HomeMy WebLinkAboutApplication and WC ' �OF��'9R
�,� -�` _ _`�� TOWN OF YARMOUTH H��f
0 =. ' "j 1146 ROUTE 28, SOUTH YARMOUTH,MASSACHUSETTS 02664-24451 -
N 4�rt�eMktl� $ Telephone(508)398-2231, ext. 1241 D vis n
Fax(508)760-3472
To: Yazmouth Business Establishments FAM��y �o,,� SrvR� -�k " --�'
From: Bruce G. Murphy, Director � I�`,,V '? 4 2014
Yazmouth Health Department�
HEALTH DEPT.
Date: November 7, 2014
Subject: Increase in License/Permit Fees
Please be awaze that the Yazmouth Board of Health, under the direction of the Yarmouth Board
of Selechnen, has raised a number of license and pernut fees issued through the Yazmouth
Health Department, effecfive January 1, 2015.
Attached is the Yarmouth Business License/Permit Application 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 Januazy 1, 2015.
However, if you fully complete the application, and submit it to the Yarmouth Health
Department with all 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 Swiinming Pools $ 80.00
Public WhirlpooUVapor Baths $ 80.00
Tobacco Sales $ 95.00 .pp
Motels $ 55.00
Food Service 0-100 Seats $ 85.00
_ Food�ervi�e Over i08Seats- _ $160:00-- - _ _---- ___:_ --___ . __ .
Retail Food Service <25,000 sq. ft. $ 80.00 80.00
Retail Food Service>25,000 sq. ft. $225.00
Other fees owed but not listed above:
Tota1 fees owed for your establishment: �1 .O 0
NOTE: To be entitied 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
priol' 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 spring prior to opening" on the application.J
BGM/maf
, G4�4f1f'7a4 �3a.oc7 rn��(�o�cR2 �Z��
, � � TOWN OF YARMOUTH BOARD OF HEALTH
APPLICATION FOR LICENSE/P�R�T -�Ols,S ��;y s � Z�14
��P . ?�S � �� :
* Please complete form and attach all necessary� , nme�its by Dece ber 15 2014.
Failure to do so will result in the return of�Zotu��pp�icahon`p ke EPT.
ESTABLISHMENT NAME: �I T ID:
LOCATIONADDRESS: 31 LO �QV� TEL.#: .SQ�- 398-`f9la7
MAILING ADDRESS: PO Bo 1c I o i-� �,(n�tyll?E�2 N C �� I
E-MAILADDRESS: OUpn�SS P�'a.vw (a dQ(lQ�• iD�
OWNERNAME: �Q. rl(.� [1n(LLU' Sfm 2S �F M�4 , lr�c•
CORPORATION NAME (IF FrPPLICABLE):
MANAGER'S NAME: f�Y�G l(, J6�1rl�-S- l��tylSe S(oCU(���' TEL.#: "(p�{-108 �f�7�-F
MAILINGADDRESS:�Q oK iol� C.Ina�rlLk�i �1�- aS�l
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.
l. 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 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. Z•
PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
_ - -
- �- ---- -
- -- -_ __
L �: ----- __
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 Heatth Deparhnent will not use past years' records. You must
provide new copies and maintain a file at your establishment.
1. 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-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. 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 $1l0
INN � $55 CAMP $55 SWIMMINGPOOL$lt0ea
LODGE $55 TRAILERPARK $105 WFIIRLPOOL $li0ea.
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
�<25,000 sq.ft. $150 r.r o r 3 —FROZEN DESSERT $40 �TOBACCO $110 : .I, –!S la
HnME caaNCE: $is AMOUNT DUE _ $ 2�0 .�
R�: '�P �46�- ,�`�O
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM'*•*•
�� 3 43�� 1r'zK�'�
� _,
ADMINISTRATI�N
� �' � . �
Under Chapter 152,Section 25C,Subsection 6,the Tawn of Yarmouth is naw required to hold issuance or renewal f
of any license or permit ta operate a business if a person or company does not have a Certificate of Worker's
Compensation Insurance. T�IE ATTACHEI) STATE WOIt.KEIt'S CONIPEN3ATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR
CERT. OF ZNSURANCE ATTACHED_�
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND A1'TACH�D
1"own of Yazmouth taxes and liens must be paid prior to renewal ar issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PATD:
YES � NO
MOTELS ANA OTHER X.ODGING ESTABI.ISHMENTS
1"RANSIENT 4CCUPANCY: For purposes ofthe limitatiotzs of Motel or Hotel use,Transient occupancy sha11 be
limited to the temporary and short term occupancy,ordinarily and customarily associated with motel and hotel use.
