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Home My WebLink AboutApplication and WC � . Yq� �� .-�" _�'�� TOWN OF YARMOUTH H��f � --e ' `3 1146 ROUTE 28, SOUTH YARMOUTH, MASSACHLJSETTS 0266 - �. �,�. t�`� $ Telephone(508) 398-2231, ext. 1241 _ _ Health �' �,t�E Fas(508) 760-3472 � Division t,�;,v j 0 2Ui4 y DE , To: Yannouth Business Establishments AMBASSHD02 It�N � 8U \ From: Bnxce G. Murphy, Director � ` � Q � / Yazmouth Health Departrnent �� "\ . � �G �V Date: November 7, 2014 � �� C1, Subject Incxea�e_in Licen�e/Pemut Fees R J Please be awaze that the Yazmouth Boazd of Health, under the direction of the Yarmouth Board of Selectmen, has raised a number of license and pernut fees issued through the Yannouth Health Department, effective January 1, 2015. Attached is the Yannouth 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 January 1, 2015. However, if you fully complete the application, and submit it to the Yarmouth Health Department with a11 required certifications and worker's compensation coverage informarion (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 Fee Public Swimming Pools $ 80.00 (2.� $l�o.Oo Public Wl�irlpooUVapor Baths $ 80.00 (,i� 80. 00 Tobacco Sa1es $ 95.00 Motels $ 55.00 $55•00 Restaurants 0-100 Seats $ 85.00 Restaurants Over 100 Seats $160.00 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: $ 35.0o conrrte�.g��aST Total fees owed for your establishme . 330.00 �e�� NOTE: To be entitled to pay the current 2014 rates listed above, your r`� business application, food and/or pool certifications, atong with worker's compensation information must be received, or mailed (postmarked) on or prior to December 31, 2014. [7'hose 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 springprior to opening" on the application.J BGM/maf I J �V�SJQ"�� TOWN OF YARMOUTH BOARD OF HEALTH � � APPLICATION FOR LICENSE/PERMI'1`- p� 5 � _��qs �3 n�� c �o�a * Please complete form and attach all necessary documents y December 5 2014. Failure to do so will result in the return of ybur applicahon packet. H�TM DEPT. ESTABLISHMENT NAME: = TA ID• - LOCATION ADDRESS: S 2 TEL.#:C MAILING ADDRESS: 6 E-MAIL ADDRESS: OWNER NAME: CORPORATION NAME APPLIC LE): �-�gx�,q�-�t �Q()p,q- C(�fl. MANAGER'S NAME: �`J��—(��P�� ' TEL.#: C��) 39�-�f DU7,7 MAILING ADDRESS: �— gp'rrrA� �S-P�nY� --� 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. i. P�vusrP ��zL 2. TIrU,�- P�L � Pool operators must list a minimum of two employees currently certified in basic water safery, 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. �I V/15+� �l�-� _ 2. rt 11�s� �� 3. / ,�r -� DJSO 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishxnents 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 Tile at your establishment. l. �/� 2. �,��--- _ PERSE3N�3 E�I�gfr$:---�—_---__-- 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 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. i. N��— a. 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 bvsiness. 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 �(;�' 0(I INN $55 CAMP $55 �SWIMMING POOL$l lOea—Q�T p2,5 _LODGE $55 �PRAILER PARK $105 �WHIRLPOOL $ll0ea.� FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100SEATS $125 �CONTINENTAL $35 /5—OJ� NON-PROFIT $30 >I00 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,OOOsq.ft. $150 —FROZENDESSERT $40 _TOBACCO $110 x.amEcxnrvcE: $is AMOUNTDUE _ $-�?