HomeMy WebLinkAboutApplication and WC oF'YAR
�� ��`_ '�� TOWN OF YARMOUTH Boazdof �:
j Health
�`–� � "3 1146 ROUTE 28, SOUTH YARMOUTH,MASSACH[JSETTS 02664-24451 -
`. 4'��',eMEtsv � Telephone(508)398-2231, ext. 1241 Divis n
Fax(508) 760-3472
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To: YazmouthBusinessEstablishments F�RPP� G�NOS� I0�3
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From: Bruce G. Murphy, Director
Yarmouth Health Department� HEALTH DEPT.
Date: November 7, 2014
Subject: Increase in License/Permit Fees
Please be aware that the Yannouth Board of Health, under the direction of the Yannouth Boazd
of Selechnen, has raised a number of license and pernut fees issued through the Yannouth
Health Department, effective January 1, 2015.
Attached is the Yarmouth 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 certificarions and worker's compensation coverage information
(certificate of insurance OR completed affidavit) arior to December 31. 2014, you will be
allowed to pay the 2014 rates for the following licenses:
Current 2014 Fee
Public Swinuning Pools $ 80.00
Public WhirlpooWapor Baths $ 80.00
Tobacco Sales $ 95.00
Motels $ 55.00
Food Service 0-100 Seats $ 85.00
Food Service Over 100 Seats $}50.00 � I too.00
Retail Food Service <25,000 sq. ft. $ 80.00
Retail Food Service>25,000 sq. ft. $225.00
Other fees owed but not listed above: �$ t�o. oo ��^oN ��c.
Total fees owed for your establislunent: � 220.o0
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 spring prior to opening" on the application.J
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d TOWN OF YARMOUTH BOARD OF HEALTH 5�'I / G��
��� APPLICATION FOR LICENSE/PERMIT -2015
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* P l e a s e c o m p l e t e f o r x n a n d a tt a c h a l l n e c e s s a r y'�d Q c U m e n Y:� y'U��e m e r 1 5 2 0 1 4.
Failure to do so will result in the retur�of�yot��gli�atior�pa et. H��{ ��,
ESTABLISHMENT NAME: PaBa �+�0'S � i TAX ID:
LOCATIONADDRESS: �.}. 211 S, y4���t�, NIQ 02664 a�`I�0 TEL.#: 50�-59�-i�y6
MAILING ADDRESS: �'=���ds 600 Prov�aence Hwy.Dedham,NiA Cc;
E-MAIL ADDRESS: J'K,or��ar@ P�Pa9�n�S.Gor-,
OWNERNAME: Pp�� ��^�s s��
CORPORATIONNAME (IFAPPLICABLE): Pa�� ���os 1��.
MANAGER'SNAME: r��� 5��.h5o„ TEL.#:7BI-"331- 'L�o
MAILING ADDRESS: � �,rds 600 Prcv�aence Hwv �etlham,i�u r�^��
POOL ERTIFICATIONS:
The poo upervisor must be certified as a Pool erator,as required by State law. Please list the designated
Pool Opera r(s) and attach a copy of the certifi tion to this form.
l. _ _ _ _ 2
Pool operators must ' t a minimum o wo employees currently certified in basic water safety, standard First Aid
and Community Cazdio ulmonary suscitation (CPR), having one certified employee on premises at all times.
Please list the employees ow attach copies of their certifications to this form.The Health Department will
not use past years' records. ou must provide new copies and maintain a tile 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. r /iG. �rJhhSo�n 2• �
PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
1. \"�r :C. �lal`n5a✓� 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 Establishxnents, 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 51e at your establishment.
1. Fr;� Jo1,n5o�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 p►ace of business.
1. ��rc �oG�S�n Z .
3. 4• _
RESTAURANT SEATING: TOTAL# �6
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERM[T# LICENSE REQUIRED FEE PERMIT#
B&B $55 CABIN $55 MOTEL $110
INN $55 CAMP $55 � SWIMMINGPOOL$IlOea
_LODGE $55 _TRAILER PARK $105 _WHIRLPOOL $1IOea.
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 $200 . � � -io$ 1 COMMON VIC. $60 !����5� _��D KI CHEN $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. $I50 _FROZENDESSERT $40 _TOBACCO $110
� NAME CHANGE: $15 AMOUNT DUE _ $ 2�O � 00
**•**PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** ���a �Z��Qv
C� "'%�f5/7O lI/Z�1�`�
ADMINISTRATION
Under Chapter 152,Section 25C, Subsection 6,the Town of Yarmauth is now requiced to hold issuance or renewal
o£any license or permit to operate a business if a person or company does not have a Certificate of Worker's
Compensation Insurance. THE ATTACHED STATE WQ12.KER'S COMPENSATIOI'd IP3SUI2ANCE
AFFTDAVIT MUST BE COMPLETED AND SIGNED, OR
CERT. 4F INSURANCE ATTACHED y�>
OR �
WORKER'S COMP. EIFFIDAVIT SIGNED AND ATTACHED Y�s
Town of Yannouth ta�ces and liens must be paid prior to renewal ar issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES � NC}
MOTELS AND OTHER LODGING ESTABLISHMENTS
TRANSIENT OCCUPANCY: Foz purposes of the limitations of Motel ar Hotel use,Transiant occupancy shal]be
limited to the tempprary and shnrt term occupancy,ordinarily and customarily associated with motel and hotel use.