Transient occupants znust have and be able to demonstrate that they maintain a principal place of residence
elsewhere.Transient occupancy shall generally refer to cosatinuous occupaney of not more than thirry(30)days,and
an aggregate ofnot more than ninety(90)days within any six(6)month period. Use of a�;uest unit as a residence or
dwelling unit shall not be considered transient. Occupancy that is svbject to the collection af Room Occupancy
Excise, as defined in M.G.L. c. 64G ar 830 CMR 54G, as amended,sha11 generally be eonsidered Transient.
POOLS
PO(}L OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspecYed
by the Health Deparpnent prior to opening. Contact the T3ealth Departrnent to schedule the inspection three(3)
days prior fa openin�. PLEASE NOTE: People are NOT allowed to sit zn the pool area unTil the pool has been
inspected and opened.
POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count
by a State certified lab, and submitted to the Health Deparkment three (3) days prior to opening, and quarterly
thereafter.
PdCIL CLOSING:Every outdaor in ground swimming paal must be drained or covered within seven{7)days of
closing.
FOOD S�;I2��dCE
SEASONAL FOOD SERVICE OPENING:
All food service establishxnents must be inspected by the Health Department prior to opening. S'Tease contact the
I'Iealth Department to Schedule the inspection tY�ree(3) days priox to opening.
CATERING POLICY:
Anyone who caters within the Town of Yarmaixth must notify the Yarmouth Health Department by filing the
required 7'emparary Faod Servica Agplication £arm 72 haurs priar to the catered event. These farms can be
obtained at tha Health Llepartment,or from the Tawn's website at www.y_u•mouth.ma.us under Health Department,
Downlaadable Forms.
k'ROZEN DESSERTS:
Frazen desserts must be tested by a State certified lab prior to opening and monthly thereafter,with sample results
submitted to the Health Dapartrnent. Failure to do so wilI result in the suspension or revocation of your Frozen
Dessert Permit untii the above terms have been met.
OUTSIDE CAFk`S:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Boazd ofHealth.
OUTD04R COOHING:
Outdoor cookrng,prepazation,or disptay of any food product by a retail or food service establishment is prohibited.
NOTICE: Permits run annually from January 1 ta December 31. IT IS YOtTR I2ESPONSIBILITY TO RETt.1RN
"I'HE COMPLET�D RENEWAL APPLICATION{S}ANI}REQUIRED I'EE{S}BY DECEMBER 15, 2014.
ALL RENOVATTONS TO ANY FOQD GSTABF�ISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT, ETC.},MLTST T3E REPC}RTED TO�ND APPROVED BY THE BOAI2D OF HEALTH PRTQR
TO COMMENCEMENT. RENOVATIONS MAY UIRE A SITE PLAN.
I7ATE: � 1 (�- SIGNATURE:
PRINT NAME cYc TITLE: �YLQ�t�,.�t21/1tS �= �f.!'tS_�.�tLtCtl.cbl'
Rev. !1f03174
� � � The Commonwealth ofMassachusetts
Department oflndustrialAccidents
� Office oflnvestigations
1 Congress Street, Suite I00
Boston, MA 02II4-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legiblv
Business/OrganizationName: �Q,Q,ry�� �lA �(.(l�.f O Y� �{- l�/�, (Vt�l� �(n�(-
Address: �I LQV�q ��1� `)
City/State/Zip:��/�,Y✓►1,p�1'�, MA D�Cn(p�f Phone #: 5'�f's-398— `f9lo`�
Ar,�e.,{�ou an employer? Check e appropriate box: Busi ess Type(required):
1.�I I am a employer with�employees (full and/ 5. Retail
or part-rime).* 6. � RestaurantBaz/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 aze a corporarion and its officers 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, 11.❑ Health Care
with no employees. [No workers' comp. insurance req.] 12.� Other
*Any applicant that checks box#1 must also fill out the section below showing the'v workeis'compensatioa policy informatioa.
*•If the corporate officers have exempted themselves,but the coiporation has other employees,a workers'compensation policy is required and such an
organization should check box#l.
