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Home My WebLink AboutApplication and WC C r OF'}r'`�R .� _=� y �� TC) WN � F YARM � LTTH Boazdof � � Aealth Y.-,,._ ; `"�:/�, 1]46 ROUTE 28, SOUTH XATtMdUTH,MASSACHUSETTS 02664-24451 ��i� R,� �s,� Telephone(508)398-2231,ext. 1241 Division r�twE Fax{SOg)760 3472 _ _..._,,.� To; YarmouthBusinessEstabliskunents lf�� -�MO�Z— ?�(:y ; � 2�1� From: Bruce Cr. Murphy,Directar �) HERITH DEPT. Xarmouth Health Department� Date: November 7, 2014 ; `•, .: ; ;. ;.:; :. Subjeot: Increase in License/Permit Fees _ ____-----_--- - Please be auare that the Yarmoath Board of Healih, under the direction of the Yarmouth Board of Selectmen, has raised a number of license and permit fees issued through the Yarmouth Heatth Department, effective 7anuary l, 2015. Attached is the Yazmouth Business Licanse/Permit Application for 2q15. You will note that the fees tisted aze the fees effective January 1, 2015. 'Fhese fees will be due if you complete and submit the application after January 1,2015. However, if yau fuily camplete the application, and submit it to the Yarmouth Health Department with all required certifications and worker's compensatian coverage information (certificate of insixrance QR completed �davit) rrinr to December 31, 2014, you will be allowed to pay the 2d14 rates for the following licenses: Current 2014 Fee Public Swimm.ing Poois 5 80.00 �o.00 Public WhirlpooWapor Baths $ $0.00 Tobacco Sales $ 95.00 Motels $ 55.00 � 53.00 Food Serviee 0-140 Seats $ 85.4Q - Foad Ser�ice Ov��eats _ $160.OQ__ -- -. Retail Food Service CLS,ddO sq. ft. $ 84.00 � Retaif Food Service>25,04Q sq. 8. $225.04 Other fees awed but not listed above: �3 S.QO �aNn N•a3�+�sT Total fees owed for your establishment: �/70.00 NOTE: To be entitled to pay t�e enrrent 2014 rates iisted abave, yoar business application, food andlor poal certificatians, along with worker's campensatian infarmation must be received, or mailed {postmarked) on ar pT'tol' to Decernber 31, 2014. �Those establishments which open in the spring wzll be aZtowed to pravide food andlar paol certifrcations priar ta opening, however, you must note "Will provide zn the spring priar to opening" on the applzcation.J acnvmae ; : ___. ___ _ . � TOWN OF YARMOUTH BOARD OF HEALTH �� APPLICATION FOR LICENSE/PI�IZI�T . Ol�3�� ; 0� y y� * Please complete form and attach all necessary doc��s�y Decem "r�20f�7 1u�4 Failure to do so will result in the return of youx applicatiori pae et. HEALTH DE�fi ESTABLISHMENT NAME: `l�"NCL ve G rCc�r� /7�oTc/ TAX ID• ' LOCATION ADDRESS: ,� 7 �,/ sia�e Vi�,Gt9c �� TEL.#: SO�� 7/oD� L(p� MAILING ADDRESS: sa m� ' E-MAIL ADDRESS: r n Ca �� OWNERNAME:� / ' hd v��f/ -//us CORPORATION NAME (IF APPLICABLE): � y/y/f3 �i�.� al�c f/,//�oa Gr�e-n _f�oT� MANAGER'S NAME:��-c��t-/H �a �"7" T .#: So��7�D ��'�� MAILING ADDRESS: �� as �fd�� POOL CERTIFICATIONS: The pool supervisor must be certif►ed as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. 1.. _ -(�F�j �f7Cri7J f—�Gi 7 2: �otlG�Zl$� � �7Ct� Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary 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 fle at your place of business. 1. Lt�i//ia�J �� 2.�vun/i.s �csf-� 3. r :-/ ��r<� 4.�` s /Yltiv.Ohsi � 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. 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. L _ _ _ . _ - — 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 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. 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 a11 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. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQIDRED FEE PERMIT# LLCENSE REQUIRED FEE P IT# B&B $55 CABIN $55 � MOTEL $110 /a INN $55 CAMP $55 1 SWIMMING POOL$110ea Z�j LODGE $55 _TRAILERPARK $105 _WH[RLPOOL $ri0ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PE��tMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 �CONTINENTAL $35 ?�IS�7(o 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 =<ZS,OOOsq.ft. $150 —FROZENDESSERT $40 _TOBACCO $I10 NAMECHANGE: $15 �. AMOIINT�:DUE _ $ Z.SpS.O *****PLEASE TURN OVER AND COMPLE'fE�67'HEit SIDEfiF�f9R317 .