Transient occupants must have and be able to demonstrata that they maintain a principal place of residence
elsewhere.Transient occupancy shall generally refer to continuous occupancy of"not more than tlurty(30)days,and
an aggregate of not more than ninety(90)days within any six(6)mcrnth period. Use of a�uest unit as a residence or
dwelling unit shall not be eansidered transient. Occupancy that is subject to the collection of Raom Occupancy
Excise, as defined sn M.G.I,. c. 54G ar 830 CMR 64G,as amended, shall generally be cansidered Transient.
POCILS
PdOL OPENING:All swimming,wading and whirlpools which have been ciosed far the seasam m�st be inspected
by the Health Department prior to opening. Contact the Health Departrnent to schedule the inspection three (3)
days prior to opening. PLEASE N4TE: Paople are NOT allowed to sit in the poo] area until the poal has been
inspected and opened.
POdL WATEIt TES'I'ING: The water must be tested for pseudomanas,total coliform and standard plate count
by a State certified lab, and submitted to the Health Department three (3} days prior to opening, and quarterly
thereafter.
POOL CLOSING: Every outdoar in ground swirnming paal must be drained or covered within seven(7)days of
closing.
FO011 SERVICE
SEASONAL FOOD SERVICE OPENING: LL
All faod service establishments must be inspected by the I3ealth Department prior ta opening. Please contact the
Health Department to schedule the inspection three (3)days prior to opening.
CATERING POLICY:
Anyone who caters within Yhe Town of Yarmouth must notify the Yarmouth HeaIth Department by faling the
required Temporary Faod Servica Application form 72 haurs priar ta the catered avent. These farms can be
obtained at the Health Department,or frarn the Town's website at www.yazmouth.ma.us under Health Department,
Dorvnloadable Fartns.
FIZOZEN DESSERTS:
Frozen desserts must be tested by a State certifieti lab prior to opening and monthly thereafter,with sample results
submitted to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen
Dessert Permit until the above terms have been met.
CiIITSIDE CAF�S:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth.
OUT'DOOR COOKING:
�utdoor cooking,preparation,oz display of any food product by a retail or food service establishment is prohibited.
NOTICE: Permits run annually from January 1 to December 31. IT I5 YOUR I2ESPONSIBILITY TO RF'I`L3RN
"I'HE COMPLETED RBNF,'WAL APPLICATION{S}AND REQLTIREI}FEE(S}SX DECEMBER 15, 2014.
.41LL RENOVATIONS T4 ANY FOdD ESTABLISHMENT, MOTEL OR POdL (i.e., PAIN"I'ITtG, NEW
EQLIIPMENT,ET'C.), IvfUST BE RBPORTEI}1'4 AND APPROVED BY THE BQARD OF HEALTH PRIOR
T'O COMMENCEMENT. RENOVATIONS MAY REQ IRE A SITE PLAN.
�a.T�: 1�1 i7/I� sIG�aTu�:
PRINT NAME& TIT'LE: �ay 4 horn��r, l�cto�-�,�5 Puyoblc
fte.v. !1t03ti4
� Tlie Conintonwealtlz ojMassac/tccsefis ' P'rint.Form .
� De�artrne�xt o,f Industriat..<tcci�tenls
Office of Irzvestigatioras
' < I Co��gress Street,Suite I00
Soslon,M�4 02IX4-ZOI7
auwH.msss.gov/dica �
Worlcers' Compensation Insnranae A,£fidavit: General Businesses
Aonlicant Tn£ormafian � Please Print Le 'eiblv
Business/OrganizadonName: �a�a ��`no�S
Address: �+. `�g ��O I�r.;� �.cc�'
CatylStatelZip: � `/4�ha.,.�t1, /�'aq 02G6�I Phone#: 3��—'39g—IIH6
Are you an emplayer? Cheelc the appropriate box: Business Type{required):
t.� [am a employer with�� aPPrr7� employaes(full and/ S. ❑Retail
or part-time).* 6. �RestaurantlBar/Eating Estab(ishment
2.❑ I am a sole proprietor or pactnarship and have no 7. ❑Office aadlm•8ates(inci.rea(estate,auto,ete.}
emptoyees working for me in any capacity.