I am an employer that isproviding workers'compensation insurance for my employees. Befow is thepolicy injormation.
Insurance Company Name:
Insurer's Address: 1"ILl�VLI.P��
City/State/Zip:
Policy#or Self-ins. Lic. # Exp'vation Date:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and eapiration date).
-- -BailutelosP�nr �yelagg;,s r�q�ir�_d_under Section 25A of MGL c. 152 can lead to the imposirion 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
Invesrigations of the DIA for insurance coverage verificarion.
I do hereby ce fy, der e ai and enalties ofperjury that the information provided above is true and correct
Si ature: Date: I ��
Phone#: �{'��g �
Officia[use on[y. Do not write in this area,to be comp[eted by city or town officiaG
City or Town: Permit/License#
Issuing 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
� "�� CERTIFICATE OF LIABILITY INSURANCE �A7E(MM/DDNYYY)
�,z5,�o,<
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATNELY OR NEGATNELY AMEND, EXTEND OR ALTER THE COVER4GE AFFORDED BY THE POLICIES BELOW.
THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER�S), AUTHORIZED
REPRESENTATNE OR PRODUCER AND THE CERTIFICATE HOLDER.
IMPORTANT:M the certificaM holder is an ADDI710NAL INSURED,the policy(ies)must be endorsed. If SUBROGA710N IS WANED, subject to the ��
terms and conditions of Ne policy, certain policies may require an endorsement A statement on this certificate dces not confer rights to Me i,°1-.
ceR�cate holder in lieu of such endorsement�s�. � ��
PRODUCER NPME CT
a
Aon Risk Se!'ViCes SOuth, Int. pHONE . (g66) 283-0122 FAX (800) 363-0105 d
Charlotte NC Office I��No��+C Inic.No.l: a
1111 rnetropolitan Avenue, Suite 400 E-MAIL o
Charlotte NC 28204 USa aooae55: 2
INSUREFt�S)AFFOROINGCOVERAGE � W11C#
WSURED WSURERA: ACE N112f1Cd0 Insurance Company 22667
. Familv Dollar 52ores mc NSUREftB: ACE Fire Underwriters msurance Co. 20702
and all 5ubsdianes
a.o. Box 1017 � NsuaEnc: Indemnity Insurance Co of North America 43575
Charlotte NC 28201 USA HsunEao: x� xnsurance tvnerica mc 24554
NSURER E:
NSURER F:
COVERAGES CERTIFICATE NUMBER: 570054971105 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANV REQUIREMENT,TERM OR CONDffION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONSAND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLP.IMS. Limits shown are as uested
� R TYPEOFWSURpNCE POLICYNIIMBER LMrtS
LTR NSD NND MMIDO MMID
X COMMERCLILGENERALLL1BLrtY XSLG FqCHOCCURRENCE S1,OOO,OOO
CLIIMSMAOE �occua Sia applies per policy ter & condit ons $100,000
PREMISES Eaoccvra�e
ME�EXP(Arry are person)
PEftSONALBADVINJURV EZ,OOO.00O p
GEMLAGGREGATELIMITAPPLIESPER: GENERALAGGREGATE $SO,000,000 n
X POLICV ❑PE�a �LOC PRO�UCTS-COMPIOPAGG 52,000�000 N
OTHER: o
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A AUTOMOBLELLIBMY IS1 H08828143 W/Ol/2014 09/Ol/2015 COMBINEDSINGLELIMIT �
. . Eeaccitleirc $2.000,000
X ANVAUTO BO�ILYINJURY(Perperson) O
2
ALLOWNED SGHE�ULED BODILVINJl1RY(PoraccitleM) y
AUTOS AUTOS
NON-OWNED � PROPERTYpAMAGE �
X HIREDAUTOS qUT05 PeracciEe� —
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� X UMBReLLqLwB X OCCUR � US00011720L114A 09/O1/2014 09 O1/2015 EqCHaCCURftENCE $1,000,000 V
EXCESSWB CWIMSMADE SIR dppH25 p2f pO�lCy t2 & COfldlt O�5 qGGREGATE $1,000,��
DED X RETENTION
C WORKERSCOMPENSATpNAND w�2c48017939 09 O1 2014 09 O1 2015 x PERSTATUTE OTN
EMPLOVERS'LNBILffY y�N A05 -
arvvPROPRIETOR/PPRIFER/FJCELunvE ELEACHACCIDENT EZ,OOO,OOO
A OFFICERIMEMBEREXCLWE09 � N/A WRLC4$�1�92� 09/O1/2014 09/O1/2015
�MantlMorylnNH� ,qZ� Cq� Mp E.LDiSEASEEAEMP�OYEE E2,000,000
�DESGR�IONOFOPERATIONSbebw E.LDISEFSEPOLICVLIMIT $2,000,000—
_
�
DESCRNTpN OF OVERATIONS I LOLATpNSI VE11pLES(ACORD 101,Atltlitional Remarka ScheCule,may be akacM1etl if more space Is required) �
Evidence of covera9e onTy.
