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Home My WebLink AboutApplication and WC L.� � l7��Y�'!4 �.�� .�_ �`�� TQWN � F YARMaLTTH ��f 0 .,h :;, ��;, 1146 ROUTE 28, SOUTH XARMOIITH,MASSACHUSETTS 02664-24451 Heaiih L", ,c� ,� . Talephone(508)39$-2231,ext. 1241 Divieion '"��"°` Fa�c{SQ8)760-3472 To: YarmouthBusinessEstablishments t2o� 23 Ail�a 5�-�� 1NC • Fram: Bruce G. Murphy, Director � � � � Yannouth Health Departmen2�' "��` . � `lU►4 Date: November'7, 2014 HEALrH pEPT Subject: Increase in License/Permit Fees - - -- __ ._—_ _ ._ ` ---- __ __ _. Please be aware that the Yarmouth Board of Health, under the direcrion af the Yarmouth Boazd of Selechnen, has raised a number of license and permit fees issued through the Yannouth Health Department, effecrive January l, 2015. Attached is the Yannouth Business License/Permit Application for 2015. You will note that the fees listed are the fees effective 7anuary l, 2015. These fees will be due if you complete and submit the applicarion after Jannary l,2Q15. However, if you fulty complete the application, and submit it to the Yarmouth Heatth I7epartmeni with all required certifications and warker's compensation coverage informatian (certificate of insurance OR completed �davit) prior to December 31, 2014, you will be allowed to pay the 2014 rates for the following licenses: Current 2014 Pee Public Swimming Pools $ 80.d0 Public WhirlpooWapar Baths $ 80.04 Tabacco Sales $ 95.00 qS•00 Matels $ 55.00 Food Service 0-140 Seats $ 85.OQ _ Foo�Service C�ver 2fl08eats - ��(s`J:08__ _ _ _-_- --- ---_ _ _ Retaii Food Service<25,000 sq. ft. $ 80.00 Retail Food Service>25,Od0 sq. ft. $225A4 Other fees owed but not listed above: � �o.00 P-�«-�o Svc.cyosQ.FT. Tatal fees owed far your establishment: � ��kS.Cb NOTE: Ta be entitied ta pay the enrrent 2014 rates listed abave, your business applicarion, food and/or poal certifications, alang with warker's compensation infarmatian must be received, or mailed (postmarked) an or prioC to Decembel' 31, 2014. [Those establishments which open in the spring will be altowed ta pravide food arrdlar pooi certifzcatians priar ta opening, however, you must note "Will provzde in the spring przor to opening" on the application.J BGM/maf ' ' Rr.28 Pws.vSvc. lr�:� t �� TOWN OF YARMOUTH BOARD OF HEALTH APPLICATIONFORLICENSE/PE�R�I��20�5�� ;�V . � LU14 � * Please complete form and attach all necessary ocixments�y ec mb 4. Failure to do so will result in the return;of yaur apgficat on PT ESTABLISHMENT NAME: ` � '� � TAX ID: LOCATION ADDRESS: F.'o 1 /t' -r ,� ��t.�;N^,��TEL.#: �;i� �a"y/� MAILING ADDRESS: T E-MAIL ADDRESS: OWNERNAME: (,Ji�iaw�- �L1(�iK CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: �. J % 4SG,� -�}�� TEL.#:' �� ?/y 3�3 MAILING ADDRESS: 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. __ ___ _ _ — -- — _ _ _ __ 1. _ _ _ _ _ 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. 