jNo worke�s' eAmp.insuranee required] $. ❑Non-profit
3.❑ We are a cotporation and its officers have exercised 9. ❑Entertainment
iheir right of exen�ption per c. t52,�l{4},and we have �0.�Manufacturing
no enrployees. [No wqrkers' comp. insurattce requirad)* t LQ Heai€h Care
4.[] We are a non-profit organization,staffed by vaiunteers,
witl�no employees.(No workers' comp. insuraace raq.] 12.� Othsr
�'Any appticant Ihet chaeks box KI rnust also 611 out tha section belaw showing t4eir workers'compensalian policy infam�atioa � �
**If tl�e corporute afFieccs Ssave exempted thr.mselves,but Uu cncporateou 6as oWcr ea2ployees,a vmrkcrs'campoosation pali¢y is rcquimt and such an �
organizatian shoutd ct�eck box HL �
I aai arr emptoyer Jttat Ts praviding tvorkers'conrpensatiou insrtrance far n:y enrptoyees. Belp�v is llre policy l�tjornmtion.
tnsurance Company Name• �lational Union Fire Ins Co.of Pittsburgh, PA{Crum and Forster)
lnsurer's Address• 305 Madisan Ave, PQ 8ox 196Q '
CitylStatelZip: Morristown, NJ 07962
Poiicy#or Self ins.Lic.# `��684�Q� Expiration Date: 6l30t13
Atkach a copy of the tivarkers' compensation policy dec(aration gaga{shofving the po3icy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 1S2 can tead to the imposition af criminal penalties qf a
fine up to$1,500.00 andtor one-yaar imprisonment,as wetl as oivit penalties in the fonn of a STOP WORK ORDER and a fine
of up to$250A0 a day against the violatoc 6e advised ttiat a copy of ttiis statement may be£orwarded zo tlie Offca of
investigatians of ttie-DtA for insurance covera�e verification.
I rin hereby cer�ijy,�mrler rhe pnins and peieallies ofperjary tl:at tl�e iafornmlion provid¢d a�nve is true a�rd cnrrect.
Sienature: � ���._ ' Date: II�J7�L�
Phone#: �� �—��+�—i2a�
O�cia!use oii[y. Do rea[rvrite in 11rls area,to be conrpleted bp ciYy or toivit afficiaL
City or Totivn._ -- PermitfX,icense# --
Issuing Aufhoriry(circle one):
I.Board of$ealfB 2&uitding Department 3.CiEytTown C[erk 4.Licensing Bflard 5.Seleetmen's Of�ice
6.OtBer
Contact Persan: Phone#:
www.mass.gov/dia �
�,.�•.,4 SPEC9RA-01 ASMITH
'`��R�� CERTIFICATE OF LIABILITY INSURANGE °p712�ZQ�"4",'
THIS CERTIFlCATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RI6HT$UPON THE CERTIFICATE HpLDER.THIS
CERTIFICATE DOES NQT AFFIRMATlVE�Y OR NEGATIYELY AMEND, EXTEND Oft ALTER THE COVERAGE APFORDED BYTNEP6LIGES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NQT CONSTITUTE A CONTRACT BE7WEEN 7HE�SSUING INSURER�S),AUTHQRIZED
REPRESENTATIVE OR PRODUCER,ANU THE CERTIFICATE HOLDER.
iMPORTANT: if tha certificate hoider Is an ADDiTiONAL iNSURED,the poiicy(ies}must bd endoreed. If SUBROGATIpN IS WAiVED,subject t4
the terms and contlitions of khe policy,certain policies may requlre an endorsement A statement o�this certificate tloes not canfer rights to the
certif[cake hoider in iiau af sach endorsementts.
PRODUCER c rac qm8nda 9mith
NAME:
Kraoter&Campany,�CC °HON o �.1 2�_12),.,,596-3400 �_ �N 9 2, ( 1 z}5s6-3460
1350 Avenue of the Americas E,M a "
18th Floot nonnEss:
Naw York,NY t00t9 —
INSURER�S pFFORDINGCOVERAGE NAICp
a�sufe�n:�nited States Fire insnrance Compan 29113
INSUftED INSURERB:CIlA1T@f CIBI(FII'@ II15UfilYICB COIII(18I1Y 25615
Speciaity Brands Hoidings,LLC ,_ Uni4n Fire ins.Ca.of Pittsburgh PA 18445
wwaers c:Nationa(„_.._..,,,,. .—'--
600 Providence Highway INSURER 0,:
Dedham,AAA 02026 MSURER E:
WSURERF: —+
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS �S TO CERTIFY THAT THE POLICIES OP INSURANCE USTED 6ELOW HAVE BEEN iSSUED TO THE INSURED NAMEDA60VE FOR THE POL(CY PERIOD
INOICATED. N67WITtiSTRNDiNG ANY REOUIRERAENT, TERM OR COP'DITION OF ANY CONTRAC70RQTHER60CUMENTVNTHRESPECTTOWH�CHTHIS
CERTIFICATE MAY BE ISSUED 4R MAY PERTAIN, THE INSUR4NCE AFFORDEO BY THE PqLICIES DESCRIBED HEREINISSUBJECTTOALI.THETERMS,
EXCLUSIQNS ANQ C4NDITiONS OF SUCH POUCtES.17M17S SH4WN A4AY HAVE BEEN REQUGER BY PAID CtA�i�PA�S.
