HomeMy WebLinkAboutApplication and WC t �
OF�Y'�R
�� .-�" _ ��'.'�o TOWN OF YARMOUTH Ha�f
0,:.. �`� 1146 ROUTE 28, SOUTH YARMOUTH, MASSACHLJSETTS 02664-24451 -
�. �,�r�cXEt•°%'� Telephone(508)398-2231, ext. 1241 Divsion
Fax(508)760-3472
To: YazmouthBusinessEstablishments S��oNA��� ECac�v�tENCESTo�� �
From: Bruce G. Murphy, Director � RC�Cr,C�O�'/C�DD
Yarmouth Health Department�
NOY 2 E 1014
Date: November 7, 2014
HEAL7H DEPT.
Subject: Increase in License/Permit Fees
Please be aware that the Yazmouth Boazd of Health, under the direction of the Yarmouth Boazd
of Selectmen, has raised a number of license and permit fees issued through the Yannouth
Health Deparhnent, effective January 1, 2015.
Attached is the Yazmouth Business License/Permit Application for 2015. You will note that the
fees listed aze the fees effective Januazy 1, 2015. T'hese fees will be due if you complete and
submit the applica6on after January 1, 2015.
However, if you fully complete the application, and submit it to the Yarmouth Health
Department with all required certifications and warker's compensation coverage information
(certificate of insurance OR completed affidavit) 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
Public WhirlpooUVapor Baths $ 80.00
Tobacco Sales $ 95.00 5•O
Motels $ 55.00
Food Service 0-100 Seats $ 85.00
Food S�rvice Over i00 Seats - - -$Yb0.J� _ _ _ __ _ _ _ _ _'
Retail Food Service <25,000 sq. ft. $ 80.00 SO.op `'
Retail Food Service>25,000 sq. ft. $225.00
Other fees owed but not listed above:
Total fees owed for your establishment: �I'?5.00
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 andlor pool certif:cations prior to opening, however, you must note
"Will provide in the spring prior to opening" on the application.J
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` • STAi'lOhl/4JE.COt�1�6NlENCIE
a TOWN OF YARMOUTH BOARD OF HEALTH � C3��(��b�� ""'=
��� APPLICATION FOR LICENSE/PEE�I'�''-�,��0��;�� � Nn 9
�'" * Please complete form and attach all necessaa�y doc�nen"ts byDece ber 7S�2dhl.2O�4
Failure to do so will result in the retum of your application pa etH�LTH DEPT.
ESTABLISHMENT NAME: Ttean. Cna-o. �AR SI��;��, �4L�p c��a.TAX ID:
LOCATIONADDRESS: t-15~t �iic�;o�r� R,le. �.Uaam«,+G mw_oz6�LU TEL.#: So�s-=,9g-�SYsz%
MAILINGADDRESS: P.i3-(3c�r.. ��o. Gast �arndLL�:r_1,., tY1F\-o2�'��`7
E-MAIL ADDRESS: U tsh� �'l21'7 6 � LIcr.G,00.c.nm--.
OWNERNAME: il i�ha.f.. �,huk1L�
CORPORATION NAME (IF APPLICABLE): 'j-I't��--r, Cn��a49, ��cft_
MANAGER'SNAME: �ipa-i Shuk �� TEL.#: ��_52�i-1626
MAILINGADDRESS: j Paia-;rh� �U�1�/, �oxe�ddc5kn, m� -o��u
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator,as required by State►aw. 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 Cardiopulmonary Resuscitation (CPR), having one certified employee on premises at a11 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.
L 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 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 Sle 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 ttte premises at a11 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. Z•
3. 4.
RESTAURANT SEATING: TOTAL #
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERM[T# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
B&B $55 CABIN $55 MOTEL $I10
INN $55 CAMP $55 SWIMMINGPOOL$110ea.
LODGE $55 TRAILERPARK $105 _WHIRLPOOL $il0ea.