�k8-6@- .00 *"*•*PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FOR ***** - _ �=`� 3 3�L�� 4�� r � ADMINISTRATION Under Chapter 152, Sectian 25C, Subsection 6,the Town of Yarmoutla is now required to hald issuance ar renewal� of any license or permit to aperate a business if a person or company does not have a Certi�cate of Worker's Compensation Insurance. THE ATTACHED STATE WQRKER'S COMPENSATION INSURANCL AFI+IDAVIT MUST BE COMPLETED APiD SIGNED, OR CERT. flP 1NSUf2ANCE ATTACHED OR WOFt.KEK'S COMP. t1FFII7AVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: � /'� YES L/' IVOv MOTELS AND CITHER LOAGING 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,ordinarily and customarily associateci with motel and hotel use. Transient occupants mnst have and be abte tp deznanstrate that they maintain a prancipal place of residence elsewhere.Transient occupancy sha11 generally refex to continuous occupancy af not more than thirty{30)days,and an aggregate nf nat mare 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. Oocupancy that is subject to the collection af Room Occupancy Excise,as deiined in M.G.L. c. 64G or 830 CMR 64G,as amended,shall generally be considered Transient. POOLS POC}L fJPENING:All swimming,wading and whirlpools which have been closed far the season must be inspected by the Health DepartmenY prior to opening. Contact the Health Department to schedule the inspection three(3) days pr'tor to opening. PI,EASE NOTE: Paople are N{JT allowed to sit in the paol area until the pool has been inspected and opened. POOL WATER TESTING; The water must be tested for pseudomanas,total coliforrn and standard plate count by a State certified lab, and submitted to the Health Department three (3) days prior to opening, and quarterly thereafter. Pf3f�L CL€}SING: Every outdo€rr ifl ground s�vimrning�ool must be drained or eovered within seuen{'1}days af closing. FOOA SERVICE SEASONAL FOOD SERVICE OPENING: All food service establishments must be inspected by the Health Department prior to opening. Please cantact the Health Departmant ta schedule tke inspection three(3) days prior to opening. CATERING POLICY: Anyone wha caters within the Town of Yarmouth must notify the Yarmouth Health Department by �ling the required Temparary Foad Service Application form 72 haurs prior ta the catered event. These forms can be obtazned at the Health Aepartment,or from the Town's website at www.yarmouthma.us under Health Department, Downloadable Forms. FROZEN DESSERTS: Frozen desserts must be tested by a State certified lab priar to opening and monthly thereafter,with sample results submitted to the Health Department. F'ailure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the abave terms have been rnet. OUTSII►E CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must haue prior approval frorn the Boazd af Health. — OUTDOOR COOHING: Outdoor cooking,prepazation,or display of any food product by a retail or foad service estabtishmarn is prahibited. IYOTICE:Permits run annually from January 1 to I3ecember 31. IT IS YOUR I2ESPONSIBILITY TO I2E"I't.1RN THE CC}MPLETED RENEWAL APPLICATION(S}AND RFQUIRED ��EE{S} BY DECEMBER 15,2014. ALL RENOVATIONS TO ANY FOOD ESTABLISFIMENT, MOTEL OR OOL (i.e., Pt�IN"CING, NEW EQUIPMBNT,ETC.), MIJST BE REPORTED TO ANI)APPItQVED B T BOA t?F HEALTH PRIQR 'CO COMMBNCEMENT. RENOVATIONS MAY REQUIRE A SITE P N. DAfE:�� (��SIGNATURF.: " PR1NT NAME& TITLE:�1�r�-��, —' � �_,.___ 1 -___ ... Rev. 1110}t7A -.�------�—�--_____._---.._.—. . � � The Commonwealth ofMassachusetts Department of Industrial Accidents ' Offzce oflnvestigations 1 Congress Street, Suite I00 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensat►on Insurance Affidavit: General Businesses AaaGcant Information Please Print Leeiblv Business/Organization Name:� �-f'�/i ��f�� ►�—� Address:_ J �, 1 C� , YY).QI-f N S'—t62 �—�=�1� ��2g Ciry/State/Zip: �'j0• 2 Phone #: g �j — 1Jll� Are y an employer? Check the appropriate box: Business Type(required): L I am a employer with�eanployees{full and/: - . 