HomeMy WebLinkAboutApplication and WC OF�Y'9R
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To: Yazmouth Business Establishrnents �R�'t��5
r� NOV 2 5 2U14
From: Bruce G. Murphy, Director �;
Yatmouth Health Department� H�ALTH pEpT
Date: November 7, 2014
Subjeot: Increase in License/Permit Fees
_ _. __ ----- - -- — -
Please be aware that the Yannouth Iioard of Health, uader the directian of the Yarmouth Board
of Selectmen, has raised a nurnber of license and permit fees issued through the Yazmouth
Health Deparlment, effective January 1, 2Q1 S.
Attached is the Yazmouth Business License/Permit Application for 2015. You will note that the
faes listed are the fees effective Jannary 1, 2425. Thesa fees will be due if you complete and
submit the application after January 1,2q15.
Hawever, if you fully comp2ete the applicatian, and submit it to the Yannouth Health
Department with all required certifications and warker's compensation coverage information
(certificate of insurance OR cornpleted �davit) prior to Aecember 31, 2p14, you will be
allowed to pay the 2014 rates for the following licenses:
Current 2014 Fee
Public Swimming Pools $ sa.aa
Public WhirlpoollVapar Baths $ 80.00
Tobacco Sa1es $ 95.00
Motels $ 55.00
Food Service 4-144 Seats $ &S.QO �gs.�
____ _ Food Service Over_100 Seats _ _ __ _ $160.00 ,
Retail Food Service<25,000 sq. ft. $ 80.60 ^ �
Retail Food Service>25,440 sq. ft. $225.44
Other fees owed but not listed above: � �o.oo c�MnoN ��c.
Tatal fees owed for your establishment: �I�}S.oO
NQTE: To be enfitled to pay the current 2414 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. jThose estabfzshments which open in the spring will be
altowed to provide food andlor poot certifrcations prior io opening, however, you must note
"Will provide in the spring prior to openzng" on the appHcation.J
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» � GiGC�C�UIvIL�D' s
��°' � TOWN(}F YARMt)UTII BC}ARD 4F HEALT�I.,,_., i
APPLICATION FOR LICENSElPERMdT 2 i ��' 1'� ff�y l � ��14
* Please complete forrn and attach ali necessary do��t��De . be
Faiture to do sa will result in the return af your applioation PT
ESTABLISHMENT NAME: L D: u�c�, IQa..t ��
LocA�arr aD��ss: 5i�p MA�� 572t�7"� I.�1�Sr YAJ1�� �'�L#� �'i'oB-?-?7 l&'S�"
MAILING ADDRE3S: ,'' yy��� y�} _ b
E-MAILADDRESS: i'►7�HcYUy/"�`�1OCtI� fFUT F�:C_ l�GW9'
OWNERNAME: Y�Y7cW1 U
CORPORATION NAME{IF PLICABLE}: C(Q 1Q,�f{�MMcatJ"'- ,,,,,�/1r�o .
MANAGER'S NAME: YvbtclNl'> crI TEL.#: '� -
MAILING ADDRESS: 14 r dv 1 /F LG 7
POOL CERTIFICATIONS:
The pool superviso must be certified as a Paol Operator,as required b State Iaw. Please list the designatad
Pool Operator(s) and ch a copy of the certification to this forrn.
1. _ _ ___..- - ._ �
Paol operators must list a rninimurn of two em�layees currently certified in basic water safety, standard First Aid
and Community Cazdiopulmonary Resnscitatian (CPR), hauing one certified employee on premises at alI times.
Please list the empioyees below and attach copies of their certifications to this farm.The Aealth Department wili
not use past years' records You must provide new copies and maintain file at your place af business.
1. �.
3. —_—�— 4 — —
FQOD PROTEGTION MANAGERS -CERTIFICATIUNS:
All food service establishrnents aze required to have at least one full-time ernployee who is certified as a Food
Protaction Manager, as defined in the State Sanitary Code for Food Service Esfablishments, 105 CMR 590.00q.
Please attach capies afcertification ta this application. The ITealth Department will not use pask years'recards.
You must provide new copies and raaintain a file at your establishment.
i. ERiI� C�1��1,eY a.�El.(�� �' ��lK �iEIC.-
PERSON IN CHARGE.