FOOD 5ERVICE:
LICENSE REQUIRED FEE PERMIT I! LICENSE REQUIRED FEE PERM[T# LICENSE REQUIRED FEE PERMIT#
0-100SEATS $125 _CONTINENTAL $35 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
�Q5,000 sq.ft. $150 ._��'_�.2,y _FROZEN DESSERT $40 �TOBACCO $1l0 ��
NAME CHANGE: $15 AMOUNT DUE _ $ Z-���OO
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** r!�G�� t���
_ ��3��� ���(��
ADMINISTRA.TIIJN
Under Chapter 152, Sectian 2SC, Subsection 6,the T'own of Yarmouth is now required to hold issuance or renewal
of any license or perrnit to operate a business if a person at cornpany does not have a Certificate of Worker's
Goinpensarion Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR
CERT. OF INSURANCE ATTACHED �"'
Ol2
WORKER'S COMP. AFFII3AVIT SIGNED AND ATTACHED
Town of Yarrnouth taaces and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROARIATEI.Y IF PAID:
YES_'� NO
MO'I'ELS A1VD OTHER LOl)GING ESTABI�ISHMF.NTS
TRANSIENT OCCUPANCY: Far purposes of the limitations of Motei or Hatel use,Transient occupancy sha(1 be
limited ta the temporary and short term occupancy,ordinarily and customarily associated with motel and hotel use.
Transient oocupants must have and be able to demonstrate that they maintain a principal place af residence
eisewhere.Transient occnpancy shall generally refer to continuous ocaupancy of not mare than tliirty(30)days,and
an aggregate of not more than nineYy(90)days within any six(6)month period. Use of a guest unit as a residence or
dwelling unit sha11 not ba considered transient. Oecupancy that is subjeet to the eollection of Raom Occupaney
Excise, as defined in M.G.L. c. 54G or &30 CMR 64G, as amended, shall generallp be considered Transient.
POOLS
PO(3L fJPENIN+G:All swimming,wading and whirlpools which have been closed for the seasan must be inspecced
by the Health Department prior to opening. Cantact the Health Department to schedule the inspection three(3)
days prior to openiag. PLEASE NOTE: People are NOT allowed fo sit in the paol area unril the pool has been
inspected and opened.
POOL WATEB TESTING: The water must be tested for pseudomonas,total colifarm and standard plate count
by a State certified lab, and subm3tted to the I3ealth Department three (3} days prior to opening, and quarterly
thereafter.
P4t}L CLOSING: Every outdoor in ground swimming paal must be drained or covered within seven{7}days of
closing.
FOOD SERVICF,
3EASdNAL FOOD SERVICE OPENING:
All food service establishrnents must be inspected by the Health Department prior to upening. Please cnntact the
Health L?epartment to schedule the inspection three (3)daps prior ta opening.
CATERING POLICY:
Anyone whn caters within the Town of Yannouth must natify the Yarmouth Health Departrnent by filing the
required Temparary Foad Service Application form 72 haurs prior ta the catered event. These forms can be
obtarned at the Health Department,or from the 1'own's website at www.yannouth.ma.us under rIealth Department,
Downloadable Forms.
FR4ZEN DESSERTS:
Frozen desserts must be tested by a State certified lab prior to opening and monthly thereafter,with sample results
submitted tp the Health Department. Pailuze ta do so will result in the s�xspension or revacation of your Frozen
Dessert Fermit untii the above terms have been met.
dUTSI1?E CAF�.`S:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval fram the Board of Health.
OUTD0012 COOKINC>:
Outdoor cooking,prepazation,or display of any food product by a retaif or food service establishment is prohibited.
NOTICE:Fermits run annually fram January 1 to December 31. IT IS YQUR RESPONSIBILITY TO RE'I'[7RN
THE CC?MPLETED RENEWAL APPLICATION{S)AND REQUIRED FEE{S} BY DBCEMBER 15, 2014.
ALL RENOVATIONS 1'd ANY FOOD ESTABLISHMENT, MOTEL OR PdOL (i.e., PAINTING, NEW
EQti1PMENT,ETC.},MUST BE REPQRTED TO AND A]'PROVED BY THE BQARD OF I3EALTH PRIOR
TO COMMENCEMBNT. RENOVATIONS MAY REQUIRE A SITE P N.