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 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. �- 1 :- -- - -- _ _- --- ._— - -- __2. _. ALLERGEN CERTIFICATIONS: All food service establishments are required to have at least one fixll-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 establishxnents 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 $110 1� $55 CAMP $55 SWIMMINGPOOL$ll0ea. _LODGE $55 =1RAILER PARK $105 _WHIRLPOOL $110ea. . FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100SEATS $t25 _CONTINENTAL $35 NON-PROFIT $30 _>]00 SEATS $200 _COMMON VIC. $60 —WHOLESALE $80 RETAIL SERVICE: —RESID.KITCHEN $80 LICENSE REQUIRED FEE P$RMIT# LICENSE REQUTAED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �<50 sq.ft. $50 #1"lJ—022 >25,000 sq.ft. $285 VENDING-FOOD $25 _<25,000 sq.R. $150 _FROZEN DESSERT $40 �TOBACCO $110 ��j�' xnniE c�.rvcE: gis AMOUNT DUE _ $� �p ,n n *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM ��t� ��'�Q •..�. c�(�ad 1i ��9�i`{ ADMIN[STRA'TION Under Chapter 152,Section 25G, Subsection 6,d1e Tawn af Yarmouth is naw reyuired 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 Warker's Compensation Insurance. THE ATTACI�ED STATE WORKER'S COMPE . SATIQN IN3URANCE AFFIAAVTT MUST BE COMPLETED AND SIGNED, OR CEBT. QF INSURANCE A`CTACHBD OR WORKER'S CdMP. APFIDAVIT SIGNED AND ATTACF�BD Town oF Yarrnouth taates and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPItIATELY IF PAID: YE3 NO MOTELS AND OTHEl2 LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitatioT�s ofMotel or Hotel use,Tr�nsient occupancy shall be limited to the temporary and short term occupancy,ordinarily and customarily associated with matel and hotel use. Transient occupants must have and he able to demanstrate that they maintain a principal place of residence elsewhere.Transient occup;�ncy shall geilerally refer to continuous accupancy of not rnore than thirty(30)days,and an aggregate of nok 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 subject ta the collection of Roam Occupancy Excise, as defined in M.G.S,. c. 64G ar 830 CMR 64G, as amended, shall generally be considered Transient. PQOLS POOL 4PENING;Atl swimming,wading and whiripoals whach have been closed for the season must be inspected by the Health Departrnent pzior to opening. Contact the Health Department to schedule the inspection three(3) days priar to opening. PLEASE NOTki: People are NdT allawed ta sit in the pool area until the paai has been inspected and opened. PQOL WATER TESTING: The water must be tested for pseudomonas,total coli£onn and standard plate count by a State cerCified lab, and submitted Co the Health Department three (3} days priar to opening, and quarterly thereafter. POOL CL43ING: Every outdoar sn ground swirnming pool must be drained or covered within seven{7)days of closing. FOOD SERVICE SEASONAL FOCID SERVICE OPENINC'>: All food service establishments must be inspected by the Itealth Department priar ta opening. Please contact the Flealth Department to schedule the inspection three (3) days prior to opening. CATERiNG POLICY: Anyone who caters within the Town af Yarmouth must notify the Xarmouth Health Department by filing the required Temporary Food Service Applicatian form 72 hours prior ta the catered event. These f'orms can be obtained at the Heaith I7eparhnent,or from the Town's website at www.yarmouth.ma.us under Heatth Department, Ttownloadable Forms. FROZEN DESSERTS: Frozen desserts must be tested by a State certified lab prior to opening