Each food eskablishment inust have at least one Person In Charge (PTC) on site during hours of operatian.
i.� ��-..���.�`{ �:- �.�:�l��iu� /20�
ALLERGBN 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 590.069(G}(3)(a). Please attach
capias of certification to this appiicatian. The�Ieaith Departmenk will not use past years' records. 'You must
provide new copies and maintain a �le at your establishment.
1���V�.�h1V.> �t a.
HEIMLICH CERTIFICATI4NS:
All food service establishrnents with 25 seats or more must have at least one employee trained in the Heirnlich
Maneuver an the premisas at all times. Please list your employees trained in anri-choking procedures belaw and
attach copies of employee certifications to this form. The Health Department will not use past years' reeords.
You must provide new eapies and maintain a file at your piace of husiness.
�. i; � E �►� , �.��� 2. �p�o �,t c�-��eo
3. 4.
RESTAURANT SEATING: TOTAL#��._..___
OFFICE CJSE ONLY
LODGIPiG:
LICENSE REQiJIRED FEE PERMIT# LICENSE REQt1IRED FEE PERMIT# LICENSE ItEQUIRF:i7 FF'.E PERMIT#
B&B $55 CABIN $55 MOTEL $I10
� IMT $SS �� � CAA9P $55 SWIMMINGPOOL$I16ea.
_LqDGE $55 _7'RAII.,ER PARK $lOS �__ ^WHIKI.POOL $I IOea..
FOOA SERVICE: �
LICENSE REQU[RED FEE PF.RMIT q LICGNSE REQUIREp FBE PERMIT# LICENSE RE�UIRF,D FFE- PERMIT#
�0-IOO SEATS $I25 CONTINENTAL $35 N4N-PR6 IT $34
>I00 SEATS $200 TCOMMON VIC. $60 �WHOLESALE $&0
� —RESID.KITCHEN $80 �
RETAIL 5ERVICE:
LICENSE REQUIRED FEC PBRMIT# LICENSE REQL�IREU FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
<50 sq.ft. $50 >25,000 sq.ft, $285 VE7�IMG-FOOD S25 ,
<25,OOOsq.ft. $l50 =FROZLNDLSSERT $40 _7'OBACCQ $110
NAME CFIANGE: $15 AMOUNT DUE _ $ (��j.OC'l
*****PLEA9E TURN OVER ANU COMPL�TE pTHER SIDE OF FORM***** �-4 � � t����
c� �`�� �1��ty
_ _ _.._ _
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: ..
ADMINISTRATION
Under Chapter 152,SecYion 25C, Subsection 6,the Town of Yannouth is now required to hold issuance or renewal
ofany license or permit to operate a business if a person or company does not have a Certificate of Warker's
CompensaUon Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR
CERT. OF INSURANCE ATTACHED
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth taaces and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES NO
MOTELS AND OTHER LODGING ESTABLISHMENTS
TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be
limited to the temporary and short term occupancy,ordinazily and customarily associated with motel and hotel use.
Transient occupants must have and be able to demonstrate that they maintain a principal place of residence
elsewhere.Transient occupancy shall generally refer to continuous occupancy of not more than thirly(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. Occupancy that is subject to the collection of Room Occupancy
Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient.
POOLS
POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected
by the Health Department prior to opening. Contact the Health Department to schedule the inspection three(3)
days prior to opening. PLEASE NOTE: People are NOT allowed to sit in the pool azea until the pool has been
inspected and opened.
POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standazd 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 swimming pool must be drained or covered within seven(7)days of
closing.
FOOD SERVICE
SEASONAL FOOD SERVICE OPENING:
All food service establishments must be inspected by the Health Department prior to opening. Please contact the
Health Department to schedule the inspection three (3) days prior to opening.
CATERING POLICY:
Anyone who caters within the Town of Yannouth must notify the Yarmouth Health Department by filing the
required Temporary Food Service Appiication form 72 hours prior to the catered event. These forms can be
obtained at the Health Department,or from the Town's website at www.yarmouth.ma.us under Health Department,
Downloadable Forms.
