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Home My WebLink AboutApplication and WC , : 'o� .YA� �� =�`_ �Q TOWN OF YARMOUTH e��f � -: �}`j 1146 ROUTE 28, SOUTH YARMOUTH, MASSACHiISETTS 02664-24451 - �. �� E��' � Telephone(508)398-2231, ext. 1241 Health �AGNE Fax(508)760-3472 Division To: Yarmouth Business Establishxnents A�N t FgaNs K-rru+EN From: Bruce G. Murphy, Director G�C�CSC�DMC�D Yarmouth Health Department Utt; 'r 1 2014 Date: November 7, 2014 HEAITH DEPT. --_— -Subjeet: — �erease-in License/Permit Fees Please be awaze that the Yazmouth Board of Health, under the direction of the Yannouth Boazd of Selechnen, has raised a number of license and pernut fees issued through the Yarmouth Health Department, effective January 1, 2015. Attached is the Yarmouth Business License/Permit ApplicaUon 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 fixlly complete the application, and submit it to the Yannouth Health Department with a11 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 Swiuuning Pools $ 80.00 Public Whirlpool/Vapor Baths $ 80.00 Tobacco Sales $ 95.00 _ MoteIs _ $ 5�.00 Restaurants 0-100 Seats $ 85.00 $ 85.00 Restaurants Over 100 Seats $160.00 Retail Food Service<25,000 sq. ft. $ 80.00 Retail Food Service>25,000 sq. ft. $225.00 Other fees owed but not listed above: � �o.00 COKMON V\C. Total fees owed for your establishment: � l�4 S.00� NOTE: To be entitled to pay the current 2014 rates listed above, your business application, food and/or pool certifications, along with worker's compensation information must be received, or mailed (postmarked) on or prior to December 31, 2014. [Those establishments which open in the spring will be allowed to provide food andlor pool certifications prior to opening, however, you must note "Will provide in the springprior to opening" on the application.J BGM/maf . a 1 a � TOWN OF YARMOUTH BOARD OF HEALTH � �� APPLICATION FOR LICEN ��I�lc� UEC 1 1 [014 `'" * Please complete form and attach all nece�s, � ume�'fs by De'e be IS 2014. Failure to do so will result in the re�n o$�app licatio`n P T ESTABLISHMENT NAME: � AX ID: � LocaTiorr aDD�ss: �71 � �.Sr 'rEL.#: So8- 7�5- '777/ MAILING ADDRESS: M 3 E-MAIL ADDRESS: j 1,1' � [� MCCt� , /1 OWNERNAME: r + �{ 7 r.uLr CORPORATION NAME (IF APPLICABLE): K L MANAGER'S NAME: '�i .p TEL.#: D � - 7 � MAILING ADDRESS: !" IJ {�' O !a POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated �'aot{3peratarfs) a�d�ttaci�a copy of the certification to this form. L 2. Pool operators must list a minimum of two empl es ently certified in basic water safety, standazd First Aid and Community Cardiopulmonary Resuscitation ), having one certified employee on premises at all times. Please list the employees below and attach cop' of thei ertifications to this form.The Health Department witl not use past years' records. You must� ide new co ' s and maintain a file at your place of business. / 1. / 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: 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 certifica6on to this application. The Health Deparhnent will not use past years'records. You must provide new copies and maintain a file at your establishment. 1. �l `1/eY' �ua� 2. F2i��}n,ond �n�a�r�san _ PER30N 3�f C�Iz1Rf7E: - - -- _ _ _ Each food establishment must have at least one Person In Chazge (PIC) on site during hours of operation. �. �/IPr �, .ar-�e. 2. Kr� 1a `� �,�,c�,t��- ALLERGEN CERTIFICATIONS: All food 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. �. �r'yle�-- ��„��-/�. z.�. 7ca.c,�,r�e 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. � (llill �OVII�C Dvivi' �D �0�/7%/�2.