and rnonthly thereafter,with sample results submitted to the Health Department. Failure to do so �vill resuit in the suspension or revoeation of yaur Frozen Dessert Permit untii the above terms have been met. OUTSIDE CAFES: dutside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Boazd of Health. OUTDQOR COOHING: dutdoor cooking,prepazation,�r display of any 1'ood product by a retail or food service establishmeni is prohib'sted. NOTICE:Pezmits run annually from 7anuary 1 ta December 31. IT IS YOUR RE5POPiSIBILITY TO RETLJRN THE C{}MPLETEI}RENEWAL APPLICATION(S}AI`dD REQUIRED �'EE(S) BY DECI:MBER 15, 2014. ALL RENOVAfiION5 TO ANY FOOD ESTABLISHMENT, MOTEL 4R PO4L {i.e., PAINTING, NEW EQUIPMENT,E'1'C.}, MUST BE REP4RTED TO AND APPROVEL?BY THE BQARD OF HEALTH PRIOR TQ CQMMENCEMENT. RENOVATION5 MAY REQUIFtE A SITE PLAN. DATE: //��///„/ _ _SIGNATTJRE: �-�'�`_.-%"�� PRINT NAME&TITLE: /A��,�p,r2'�2_"��'�'�K ��'� — Rev. t ll03114 � � The Commonwealth ofMassachusetts Department oflndustria[Accidents Office oflnvestigations I Congress Street, Suite I00 Boston, MA 02I14-20U www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legiblv Business/Organization Name: /�� a.� �� `Q�u,`Cs� i�r Address: �fp� f1 fi � � City/State/Zip: � o Phone#: � � �s,-�`}/ � Are you an employer? heck the appropriate bos: Business Type(required): 1.� I am a employer with�employees(full and/ 5. ❑ Retail or part-rime).* _ 6. ❑ RestauranUBaz/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 corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §I(4), and we have �0.❑ Manufacturing no employees. [No workers' comp. insurance required]* 11.❑ Health Care 4.❑ We aze a non-profit organization, staffed by volunteers, n` with no employees. [No workers' comp. insurance req.] 12.�Other l�y S � O� *Any applicant t6at checks box#1 must also fill out the section below showing tLe'v workecs'compensation policy information. ••If the coiporete officers have exempted themselves,but the corporation has other employees,a workers'compensatioa policy is=equired and such an organization should check box#I. I am an employer that isproviding workers'compensation insurance for my employees. Be[ow is thepolicy informatioa Insurance Company Name: T'r'[} �� 0 .� � (/�L4 f/�Q � � � Insurer's Address: �(� �7� �( 3��p City/State/Zip: V��c-Ll tl— � a ��a" � SS Policy#or Self-ins. Lic. # � � �`Q 1,�t��-�-3 61 xpiration Date: � - � Attach a copy of the workers' compensation policy declaration page(showing the policy number and eapiration date). - Failure tasecureLoverage assaqn;red nnrlPr�Q�tiQll2�A ofMC�L�,_1�2 can lead to_the impo_sition of criminal penalries of a fine up to $1,500.00 and/or one-yeaz imprisonment,as well as civil penalties in the form of a STOP VJORK 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 certify,under thepains andpenalties ofperjury thai the information provided above is true and correct. S�ature: � r�.,+e. /i�� Phone#: �� /S �95�� i Official use on[y. Do not write tn this area,to be completed by city or town officiaL City or Town: Permit/Licease# Issuing Authority(circle one): 1.Board of Health 2. Building Department 3. City/1'own Clerk 4.Licensing Board 5. Selectmen's Office 6.Other Contact