FROZEN DESSERTS:
Frozen desserts must be tested by a State certified 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.
OUTSIDE CAFES:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth.
OUTDOOR COOHING:
�atd6or coaking,preparation,ar�isplay o€zny food prcjdae�b3�a retatl or foed service esYaUlislunentasprnhibited. _
NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 15, 2014.
ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY E�PLAN.
DATE: OV �ivl SIGNATURE� . �
PRINT NAME&TITLE: �y�y �W� �(?�
Rev.11/03/14 �p��� � ��, �rq—y�I�/� �(u,'�� �'l�•
t4'/7 �'�1
� 11/2A/2011 ISc74 f349-6311 430-1532 BYANDD Kathy Jones�Town of Yarmouth � 1/1
ACORO� CERTIFICATE OF LIABILITY INSURANCE °"TE""'"'°aW�"
�� i�rzarzo�a
THIS CERTFICATE IS ISSUED AS A MATTER OF�NFORMA110N ONLY AN�CONFERS NO RIGMTS 11PON THE CERTIFICATE HOLOER.THIS
CERTIFICATE DOES NOTAFFIRMATIVELY OR NEGAl1VELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDEO BY THE POLICIES
BELOW. THISCERTiFICATEOFINSURANCEDOESNOTCONSTITUTEACONTRACTBETWEENTHEISSUINGINSURER(S�,AUTMORIZED
REPRESENTAi1VE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the rertificate holtler is an AODITIONAL INSUREO,�he palicy(ies)must be endorsed. II SU9ROGAiION IS WAIVED,subject to
the terms antl contlitions ot Ihe policy,certain policies may require an endorsement. A slatemenl on ihis certifcate does not confer rights ta the �
certifcate holder in Ileu of such endorsement(s).
P�acER Benson Young&Downs Ins B0�^.� Kalhy Jones
S65A Route 28 PHONE (SOBJ 032-'IQIB A�� Na_(508)430-9532
P O 8ox 158 E�^V'�� kathyjonesflbyandC.com
Harwich Port MA 02646-0158
INSURERS AFFOROINGCOVERHGE NhICI
iNsuxERA.Hartfwd Fire Insurance Company 'i9682
irvsuREo iNsueen e:
Raymond C. Roy and RCR Management Inc
Saltys iNsun�c:
540 Main Street,Rle 28 iNsuaerto:
West Yarmouth M�A OZB�J- INSURERE�.
I RF:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFV THAT THE POLICIES OF INSURANCE LISTED 9ELOW HAVE 9EEN ISSUED TO THE MSURED NAMED ABWE POR THE POLICY PERIOD .
INOICATED. N01WI7HSTANDING ANY REQUIREMENT.TERM OR CONOITION OF ANY CONTRACT OR OTHER DOCUMENT WI7H RESPECT TO Wr11CH THIS
CERTIFlCATE MAY 8E ISSUE� OR MAY PERTAIN, THE WSURANCE AFFORDED BY THE POLIqES �ESCRIeEO HEREIN IS SUBJECT TO ALL TME TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAYHAVE BEEN REDUCED BY PAID CLAIMS.
�N� TVPE0FW5URANCE ��LSUBR pOLICYNUMBER pOLICYEFF POLICYE%P LIMITS
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ANOEAIPLOVERSLINEIIITY y�N 1DO,OO�
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OESCRIPTIONOFOPERATIONSILOCATIONSfVEWCLES (ACORp10t,AdtlitionalRemarksSchetlule,mryEeattachetlilmorespacelsrequiretl) � 4 �
Seasonal Restaurant _ ._
Worksrs Canpensation coverege is not provided for Ramontl C. Roy. '..,. J� ` � 20��
HEALTH DEPT.
CERTIFICATE HOLDER CANCELLATION AI OOB455
SHOULO ANY OF T7EABOVEDESCRIBED POLICIES BE CANCELLED BEFORE
Town of YarmWth THE E%PIRATION OATE THEREOF,NOTICE WILL BE DELIVEFEO IN
Heal�h Depf. ACCORDANCE WITN TXE POLICY PROVISIONS.
1146 Rte 28
South Varmouth MA 02664- A�*+owzeoRePr+�sEN.nrrvE � J
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