� 3. RESTAURANT SEATING: TOTAL# �� OFFICE USE ONLY LODGING: L[CENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $110 I1VN $55 CAMP $55 SWIMMINGPOOL$110ea. _LODGE $55 —TRAILER PARK $105 WHIRLPOOL $110ea. FOOD SERVICE: L[CENSE REQUIRED FEE P R�IIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMiT# �0-100SEATS $125 15' b� _CONTIIVENTAL $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.fr. $285 VENDING-FOOD $25 =<25,OOOsq.ft. $I50 =FROZENDESSERT $40 TOBACCO $l10 NAMECHANGE: $IS AMOUNTDUE _ $ 186„-C�O � *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** �"�L +"` /��v c�# 2�73 /�ll��l � . ADMINISTRATION � ' Under Chapter152, Section 25C,Subsection 6,the Town of Yannouth is naw required ta hold issuance or renawal of any license or permit to operate a business if a person or company does not have a Certificate af Worker s Compensation Insurance. THE ATTACHED STATE W4I2KER'3 COMPENSATI4N INSURANCE AFFTDAVIT MUST BE COMPLETED AND SIGNED, dR CERT. OF iNSURANCE ATTACHED ✓ OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACH�D Town of Yarmouth taates and liens musk be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPIZIA'PELX IF PAtD: YES f NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitatioils of Motel or Hotcl use,Transient occupancy shall be limited ta the temporary and short term occupancy,ordinarily and oustornarily assoc'rated with motel and hotel use. Transient occupants mnst have artd be able to demonstrate that tiiey maintain a principal place of residence elsewhere.Transient occupancy sha11 generally refer to continuous occnpancy ofnot more than thiriy(30)days,and an aggregate af not more than ninery(90)days within any six(6)month period. Use of a guest unit as a residence or dwelling unit shali not be cansidered transient. Occupancy that is snbjecti to the calleetion of I2oam 4ecupancy Excise,as defined in M.G.L. c. 64G ar$34 CMR 64G, as amended, shall generally be considered Transient. I't}OLS POQL OPENING:All swimming,wading and whirlpools which have been ciosed for the season must be snspected by the Health Department prior to openzng. ConYact the Health Departmetit to schedule the inspection three(3) days prior to opening. PLEASE 1VC}T`E: People are NOT al]owed to sit in the poo] area until the poal has been inspected and opened. POOL WATER TESTING: The water mast be tested for psendomonas,total coli£orm and standard plate caunt by a State certified lab, and submitted to the HeaIth Department three (3) days ptior to opening, and quarterly thereafter. P(}OL CLOSING: Every outdoor imgrou.nd sw�imming paoi must be drained or cov�red within seven(7)days af closing. FOOD SF.RVICE SEASONAL FOQD SERVICE OPENING: AII food service establishmenis must be inspected by the Health Depastment prior to opening. Flease contact the Health Departrnent to schedule the inspection three (3)days prior to apening. CATERiPtG POLICY: Anyone who caters within the Town oi Yarmouth must notify fhe Yarmouth Health Department by filing the raquired Tempara�y Food Service Application fbrm 72 hours priar to the catered event. These farms can be obtained at the Health Department,or fram the Town's website at www.yarrnouthma.us under Health Department, Downloadable Forms. FROZEPTDE3SERTS: Trozen desserts must be tested by a State certified lab prior to opening and monthly thereafter,with sampla results submitted to the Health Deparqnent. Failure to do so will result in the suspension or ravocafion of yow Frozen I7essert Permit until the above terms have been met. t?IITSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. __ _ - _ _ _ _ OUTDOOR COOKING: - Outdoor cooking,prepazation,ar dispIay of any food}�roduct by a ratail ar food service establishment is prohibited. 