Person: Phone#• www.mass.gov/aia Rightfax C2-1 10/8/2014 4 :54 :18 AM PAGE 2/002 Fax Server '�' CERTIFICATE OF LIABILITY INSURANCE DATB(MMIDDNYYY) FIGATE 4S 65SUED AS A�iATTER OF INF4ftMATtON ONIY AND CONFERS Nd fl�HTS UPON THE CERTIFiCATE HOLDER. THIS CER7IFlCATE DOES NOT AFFIqMA71VELY Ofl NEGATIVELY AMENp,EXTEND OR ALTER THE COVEflAGE AFFORDED BY 7HE POUqES BELOW. T WS CE{3TIP�ATE QF INSURA.NCE�tES NdT CONS71TtfTE A C4NifiACT BElWEEN THE�SUING IFLStIRER{S},AilTHORt2ED REPRESENTATiVE MPORTANT:tt the certH�ate haWer is an AD�TIOMAI tNSUHED,tt�e poU�}r(les)must be endwsed. H SUBN06ATION IS WAIVED,s+�JeIX to#he erms and condttlais af Me poilcy,certein pollcieu may require and endorsement A statement an thls certHlcate dces not conMr rlghTs to the certificate 6older in Ileu d such endoreemen s. PRODUCER COMACT NAME: BRYDEN&SULL[VAN INS AG pHONE FAX PO BOX 149'7 � �No, M}� , , }...�.��.��. E-MAIL S027TH DENNIS,MA 02b66 poURE53: 95BKG MSURER{9)AFFORDINQGQYEIiAGE NAIC# INSURED INSURERA: TRAVB[EHSPROPERTYCASUALTYCOhIPANYOFAMHRICA ROUTE 28 AUTO SERY[CES INC lNSURER 8. .�—�� INSURER C: ��,��.� .� .�� It�iRER 0: 60I ROU7E 2S INSURER E: �T WFS2YARMQUTH,YIA 02673 IHStipERF: COVERA�ES CERTFiCA7ENUMBEft: REYISIONNIIMBER: FVTHA iHE CE8 N8Ufl tJ BEL H� EEN OTXEN9UflE6NU1F�ABOVEFOpTHEPOLiCYPEflqDNDICATED.NOTWffHSTANONG ANY NEWIflENENT�TEqM Oq CWlURION OF ANYCONTPACf tM 07NFA UOCUNENf WffH IIEBPECT TO WNICYI TNI9 CEA'fFICATB NAV @E B9UED OII MAV PEJiTAN.THE N8Wi4NCE lFFOROED BY THR POLKqFB�IBEDlffAEW 68UBJE4T TOAIITNETEflY3,EXfAU&ONS AtMt CONf)(IIOM30F BIK:N PoLIdEfi l�,ii288f(OWN MAY HAVEeB3!ft�E)�R BY YA6 QAIMB. N811 110D 8 P9LiCY EfF DATE POf.CY EE%P�D4TE liii TYPE�FNBUAhNCE l fl PoLICVNUNBEfl (fM�OMYYYY) (NMDDIVYY'n WRB GENERALUABWTY CHOCCURRENGE g � CAMMERCIAi.GENERAL LIABILRY �—�"" AMAGETORENTED $ CLAIMS MADE �OCCUR. REMISES(Eaocaarence} E�EXP(My o�re persm) $ ERSONAL&ADV IWUiiY $ GENL AGGREGATE LIMfT APPLIES PER: ENERAL AGGflEGATE 3 PDIICY �PR0.IEGT Q lQG RO�UCTS-COMP/OP AGG $ AUTOMOBILE LiA&III�Y B�'ED S�IE $ ANY AUTO LUA(f(Ea aCcideirt) ALLOWNEQAU70S B�DIlYM11URY $ . SCHEDULE A41TOS (�'�°^) HIREQAUTOS BOOII.YWJURY $ (Peraccitleirt NpN-OWNEDAUTOS PROPER7YDAMAGE $ Peraccidera) UM9REI.LA lIAB OCCUR ACH OCCURRENCE $ EXCESS LIAB CLAIMS#AAQE AGGREGATE $ DEOUCTIBLE � RE7ENTION $ S A WOHItEflSCOMPENSA7iONAND X WCSfAMORV oTHER ' EMPLOYER'SLIABILITY YM UB-2EOT123844 03A07/2tl14 03l07@Q15 LIMITS nNYPAOPEtiiTOWPARRtEWEXEGiTiVE �WA E.LEACHACCIDENT $ 10p,00p OFFICEIM/EMBEfl EXCLUDED? {Mrwaary h Nxy EL QISEASE-EA Et.�t01'EE $ �pp,Opp If Ye%.tleaaPoeuMer DEScplPnanOr'oaERATioN3mmw E.L.OISEASE-POLICYLIMR $ $a0�000 DES4RIP7i0M�OPERATIONStIOCATOMSJYEFRGIESfiiESiRICIiONSfSPEGIAL ITEMS TIffS RL�PLACfiS ANY PRtpR CBRTQdCATE ISSUED 7'O THE CFD27iFTCAT9 HOLDHR AFFBi.'IING WORKERS COMP COVCAAqE. CERTtFlCATE HOLDER CANCELLATION RTE 28 AUTO SER V ICES stiOUtD ANY OF 7XE ABOYE DESCWBED PDtIdES BE CAt7CE�LER 601 RTE 28 gEfOREIHE E%pIRATION DATE 7116REOF,NOTICE WILL BE OELIVERED IN ACCORDANCE WIh1 THE POLICY PHOVISIaNS. AtrtHqR2EDREPRESEN'� VE WEST YARMQUTH,MA 026'73 �f�,�_, �,�',,,y;_ ACORO 25(2810/65} The ACOHD name and logo are reglstered marks of ACORp 1998-20Y 0 ACOHD COHPORATI6N. All rlghts reserved,