HomeMy WebLinkAboutApplication and WC ,
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�� .-��`�c TOWN OF YARMOUTH Boazdof
Health
��\\�y 1146 ROUTE 28, SOUTH YARMOUTH, MASSACHiJSETTS 02664-24451 -
�: �, ,� 'r Telephone(508)398-2231, ext. 1241 Health
r���NEE DiVision
Fax(508) 760-3472
To: Yannouth Business Establishments EcoNol_oDcsE � Q Z014
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From: Bnxce G. Murphy, Director HEqLTH DEPT.
Yarmouth Health Department
Date: November 7, 2014
Subject: Increase in License/Permit Fees
Please be aware that the Yannouth Boazd of Health, under the direction of the Yannouth Boazd
of Selectmen, has raised a number of license and permit fees issued through the Yarmouth
Health Deparhnent, 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 all required certifications and worker's compensation coverage information
(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
Pubiic Swiimning Pools $ 80.00 $ f3o.CX�
Public WhirlpooUVapor Baths $ 80.00 80.
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: �-oo conmw�2EP.kFAsr
Total fees owed for your establishment: 22 D.W
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 and/or pool certi,fications prior to opening, however, you must note
"Will provide in the spring prior to opening" on the application.J
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w TOWN OF YARMOUTH BOARD OF HEALTH �j �
e��� APPLICATION FOR LICENSE/PEIZMIT-��2��0�1.����' �;;;y 0 LU)4
" * Please complete form and attach all necessarp documents Tiy Dece er I S 2014.
Failure to do so will result in the return of yout application pa ket.HEALTH DEPT.
FSTABLISHMENT NAME• � CNv l—C;'�k,�- l= TAX ID: �}
LOCATION ADDRESS: `'�i 1 �=- • MPr�-N ST TEL.#: ��5-17 I o��
MAILING ADDRESS: 1ZOU�- �g
E-MAIL ADDRESS: l=Lc�N C i_t?�L�E�ik1'L.�7 �7 C�M c-i� � C�'M
OWNERNAME: �i=-vf�N�� P�'t��-�--
CORPORATION NAME(IF APPLICABLE): `�P�Nk��' CC�6Z�
MANAGER'S NAME: "=Li=S l-F 1�i�AL-�/}� TEL.#: jb8-�1'71•-vG-"icl
MAILING ADDRESS: S� C N1liit�l �� ��a� w��y/�'2INClu�l-� Ml�r c%"'�'i 3
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated
Pool Operatar(s) and attach a copy of the certification to this form.
i. �►��NPRTIKUY\�� � T�\�1Y.�LW�"L�- 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 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 tile at your place of business.
1. � �.�5�,t 'V�AC--��� 2. SF�iL�/�"(Z �'J'`�1�1C-r l�-1
3. 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 Healt6 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. Z•
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 Deparhnent will not use past years' records. You must
provide new copies and maintain a fle 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 all 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. Z•
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 ZFlS-d�S
—INN $55 CAMP $55 �SWIMMINGPOOL$ll0ea.-��9
LODGE $55 _TRAILERPARK $105 �WF{IRLPOOL $t10ea. J
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# L CENSE REQUIRED FEE P$ IT# LICENSE REQUIRED FEE PERMIT#
- 0-100SEATS $125 �CONTINENTAL $35 �iR/r�08� NON-PROFIT $30
>100 SEATS $200 COMMON VIC. $60 WHOLESALE $80
— — —RESID.KITCHEN $80
RETAIL SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQU[RED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
<50 sq.ft. $50 >25,000 sq.ft. $285 _VENDING-FOOD $25
—<z5,000sq.ft. $l50 _FROZENDESSERT $40 _TOBACCO $110
NAMECHANGE: $15 AMOUNTDUE _ $ .�i�S�1oO
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** ��t� " ��`OO
cP�,�#'t.36�1 I/2a��
ADMINISTRATION
Under Chapter 152,Section 25C, Subsection 6,the Town of Yazmouth is now required to hold issuance or renewal
of any license or permit to operate a business if a person or company does not have a Certificate of Worker's
Compensation 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 priar to renewal ar 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 thirty(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 Deparirnent prior to opening. Contact the Health Departrnent to schedule the inspection three(3)
days prior to opening. PLEASE NOTE: People are NOT allowed to sit in the pool area until the pool has been
inspected and opened.
POOL WATER TESTING: The water must be tested for pseudomonas,total wliform and standard plate count
by a State certified lab, and submitted to the Health Departrnent three (3) days prior to opening, and quazterly
thereafter.
POOL CLOSING: Every outdoor 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 Yarmouth must notify the Yarmouth Health Department by filing the
required Temporary Food Service Application 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.varmouth.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 yoar 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 of Health.
OUTDOOR COOHING:
Outdoor cooking�preparation,or display of any food product by a retail or food service establishment is prohibited.
NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILTTY 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 REQUT A�AN.
�DATE: � ( '�O I I 4 / �IGNATURE: C�.
—�—
� PRINT NAME& TITLE: ZLbS l-I I3 EF��
Rev. 11/03/14
� The Commonwealrh ofMassachusetts
Department oflndustrialAceidents
O�ce of Investigntions
1 Congress Street, Suite l00
Boston, MEt 02I14-201�
www.mass.govldia
Workers' Compensation Insurance Affidavit: General Businesses
Annlicant Information Please Print Le�iblv
BusinessiOrganization Name: �L 1�C Z, t...i_.C
Address: `.��� t= N(l(�i� S�C"
Ciry/State/Zip: �% Y142tWh:�l-4 MPt C�`7 3 Phone#: "�t,�,�7� 1,- U���l
Are you an employer? Check the appropriate box: Business Type(required): �
1,(� I am a employer with_�__employees(full and/ 5. ❑ Ratail
ar part-rime).* 6. ❑ RestaurantlBazfEating Esfiablishtnent
2.❑ I am a sole proprie4or or parmership and bave no
7. ❑ Office and/or Sales(incl.real estate,auto, etc.)
emplayees working for me in any capacity.