5:,,�] Retail._, - ` —. • � —_ . or part-time).* 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] $• ❑ Non-profit 3.❑ We aze a corporation and its officers have exercised 9. ❑ Entertainment their right of exemp6on per a 152, §1(4), and we have 10.0 Manufacturing no employees. [No workers' comp. insurance required]* 11.0 Fjealth Caze 4.❑ We aze a non-profit organization, staffed by volunteers, / y with no employees. [No workers' comp. insurance req.] 12.6U Other •Any applicant that checks box#I mus[also 511 out the section below showing their workers'compensation policy infotmatioa. '*If the coiporate officers have exempted themselves,but the cotporation has other employees,a workers'compensation policy is requiied and such an organization should check box#1. I am an emp[oyer that is providing workers'compensation insurance for my employee�s.+ Below is the policy information. InsuranceCompanyName:�� -Ly ''YI,�U'd'G7Y7CP ( OIU.LlY'ti'VL.4- � Insurer's Address:_n' _, '�(' ; �q� � City/State/Zip: rY 1�� 'L�- �— ��! F, , - _ - Policy#€ or SeZf-u�s:L�`c:� -- �,L�2� : `�s�f��'��— __ . �xpiraUon Date: � d� , — — Attach a copy of the workers' compensation policy declaration page(showing the policy number nd ea iration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of crimjnal 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 WORK ORDER and a fine of up to $250.00 a day agai the violator. Be advised that a copy of this statement may be forwazded to the Office of Invesrigations of the DIA fo i surance coverage verificarion. I do hereby certdfy,unde he girfs d penalties ofperjury that the information provided above is true and correct. Si ature: - Date: ) Phone#: Official use only. Do not write in this area,to be comp[eted by city or town officiaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Hea1tL 2. Building Department 3.City/Town Clerk 4.Licensing Board 5. Selectmen's Office 6.Other Contact Person: Phone#• www.mass.gov/dia Technology Insurance Company A Stock Insurance Company WORKERS COMPENSATION WC 99 00 01 B AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE Ncci Code: 39071 1. Insured: Poticy Number: TWC3400962 Gayai Krupa Corp. DBA:Ambassador Inn&Suites 1314 Rou[e 28 Individual Partnership South Yazmouth,MA 02664 X Corporation Other workplaces not shown above: — See Extension of Information Page Federat Tax ID: Risk Id: Producer: Renewalof: WWC3051916 AmTrnst Norrh America,Inc. c%GH Dunn Insuiance Agency,Inc. - P.O.Box 49� Mattapoisett,MA 02739 2. The policy period is from 3/9/2014 to 3/9/2015 12:01 a.m.at the insured's mailing address. 3. A. Workers Compensaaon Insurance:Part One of the policy applies to the Workers Compensation Law of the states listed here:Massachusetts B. Employers Liability Insurance:Part Two of the policy applies to work in each state listed in item 3.A. The limits of our liability under Part Two are: State Bodily Injury by Accident Bodily Injury by Disease Bodily Injury by Disease $500,000 each accident $500,000 policy limit $500,000 each employee C. Other States Insurance:Part Three of the policy applies to the sta[es,if any,listed here: All states except ND,OH,WA,WY and State(s)Designated in Item 3A. D. This policy includes these endorsements and schedules: See Extension of Information Page 4. The premium for this policy will be determined by our Manuals of Rules,Classifications,Rates and Rating Plans.All informarion required below is subject to verification and change by audit. See Extension of Informaaon Page TOTAL ESTIMATED ANNUAL PRENIIUM 919 STATE ASSESSMENT 21 TOTAL ESTIMATED COST 940 Minimum Premium 396 Deposit Ptemium � . 940 Issue Date: 2/14/2014 Countersigned by: t�t orized Representative N W � � O O N � 0 