DATE: ��-� q_ rLp��..� SIGNAT'URE: l��a�<�—
PRiNT NAME&TITLE: v i�i�n� ��'}U}t 1 t�.; � d t-c.? �3�Q?s- 7
Reu llf43f14
� � � The Co»unonwealth ofMassachusetts
Department of Industrial Accidents
Office oflnvestigations
I Congress Street, Suite I00
Boston,MA 02I14-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Aualicant Information Please Print Le¢iblv
Business/Organization Name:�' c,�. �.o-,rm `�(�.Q . S+c�;c� e_C�,n 1p_
Address: i.�5-� Siz�,l-i nm Yk✓�
City/State/Zip: _uQ�-r»ou i-� ,��654 Phone#: So��- '�a�-'l soo
Are you an employer? Check the appropriate bos: Business Type(required):
1.� I am a employer with�employees(full and/ 5. ❑Retail
or part-time).* 6. ❑ RestauranUBaz/Eating Establishment
2.❑ I am a sole proprietor or partnership 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 are a corporation and its officers have exercised 9. ❑ Entertainment
their right of exemption per c. 152, §I(4), and we have 10.Q Manufacturing
no employees. [No workers' comp. insurance required]* 11.❑ Health Care
4.❑ We are a non-profit organization,staffed by volunteers,
with no employees. [No workers' comp. insurance req.] 12.❑ Other
•Any applicant thaz checks box#1 must also fill out the section below showing their workers'wmpensation policy information.
'fIf the coryorate officeis have exempted themselves,but ihe cocporation has o[ha empbyees,a workecs'compensation policy is required and such an
organiza6on should check box#L � �
I am an emp[oyer that is providing workers'compensation insurance for my employees. Be[ow is the policy injormalios.
Insurance Company Name: ����{-�y,j �ptrS •
Insurer's Address:
City/State/Zip:
Policy#or Self-ins. Lic. # 0\L1(�n(L.�j7 '? 1 C-�l l '3 Expiration Date: 1 - 1 - 2a� �
Attach a copy of the workers' compensation policy declaration page(showing the policy number and espiration date).
Failwe to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition 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 WORK 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
Investigations of the DIA for insurance coverage verification.
I do hereby certi ,under the pains andpenalties ofpesjury that the information provided above is true and correct
Signature• �� `-t��— Date: �1- 2�-4 - ?1�� �
Phone#: Sores- '�°14's -'1�cS�
Off:cial use anly. Do not write in this area,to be comp[eted by city or town offaciaL
City 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: Phone#:
www.mass.gov/dia
A� R��` CERTIFICATE OF LIABILITY INSURANCE �"TE ,M"���
,vos�zo,a
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATNELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER AND THE CERTIFICATE HOLDER.
IMPORTANT: If Ihe certHiwte holtler is an ADDRIONAL INSURED, the policy(ies) musl be entlorsetl. If SUBROGATION IS WAIVED, subject to
the tertns and contlitions oi the policy,cer[ain policies may requlre an entlorsemenl. A statement on Ihis cerlificate does not confer righls to the
certificate holtler In Iieu oi such entlorsement(s).
PRO�WER Phone: (508)]513132 Fax: 50&]59-]1]] H�EA�T Deborah Hathaway
GHDUNNINSURANCEAGENCY,INC. adorvE— � ���� ��� ^'° . 508-295-0360 ���
P O BOX 330 uc�E.i: 508 295-0005 ���2,
E-"i"" deboreh hdunn.com
215 MAIN STREEf nnoaEss . ,...... �9
BUZZARDSBAYMA02532 �NSUREWS�AFFORDINGGOVERAGE�� �� NAICN
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SOUTH YARMOUTH MA 02664
INSURER E :
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COVERAGES CERTIFICATE NUMBER: 23820 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICV PERIOD
INOICATED. NOPNITHSTANDING ANY RE�UIREMENT, TERM OR CONDITION OF ANV CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAV BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALLTHE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAV HAVE BEEN REDUCED BY PAID CLAIMS.
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DESGRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,AtlGltlonal Remarka ScheENa,i/more npace Is roquiraG)
CERTIFICATE HOLDER CANCELLATION
ToWn of Y3fmouth �'. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
: THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
'; ACCORDANCE WITH THE POLICV PROVISIONS.
�. .. . _. _ _. _ ._— __ ..- ___. _._
.. MttHORREO REPRESENTTTIVE �
Attention: � �''.
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The ACORD name and logo are registered marks of ACORD