��Tp NPEOFINSURANCE POUCYNUMBFA N� F MN61YYri LIMITS
A X conuaennc�n�aFNexntune�un Facnocc��zence s 1,000,00
CLAIMS-MA�E �OCCUR 54'1�00204-4 tl613012014 06I3012015 pREMISES ocarteoce 5 ����p���
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X Pp�.iCY❑PRO' � PROOUGTS-CpMPtOPAfi6 5 Z.QOQrQ
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B ANVAUTO BA-3D5451&9•14-AUF OBI3012014 p6130l2015 BODILYINJUftY(Pxperson) 5 �
AUTOS ED �( �605UGED BQDIIYtNJUftY(Peracudanq 5
NpN-0WNEO ROP. TY AG 5
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WORKERS COMPENSATION X
ANDEMPLOYERS'LIABILITY TATUT ERH
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ttyes,aescrine�aer
DESCRiPTtONOF6PEkATIONSOeiar E.L�ISFASE�POUCYLIMIT 5 1,800,08
q l.iquor Legal Liabili 641700204�4 06I30@074 OBI30/2�15 4ommon Cause 1,QOQ00
A liquor Lega�Lia6iii 54�700204�b 08/3012014 06/30I2015 Agg�egate 2,000,00
�ESCRIPTION OF OPERAilONS i LOCATIONS I VEHICLES(ACORp 701,Atltlltlo�ul Remarks Schedule,may be atta<�etl Rmore xpace Is requlred�
Thirry(30)days written notice of cancellation,Ten(7Q)days writteo noNce of cancellation tor non-payment of premium.
CERT�FlCATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED PqLIC1E$BE GANCE4LED 6EFOftE
EvStlenceofinsuranCe ��- 7'NE EXPIRATlON DATE 7HEAEOF, NOTICE WILL BE pELNEftE��-IN
ACCOROANCE WITN THE POLiCYPRA{7�SIONS.
AV7•N/6R✓Rk6REPRESENTATWE
V �
� �O 1988-2014 ACORD COftPQRATiON. Ali righYs reserved.
ACORD 25(201AI07) The ACORD name and logo are registered marks af ACORD
AGENCY CUSTOMER ID:SPECBRAAI ASMITH
�.�� �ac#: 2
A�D" ApDIT10NAL REMARKS SCHEDULE _ _
Page 1 of 9
AGBNCV NAMEDINSURED
Krduter&Cpmpany,L�.0 Speclaity Bran�NoiGings,CI.0
6p0 Pravitlence Highway
POUCY NUMBEft D9Altdlfl�MA OZOZB
SEE PAGE 9
CARRIER NAIC CQOE
SBE PAGE 1 SEE P 7 erFecnve oat�:SEE PAGE 1
ADDITtQNAL REMARKS
THIS AD�ITIONAL REMARKS FORM IS A 3CHEOULE TO ACORD FORM,
FORM NUMBER: ACORD 23 FORM TITLE: Certiflca[e of LiabilfN Insurencg
Remarks:
Additional Named Insureds:
Papa Ginds,Inc.
Papa Gino's Holdings,Corp.
Papa Gina's Fre�chising Gorporallon
Papa Gino's/p'Angelo Card Services, Inc.
D'Angeio Franchising Carp.
D'Angelp's Sandwlch Shops,Inc.
The Smith 8.Wotisnsky Rest�urant Group,inc.
S&W of Miami, L.L.C.(DE)
S&W D.C.,L.i.»C.(DE)
Smith 8�Wollensky of Boston LLC(DE)
Smith&Wotiensky of Housfon lLG{DE)
Wo�iensky Beverage,lnc.
Houston S&W,L.P.
S&W of Las Vegas,L.L.C.(DEj
SSW of Philadelpbia,LLC{DE)
Sm3th&Wollensky of Ohio LLC{pE}
Smith&Woliensky of America LLC
1 Washington Avenue Corp.
Prpject Grill I .
PGHC Hotdings,lnc.
Delops,Inc.
Soath Poinfe Hospitality,inc.
Project Grill II
Progressive Food,lne.
Smith&Wollensky Atlantic Wharf LLC
S&W Chicago,LL.C.
ACORD 101 (2008/01) O 2qQ8 ACORD GORPORATlpN. A!i rights reserved.
The ACQRD name and lago are registered marks of ACORD