc Division Fas(508) 760-3472 To: Yazmouth Business Establishments So��. y�a,�.�o�-�c+ D��Rv Qu�N From: Bruce G. Murphy, Director � � Yarmouth Health Departrnent� �CV 'L ' 2U14 Date: November 7, 2014 HEALTH DEPT. Subject: Increase in License/Permit Fees Please be awaze that the Yarmouth Boazd of Health, under the direction of the Yarmouth 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 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 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 inswance 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 W1�irlpooUVapor Baths $ 80.00 Tobacco Sales $ 95.00 Motels $ 55.00 Food Service 0-100 Seats $ 85.00 SS•O Food Service Over 100 Seats — $1E0.00 — 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: Ioo.Oo �a�-MoN ��c:� �oz� xss� Tota1 fees owed for your establishment: 85. 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 and/or pool certifications prior to opening, however, you must note "Will provide in the springprior to opening" on the application.J BGM/maf , . - s.y�n�P- -- d TOWN OF YARMOUTH BOARD OF HEALTH �� APPLICATION FOR LICENSE/PERIVITT -2 1 �:�V � " Z014 �. �� . * Please complete form and attach a11 necessary doc w�hent bq Decemb r IS 2014. Failure to do so will result in the return of your application pac t. HEALTH DEPL ESTABLISHMENTNAME: Scv+to yarmoH�►�h Da�'r.� QNrer� TAX ID: � LOCATION ADDRESS: 9 rl R�}P• 028 TEL.#: Sof!-39 y-9 S 3 s MAILINGADDRESS: q�� Rf[. �28 - S�.ya�mvw��mA o:�t�6�F E-MAILADDRESS: olanccl ho�ma�►� Com OWNERNAME: T�c( Imt�avv�loS _ CORPORATION NAME (IF APPLICABLE): 1JARFl f7Jac�S� ��C- MANAGER'SNAME: l��n Chns�ri au.los TEL.#: $GO-Sos-�n3� �Lr[vGaDD�ss: 53r+ a�k,��s A/ecl� 2d. -Sa. ycc/'m � rn� vaGd '� 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 cturently 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 p►ace of business. ! I_ 2. , 3 4. �OOD 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 applica6on. The Health Department will not use past years'records. You must provide new copies and maintain a file at your establishment. i, l�an�e ► Chns�o�ku�n.r 2. LsQ Y—obrs PERSON IN CHARGE: Each food establishment must have at least one Person In Chazge (PIC) on site during hours of operation. l. 'J(L►1�C � '1�11'f.5�% u�iJ 2: �� '�il �MCS 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 Deparhnent will not use past years' records. You must provide new copies and maintain a file at your establishment. , �. Dan�e I Chr�s�aveulo-S 2. '7"�% V/MRCp�OK/� 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. 2• 3. 4• - - �ESTAURANT SEATING: TOTAL# o�� 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 _SWIMMINGPOOL$110ea LODGE $55 _TRAILER PARK $105 _WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �0-100SEATS $125 ��0(n� CONTINENTAL $35 NON-PROFIT $30 >100 SEATS $200 I COMMON VIC. $60 �T,��–Q_�,l�j _WHOLESALE $80 — —RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQIDRED 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 l FROZEN DESSERT $40 �43 _TOBACCO $110 NAMECHANGE: $IS AMOUNTDUE _ $ �-ZS. 00 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM•**** 1 P(�� D �/S �� y` �e �� ll 2c�`� �,i� � oQ��/ �' ADMINISTRATION Under Chapter 152,Section 25C,Subsection 6,the Town of Yannauth is now required to hold issuance or renewal af any license or permit ta operate a business if a person or cornpany does not I�ave a Certificate of Worker's Conpensation Insurance. THE ATTACHED S'TATE W012KI:R'S COM]'ENSATION Ii�TSURANCE AFFIDAVIT MiJST BE COMPLETED AND SIGNED, OR CERT. OF INSURAN{',E ATTACHED t� OR WORKER'S COMP. AFFI�AVIT SIGNED AND ATTACHED Torvn of Yarrnouth taaces and liens must be paid prior to renewal or issuance of your pertnits. PLEASE CHECK APPROPRIATEI.Y IF PAID: �s �va _ MOTELS ANA OTHER LODGING ESTA.BLISHMENTS 'TRANSIENT OCCUPANCY: For purposes of the limitations ofMotel or Hotel use,Transient occupancp sha11 be limited ta the temporary and short term occupancy,ordinarily and customarily associated with motel and hotel use. Transient occupants must have and be ahle to demonstrate that they maintain a principal place of residence elsewhere.Transient occupancy shall generally refer ta continuous occupancy o£not more than tttirty(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. C}ecupancy that is subject to ihe collecrion of IZoom Qoeupancy � e Excise,as defined in M.G.L. c. 64G or 830 CMR 64G, as amended,shall generally be considered Transient. POOLS POC1L OPEI\TING:All swimming,wading and whirlpaols which have been closed far the saason must be inspected by the Health Department prior to opening. ConYact the Health Departrnei�t to schedule the inspecttion three(3) days prior