w�
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CERTIFICATE HOLDER CANCELLATION �
SHOUID ANY OF THE ABOVE DESCRIBFD PoLICES BE CANCELLED BEFORE THE
EJffRATqN DATE THEAEOF, NOTICE WLL BE DELNE0.FD N ACCOROANCE WRH THE >{'
PoLILV PROVRpNS.
Fdmlly DO��df SiOPES� IOG AUTHOR�REPRESENTRTNE �
PO BOX 1011
Charlotte NC 28201-1017 USA !� �� p �p
e�am ✓G.�6YS�itst�eN �w�G1i ��sa
OO 1988-2014 ACORD CORPORATION.All rights reserved.
- ACORD 25(2014/Ot) The ACORD name and logo are registered marks of ACORD
� � AGENCY CUSTOMERID: 570000060940
LOC#:
"4✓� ADDITIONAL REMARKS SCHEDULE Page _ of _ '
AGENCY NAMEOINSURED � .
non aisk services south, inc. Family oollar stores mc
POLICYNUMBER
See certificate Number: 570054971105
CARRIER � NAIC CODE
See Certificate rvumber: 570054971105 eFcecrweoare
ADDITIONAL REMARKS
THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FOR1M,
FORM NUMBER: ACORD 25 FORM TITLE: Certificate of Liability Insurance � .
INSURER�S)AFFORDING COVERAGE NAIC#
INSURER
INSURER
INSURER
MSURER
ADDITIONAL POLICIES �a policy below dces not include limit information,refer to the corresponding policy on the ACORD
certificate form for policy]imits.
INSR ADDL SUBR � POLICYVUNIBER pOLICY POLICY L�M����S
�� TYPEOFINSURAMCE �rySD �,p EFFECfIVE EXPIRATTON
DA'IE DATE .
(MM/DD/YYYY) (MM/DD/YYYl�
WORKERS COMPENSATION
g � N/A SCFC48017940 p9/O1/2014 09/O1/201$
wi
ACORD 101(200&0�) . �2008 ACORD CORPORATION.All tlghts reservetl. �
The AGORD name antl logo ata�egistered marks of ACORD
J ,
bf Form CT-3T (j2�'�'�
Massachusetts Departme�t o#Revenue �(}14 - 2U16
Cigarette Excise Unit
'� Retailer License for Sale o#Cigareites and Cigars and Smoking Tobacco
43as L�ense tnust De posted arul visibie at aii.i"ar�es. Sales ta perr,ans um7er 78 years of�e are proAibitetl by taw:
� applica8on Number: AD9Q7 License Number; Dat��Of ISsus:. , .
Federat 3dentifiicattaf or sacrai Security Number: 03Q11 D9/11I2014
— —._..—. _ _ _.
�°��tt�-�..
. Mailing addrnss for Gcanse: �� �_ Rehail saie location(if different thati maiiing address)
�AMILY D{?t�LAR STORES OF FAflAtLY dOLLAFt STdRES O�MASSAC#iUS ;
PO BOX i017 31 LOIdG PC1ND I ;
CNARLC?TTE, NC 2P201 SOUTH YARMOUTH, PAA 0266d i
�.. -- ___ _ _ _.—..e_.�_—__
This�certifies tfiat�the taxpayer named atiove has paid the required Iicense.fee antl is licensed to.seli at refail at the address stiown abwe urdil ��,
seof,ai»ber 30.2CY16: This iiaense is.n��transfi;iabie,�and i�subjec[to suspension MriaiWre ta cromply with the law. .
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