<.:� ��-�a ��.L d c4c�51�Y j� '�� , w ADMINISTRATION Under Chapter 152,Section 25C,Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal o£any license or pemait to operate a business if a person or company does not have a Certificate of Worker's Gompensation Insurance. THE ATTACHED STATE WOIiKER'S COMPENSATIQN INSURANCE AFFTDAVIT MUST BE COMPLETEA AND SIGNED, OR CERT. 4F INSURANCE AT'TACHED OR J WORKER'S C,OMP. AIFIDAVIT SIGNED AND ATTACHEI3 V Town of Yannoufh taxes and liens rnust be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES �� NC}—..-- MOTELS AND OTHER LODGING FSTABLISHMENTS T'12APISIENT'OCCUPANCY: For purposes of the limitations ofMote]or Hotel use,Transient occupancy shall be lirnited to the temporary and shart term occupancy,ordinazily and austomarily associated with motel and hatel use. Transient occupants musT have and be able to demonstrate that they maintarn a princigal place af residence elsewhere.Transient occupancy shall generally refer ta continuous occupancy of not more than thirty(30)days,and an aggregate of not more than ninety(90)days within any six(6)month period. Ilse of a guest uni#as a zesidence or dwel3ing unit shall not be considered transiant. C}ccupancy that is subject to the collection of Raam Occupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient. P4QL5 P(}OL OPENING:All swimming,wading actd whirlpaols which have been ciosed for the season musi be inspected by the Health llepartrnent prior to opening. Coniact Lhe Nealth Departrnent to schedule the inspection three (3) days priar to opening, PLEASE AIOTE: People are NO'1'allawed to sit in the pot�l,area until the poal has been inspected and opened. 1'QOL WATER TESTING. The water must be tested far pseudomonas,total coli£orm and standard plate count by a State certified lab, and submitted to the Health Department three (3) days pxxor to opening, and quarterly thereafter. Pt?CiL CLQSING: Every outdoor in ground swimming paoi must be drained or covered within seven(7}days of closing. FOOD SERVICE SEASONAL FO()D SERVICE OPENING: All food service establishments must be inspected by the Iiealth Departrnent prior to opening. Please contact the I3eaith Department ta schedule the insp�ctian three(3) days prior to opening. CATERIIYG POLICY� Anyone who caters within the Town of Yarmouth must notify the Xazmouth Health Department by filing the required Temporary Faod Service Application farm 72 hours priar to the cazered event. These forms can be abtained at the Health I7epartment,or fram the Town's website at www.yarmouth.ma.us under Health Deparhnent, Bownloadable Forms. FROZEN DESSERTS: Frozen desserts must be tested by a State certified lab prior to opening and monthly thereafter,with sample resrrlts submitted to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Fermit untii the above terms have been met. OUTSIDE CAFES; Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval frorn the Board of Health. OUTDOOR COOHING: Qutdoor cooking,prepazation,or display of any food product by a retait or faod service establishment is prohibited. NOTICE:Permits run annually from January I to December 31. IT I3 YOUR RESPONSIBILITY TO RETURN `THE COMPLETED RENEWAL APPLTCATIQN{S}AND REQUIRF,D FEE(S}BY DECEMBER 15, 2014. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR PQOL (i.e., Pt1TN'1'ING, NEW EQUIPMENT, ETC.}, MUST BE REPC?RTBI}TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TQ CQMMENCEMENT. 12ENOVATIONS MAY$E(�UIRE A SITE PLAI�I. � c� DATE:_1��_SIGNATURE: '� PRINT NAME c� TIT'LE: ,Ur'v�r� C�, /�i i2tT // /7 Rcv. lltti3J14 � ' ` � The Commonwealth ofMassachusens Department of Industrial Accidents Office oflnvestigations 1 Congress Street, Suite 100 Boston,MA 02114-20U www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print LeEiblv Business/Organization Name: /�/�.Q �nC a��C,' [�/�CZ 4�- �rc� �/ / Address: � �eGZs/a�� Vi��Q' e 6! City/State/Zip• i � Phone#: ,5'/�� 7�Z�� Are you an employer?Check the appropriate box: Business Type(required): 1.0 I am a employer with�employees(full and/ 5. ❑ Retail , or part-rime).