to opening. PLEASE NOTE: Peop2e are NOT ailowed to sit in the pool area unti2 the pool has lseen inspected and opened. POOL WATER TESTING: The water must be tested for pseudamonas,total coliforrn ancl standard plate count by a State certifiad lab, and submitted to the Health Departtnent three (3) days prior to opening, and quarterly therea$er. POOL CL4SING: Every outdaor in ground swimming pooi must be drained ar covered within seven{7}days of closing. FOOD SERVICE SEASONAL FOOD SERVICE OPENIN(>: All food service establishments must be znspected by the F�ealth Department prior Eo opening. Please contact the Iiealfh Department to schedule tha inspection three(3)days prior to opening. CA1"ERING POLICY: Anyone who caters within the Town of Yarmouth rnust notify the Yarmouth Health Department by filing the required Temparary Food Service Applicatioa form 72 haurs prior ta the catered event. These forms can be abtained at tha Health Department,or frorn the Town's website at www.�umouth.ma.us under Health Department, Dawnloadable Farms. FT20ZEN DESSERTS: Frozen desserts must be tested by a State certified lab priar to opening and rnonthly thereafter,with sarnple resulYs submitted to the I3ealth Department. Failure to do so will result rn tlae suspension or revocation of your Frozen Dessert Permit uritil the above terms have been met. C►UTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress servica),must have prior approval from the Board of Health. OUTDOCIR COOHING: Dtatdoor eooking,-}�re�acaiion,�r�isplay of anu_f�od pcoducf hy a retail or faod service establishmentis pruhibited. NOTICE: Permits run annually froar January 1 to December 3). IT IS YOUR RESPONSIBILITY TO RETURN TF-IE C4NIPLETEA RE�iEWAL APPLICATION(S}AND RGQUIREI}FEE{S}BY DECEM�ER 15, 2Q14. ALL RENOVATIONS TO ANY FOt7D F�STABLISHMENT, MOTEL OR PQOL (i.e., PAINTING, NBW BQIIIPMFNT,ETC.}, MUST BE REPQRTED Td AND AFPRdVED BY THB BOARD OP HEALTH PRIOR TO COMMENCEMENT. RENOVATTONS MAY REQU�SITE PLAN. r�ATr: �;�f�y s1�NaTur,�: PRiNT NAME& TITLE: �"'.t t?te l (��?t�S��b¢�s - �n4n¢�yr�Pa��n.e�- Rx.w. i1f03fl4 WORKII2S COMPENSATION AND II�LOYERS LIABILITY INSURANCE CERTIFICATE ZNFORMATION PAGE RENEWAL AGREE�ffi�'P Producer: Agent# 9999 MA Retail Merchants WC Group Inc. Cove Risk Services, LLC PO Box 859222-9222 PO Box 859222-9222 Braintree, MA 01255 Braintree, MA 02185 (Carrier Code: 34355) Certificate #: 014005030237114 Prior Certificate �: 014005030237113 1. The Employer: South Yarmouth Dairy Queen Dara Foods, Inc. Mailing Address: 917 Main Street Rte 28 South Yarmouth. MA 02664 Fein: Other workplaces not shovm above: Type of Business: Corporation NO OTHSE2 WORKPLACES FOR TffiS POLICY Risk ID: 2. The certificate period is £rom 12:01 a.m. on 1/fll/2014 to 12:01 a.m. on 1/O1/2015 at the insured's mailing address. 3. A. Workers Compensation Coverage: Part One o£ the certi£icate applies to the Workers Compensation Law oP the states listed here: MA B. Employers Liability Coverage: Part lbao o£ the certi£icate applies to work in each state listed in Item 3.A. The limits of our liability under Part ltao are: Bodily Injury by Accident $ 100.000 each accident Bodily Injury by Disease $ 500.000 certificate limit Bodily Injury by Disease $ 100.00� each employee C. Other States Coverage: D. This certificate includes these endorsements and schedules: WCOOOOOOA(04/42) WC000310(04/84) WC000414(07/90) WC000422A(09/08) WC200301(04/84) WC200302(OS/86) WC200303B(07/99) WC200405(06/O1) WC20060i(06/92) 4. The contribution £or this certificate will be determined by our Manuals o£ Rules, Classi£ications. Rates and Rating Plans. All information required below is subject to veri£ication and change by audit. Classifications Code Contribution Basis Rate Per. Esti.mated No. Total Estimated $100 0£ Annual Annual Remuneration Remimeration Contribntion SEE SC�DULE OF OPERATIONS Total Esti.mated Annual Contribution 1,403.00 Minimum Contribution $ 216.00 Expense Constant $ .00 WC 00 OG O1 A Issue Date: 1/27/2014 Countersigned by SCHEDULE OF OPERATIONS FQR: PAGE: 1 ***** CERTSFICATE INFORMATIQN FOR MA *w*** Sauth Yarmouth Dairy Queen Certificate #: 014�05030237114 Dara Poods, Inc. Fein: 917 Main Street Rte 28 South Yarmouth, MA 026fi4 Cofle Classification Payrall Rate Contribution 8810 CLERICAL OFFICE EMPLOYEES NOC 20, 800.00 . 09 19 .00 9074 RESTAURANT NQC 147, 44? .OQ 1.47 1,573.44 Manual Contribution 1, 592.OD Rate Deviatian 15.00� 239 .00 Merit Rating 1,353.44 Standard Gantribution 1,353 .00 Normal Cantribution 1,353.04 Eacpense Constant Foreign Terrorism 50_00 Annual Gontribution 1,403.Q6 DIA Assessment (00930) 1.1000� / 1.1000� 18.00 Merit Rating 1 .d�40 1J02f202� wC 00 00 01 A