[No workers' comp.insurance required] $• ❑Non-profit
3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment
their rsght of exemption ger c. 152, §1{4},and we have �p_� Manufachuing
no employees. [No workers' comp. insurance required]* 11.0 Health Care
4.❑ We are a non-profit organizarion, stafFed by volunteers,
with no employees. [Na workers' comp. insurance req.] 12.[�Other �"�LL� (V�(7�CZ
*Any applicant that checks box kl must also fill out the secdon below s6awiag the'v workers'compensstion policy infocmation.
"*If the eorporate officers have exempted themsefves,but�e earporaflon has other employees,a workets'compensasion poHcy is
requrred aod such an
organization should check box#1.
I am an employer that is providing worke�s'compensarion insurance for my employees. Below ts the poldcy information.
Insurance Company Name: �c Z\"C
Insurer's Address:
City/State/Zip:
Policy#or Self-ins. Lic. #_11vCL_—�U�--�D�3fv755 - �?�Lt-Q Expiration Date: 7'�4 �aU� �
Attach a copy of the workers' compensafion policy declaration page(showing the policy number and eapiration date).
Failure ta s�cwe cotrerage as requ_ired uxider Sectio_n_25A of MGL c.152 can Iead to tha imgosi#ion of criminai penalties of a
fine up to$],500.00 and/or one-year imprisonment,as well as civil penalties in tY�e form of a STOP WORK ORI7ER and a fine
of up to$2SO.Op a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Invesrigations of the DIA for insurance coverage verification.
I do hereby cerfify,undet the paixs and perttttlies of perjury that fhe infarmaYiox pravided above is true and rarrec7.
SiQnature: l��o � Data• �1 �� t i y
Phon�#: °�6 - 7�1 `-����c�
Offtcial use on[y. Do not wrue in this area,fo be completed by city or town offtcial
City or Town: Perarit/License#
Issuing Authority(circle one):
I.Board of Health 2. Building Department 3. CitylTawn Clerk 4.LicensEng Board 5.Selectmen's Of�ce
6.Other
Contact Person: Phone#:
www.mass.govldia
Client#:14255 2ECQNOLODOE
ACORD,� CERTIFICATE OF LIABILITY INSURANCE �"'�"��'
08125/2014
THIS GERTIFICATE IS ISSUED AS A MA7TER OF INFORMATION ONLY AND CtlNFERS Nd RIGHTS UPON THE CEI2TIflCATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIYELY OR NEGAI7VELY AMEND,EXTENQ OR ALTER THE GOYERAGE AFFORDEQ BY THE PQLICIE3
BELOW.THIS CEitTIFlCATE bF�NSURANCE DOES NOT CONSTRU7E A CONTRACT BETWEEN THE ISSUING IMSURER(S},AilTHUR�ZEO
REPRESENTATIVE OR PROOUCER,AND THE CER7IFICATE HOLDER.
IMPORTANT:�FF the certificate hoider is an ADDITIONAt INSURED,the poiicy(ies}must be sndaned.N SUBROGATIOht IS WANEO,aubjeGt to
the terms and conditions of the policy,certain policiee may require aa endorsement.A statement on ehis certificate does not confer Hghts to the
certiflwte hoider i�iieu of such mdorsement{s).
iRtlDUCE0. NAM ACT
Dawling&O'Meii P�N, :568775-1620 ....... �K�"'G`.N,: 54877812i8
Maurance Ageney n oo a�ess: ..... _.—.....
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H annis,MA 02601 �
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cto David Patel;59 Raute 28 iNsuaea o: ^ �
West Yarmouth,MA 02673 �rygURERE: T_,_?
INSURER F:
COYERAGES CERTIFiCATE NUMBER: REVISION kUMBER:
TMIS IS TO CERTIFY THAT iHE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANOING ANY ftEQUIREMENT, TERM OR CON�ITIONOF ANY CONTRACTOR OTHER QOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY &E ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDEO eY TNE POLlqES 6ESCRieEO HEREIN tS St�JECT Tp AIA THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHqWN MAV HAVE BEEN pRpF�D��UCELI BV PAID CLAIMS.
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DESCftIPTION OF OPERATIONS below ,,,__ .
OE3CWPTQN OF OPERAlIONS/LOCqTON3/VEHICLES(AMacM1 ACORD i01,AAtliGonal kamuka ScM1epule,V mom s0ace ie requiretl)
Insurance coverage is lirnited to tha tertns,conditions,exclusions,other limitations and emlorsements.
Nothing Contained in tMe certificate of insuronce shall be deemed to have altered,waived,or extended the
coverage provided by the policy provisions.
Insurance eoverage is fimited fo the terms,eonditions,exdusians,attrer limitations and endorsemants.
(See ANached Descriptians)
CERitFlCATE HOLDER CANCELLATION
T4Wn Of YatlflOu{I7 SND��D ANY OF TtiE ABOVE DESCRIBED POLICIES BE CANCELLED BEPORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE OELIVERED IN
f 146 Route 28 ACCORAANGE Y11TH 7HE POLICY PROVISIONB.
South Yarmouth,MA 02664 �
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k�1988�2010 ACORD CORPORATION.All rights reserved.
ACORQ 25{2614105} � of 2 The ACORD name and iago are registered marks of ACORD
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