1�iOTICE: Permits run annually from January 1 ta December 31. IT IS YOUR RE5PONSIBILITY Tt3 RE'FURN THB COMPLETED RENEWAL APPLICATI4N{S)AND REQUIRL:I}PEE(S}BX DBCEMBER 1S,2414. ALL RENOVATIONS TO ANY FOOD rSTABLISHMENT, MCITEL OR POdl (i.e., P1�IINTING, NEW F,QUIPMENT,ETG},MUST BE REPORTED TO AND AF1'RQVED BY TFiE BOARD OF HEALTH PRIQR TO COMMENCEMBNT. RENOVATIONS MAY REQUIRE A SITE PLAN. 17ATE� /o� - /p-/� SIGNt1TLJRE: �� ,�� PR1NT NAME& TI'1'LE: ��,I n t"i�, L . �(,(,�y^'� dtunt�Y� Bev_11t03114 . � �� rvrvrtmri i ivrv rNuc S+TE� WORKERS COMPENSATION AND EMPLOYERS LIABILITY PO�ICY INSURER: �TFORD ACCIDENT AND INDEMNITY COMPANY ONE HARTFORD PLAZA, HARTFORD, CONNECTICUT 06155 NCCI Company Number: 10448 THE Company Code: 5 HARTFORD � � � n 0 SUffiX � LARS RENEWAL � POLICY NUMBER: OB YdEC C 6219 00 � Previous Policy Number: NEW � �+ HOUSING CODE: SB a L Named Msured and Mailing Address: TTDR , LLC � (No., Street, Town, State, Zip Code) m 0 N 0 38 STONEY HILL DR ,-"'., FEIN Number: SOUTH YARMOUTH, MA 02664 � State Identification Number(s); � UIN: s i � Th0 Named I�Sufr:d i5: LIMITED LIABILITY COMPANY � Business of Named Insured: 12ESTALJRANT - FULL SERVICE (WAI � Other workpiaces not shown above: 471 RT 2 B � � hTEST YARMOUTH MA 02664 � 2. Poi(cyPeried: From 06/27/14 To 06/27/15 � 12�01 a.m., StandaM time at the Insured's mailing atldress. � P�OdUCBMB N8R18: MCSHEA INSi7RANCE AGINCY INC � = 1550 FALMOUTH ROAD Si7ITE 2 � CENTERVILLE, MA 02632 . � Producer's Code: �98402 � Issuing Office: THE HARTFORD � 3D1 WOQDS PARK �RIVE � CLINTON NY 13323 � (B00) 962-6170 � Total Est�mated Annual Premium: S1,228 � Deposk Premium: — Policy Minimum Premium: 5216 MA � Audit Period: �1� Instaliment Term: � The policy is not binding unless countersigned by our authorized representative. � - Countersigned by ��,yQ,�� Authonzed Representative Date Fortn WC 00 00 01 A (1) Printed in U.S.A. Page 1 (Continued on next page) Process Dete: 05/30/14 Policy Expiration Date: 06/27/15 ORIGINAL iNFQRMATION PAGE (Continued) Policy Number: OB WEC CQb219 ~ 3.A. Workers Compensatian Insuranee: Part one o#the poiicy appites#o the Workers Compensatian Law af the states listed here: MA B. Employers Liability Insurance: Part Two of the polioy appfies to wark in each state iisked in item 3.A. The limits of pur iiabil9ty under Part Tv,ro are: Bodily injury by Accident $lOp,000 each accident Bodiiy injury by Disease $500,OOd poiicy iimit Bodily iajury try Disease 5100,040 each employee C. Other States insurance: Part 7hree af the ppiicy appiies ta the states, if any, 13sted here_ ALL STATES E7CCEPT ND, OH, WA, WY, AND STA2ES DESIQ3ATED IN ITEM 3.A. OF THE ITdf'QRMATION PAGE. d. This pofity includes these endorsements and schedule: WC 20 pl O1 WC 20 01 p2 WC 20 03 03D WC 99 q3 OOD WC 00 Q4 14 WC 20 03 61 WC 24 03 02A WC 2� 04 Ol WC 24 04 45 WC 24 46 42A 4. The premium for this policy witt 6e determined ky our Manuais of Rules, Ciassificatians, Rates 8nd itating �iais. all infortnation required belaw is subject to verification and change by audit. Premiam Basis Classificatians Tatal Estimated Rates Per Estimated Code Number and Annual $100 of Mnual pescription Remuneration Remunetation Premium 4074 103, 672 1.15 1,195 L10UGfII�ITS SHOP - RETAIL MA RATE DEVIa'EIQN PREMICIM CREDIT ( .20) (9037) -239 xo�r�t, �rtEMlt7t� sv�.'�'c'T �o �c_��rr� r�ogzFzcAz��c�rt 9s6 MA - D�RIT RF:TIN� CP.E:::T (9885; .950 Fxcr:ciluri AD:iusiED isY .a'rt�Lli:r13'SvN GF rXF`r:�Ie`3JCE MOBIFICATION 90$ Tt1TAL ESRIMA3'ED AI+IIdUAL STP.NQ�IRD FREMIUM 90@ �.::.•::��:,� C::n:a'�'�Nr (09q0) 250 MAS$ACHUSE'P'PS DIA RSSESui+�r.�d'a 3.4f30 FEnCi;ivi 39 TERFCORISM (974p) 103, 872 .03q 31 TOTA'u F.^ii.�iiu=.:i,�� ..�"` ''' '.�'�=-'�-:r..- li2?,B �_=.;� r�::::::`=��-.....:In'��iifRl: S�.e��a Depasit Premium: Policy Mirtimum Premium: 5216 MA S��:a�$:u:2ri...:a u:t2;L'�k.'rstificationNumber: NAICu°: e .��...r�.t = --� r.. -,-+�.::�t�er: SIG: 5812 -- ,. -U.,,, _._,.. _. ::; _. � UIN: N0. OF �: OOQOO�i �a;n 'JUC 00 00 01 A (1) Printed in U.S.A. Page 2 Pracess Date: 4513Qt14 Pa;icy Expiratfon Date: 45/27/15