* 6. ❑ RestawanUBaz/Eating Establishment - — - -- 2.[] I am a soTe proprieTor or parEneisflip and have no �_ � Office and/or Sales (incl. real estate, auto,etc.) employees working for me in any capacity. [No workers' comp. insurance required] $• ❑Non-profit 3.❑ We aze a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per a 152, §1(4),and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]x 11.❑ Health Caze 4.❑ We aze a non-profit organization,staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.❑ Other *Any applicant ihat checks box#1 must also fill out the section below showing the'v workecs'compensation policy information. *•If the corporate of5cers have exemp[ed themselves,but the corporabon has other employees,a workers'compensation policy is required and such an � organization should check box#I. I am an employer that is provid,,in/g workers'com� pe/nsation insurance fo/r my employees. NBelow is the policy information. Insw�ance Company Name:_�Y�/' �Gt Cc d-� - �u ClYd �S < �i) � Insurer's Address: �� 7 � City/State/Zip: � /-� ✓� " a Policy#or Self-ins. Lic. # �//!/.(/� �!�b� �U Expiration Date: 7 � Attach a copy of the workers' compensa6on policy dedaration page(showing the policy number and esp' aHon ate). Failwe to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a - --- - fine up to$I,500.00 and/or one-yeaz imprisonment, as well as civTpanaIties in the fonn o�a STOI}WORI�S�bERand a fi�- - 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 Investigations of the DIA for insurance coverage verification. I do hereby cert� nder the pains and penalties of rjury thai the information provided above is due and correcG Si ature:` GYiL/� Date: / 7 Phone#: � � 7 � � � � Official use only. Do not write in this area,to be completed by city or town officiaL Ciry 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: P6one#: www.mass.gov/dia �i/f� � �tL'Cr� 1"�?07`+�/ ��,�f,,�� :� � • � 3� S,�Q V','l/aqr � i :'��_ , s��r : r<<, � �'��. BERKSHIRE HATMAWAY Woric�re'Comnensatian and Ernulaver'a tiabiittv Policv'� ��UA FtD ;��ANCE �'�'��A�Insurance Company- A Stock Company COMPANIES Pa��Y►�umber PMWC555838 Renewal of PMWC445830 NCCI No.[258�44J poiicy Information Page [i]Named Insured and Ma3iing Address Age��Y . p M B Inc SYLVIA& COMPANY INS AGY P. d. 8ox 39 . 564 Faunce Comer Road South Yarmouth, MA 02664 Building 100 -Suite 120 Dartmouth,MA Q2747 Agency Code: MASYLVIO Federal E.rnployer'SID Insul'ed is Corpa+atlan AdditionaE Names of Insnred (NZ) Village Green Motel �ocatians an PoNcy (L2) 33-37 Seaside Village Rd ,Yarmouth,MA 02664 (O6/2912014 -06/29/2015) [Z� Policy Perbd Fram 3une 29, 2014 to 7une 29, 2015, 12:01 AM,skandard time a[the insured's maiiing address. �..___ [3] Coverage A. W orkers' Gomgensation Insurance •Part One of khis policy appties to the W orkers'Compensation Law oFkhe �oi�owfng states: Massachusetts B. Employer's liabiiity Insurance -Part Two pf this pplicy applies to work in each of the states Eisked ' in ikem[3)A, The iimits of our flabiiity under Part Two are: Bodily Injury by Accident-each accident $SO�,OOQ , Badily Injury by Disease -each employee ;160,400 Bodily Injury by Disease •polity Ifmit $SOO,OOU C. Other States Insurance -Part Three of this policy appiies to ail sxates,except a�y state listed tn item [3]A. and the states of Narth Dakota, Ohio,Washinqton,and Wyoming. D. This policy includes these endorsements and scheduies: See Extension of Znfarmation Page -Schedule of Farms [4) Premium _._,—.� The Aremium Basis and,kherefore,the premium will be determined by our Manual of Rules, Classifications, Rates,aad Rating Plans. AtI required ioformetion is subjed ta ver�cation and change by audit. (Continued on another page) Tota� Estimated Poiicy Premium § 1,272 Tota{SurcM1argesJAssessmeMs $ 33.00 Totat EstimatCd Cpst g 1,305.00 � tnTearra�use xx Paga - I - Informadon Page MCA : PMWCS55630 . � WC OOOOOlA Date : �6ID9J2414 MAN07E ' �! r �b. n f+ ♦ L�h a k u iMt II 6 on 147nt dnln �++rxeue n�m�d rnm