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Home My WebLink AboutApplication and WC oF'Y`qR � . � ; �� TOWN OF YARMOUTH Boazdof � �� Health �\-�. :- `?" 1146 ROUTE 28, SOUTH YARMOUTH,MASSACHLISETTS 02664-24451 - �;'<, � �:$ Telephone(508)398-2231, eart. 1241 Health�� '"�"`� Fax(508)760-3472 Divisio To: Yarmouth Business Establishments BAsS (2tvER piZ-ZF} ��d�D DEC l� 1 2014 From: Bruce G. Murphy, Director Yannouth Health Department HEALTH DEPT. Date: November 7, 2014 Subject: Increase in License/Permit Fees Please be aware that the Yannouth Board of Health, under the direction of the Yarmouth Board of Selectmen, has raised a number of license and permit fees issued through the Yannouth Health Department, effective January 1, 2015. Attached is the Yarmouth Business License/Permit Application for 2015. You will note that the fees listed aze 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 affidavit) urior 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 Motels $ 55.00 Restaurants 0-100 Seats $ 85.00 85-00 P�estaurants Over 100 Seats $16Q.Q0 - 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: .�(op.00 cAMMoN ��c• Total fees owed for your establishment: �t4S-o0 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 certifications prior to opening, however, you must note "Will provide in the spring prior to opening" on the application.J BGM/maf a TOWN OF YARMOUTH BOARD OF H�4LTI� `. �; ��OMf�DD �� APPLICATION FOR LICENSE/PER1t��,T��{� � � r � �� DE(, J 1 L014 " * Please complete form and attach all necessary, docu��ent5liy Decem er 15 2014. Failure to do so will result in the return of your applicahon pac et. HEALTH DEPT. ESTABLISHMENT NAME: � z G�- TAX ID: Sa^`^�� LOCATION ADDRESS: e- TEL.#: MAILING ADDRESS: E-MAIL ADDRESS: � OWNER NAME: � CORPORATION NAM (IF APP CABL . MANAGER'S NAME: ` J-c ` �n ✓ TEL.#: MAILING ADDRESS: ` 2 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 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 DepaMment will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. Z• 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. v. 2. PERSON IN CHARGE: Each food establishment must have at 1 one Person In Charge (PIC) on site during h •s of operation. i. �� ,� ..�- z. - � u� � . 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 all times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health DepaMment will not use past years' records. You must rovide new copies and maintain a file at your place of business. c 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# �,g OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERM[T# � LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $110 INN $53 —CAMP $55 SWIMMINGPOOL$IlOea. LODGE $55 _TRAILERPARK $]OS WHIRLPOOL $ll0ea. FOOD SERV►CE: � LICENSE REQUIRED FEE P RMIT# LICENSE REQUTAED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �0-100 SEATS $125 I . �O�J CONTINENTAL $35 NON-PROFIT $30 _>I00 SEATS $200 ' I COMMON VIC. $60 � ( _WHOLESALE $80 � —RESID.KITCHEN $80 RETAIL SERVICE: � LICENSE REQUIRED FEE PERMIT# LICENSE AEQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 a25,000 sq.ft. $150 _FROZEN DESSERT $40 TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE _ $ I Qj 'rj.f)Q **•**PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** ^'�y y��- �-` � ��'��J __,_. �-tl�:lX�� I� 1 l ADi�IINISTRATION iJnder Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required ta hold issuance or renewal of any licensa or permit to operate a basiness if a person or conxpany does not have a Certificate of Worker's Campensatian Insurance. THE ATTACHED STATE WOI2KER'S CQMPENSATION INSUI2ANCE AFFIDAVIT MUST RE COMPLETED AND SIGNED, OR CERT. QF INSURANCE ATTACHLD OR WORKER'S COMP. AFFIDAVIT SIGNED ANI3 ATTACHED Town of Yannouth taxes and liens must be paid prior to renewal ar issuance of'your permits. PT,EASE CHECK APPROPi2IATELY IF PAID: YES � NO MOTELS AND OTH�:R LODGING ESTABLISHMENTS TRANSIENT OCCUPANCYt Far purposes of tne limitations of Mot�l or Hotel use,Transient occupancy shall be lirnited to the temporary and short term occu�ancy,ordinarily 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 rnore than thirty(30)days,and an a��regate of not moxe than ninety(90)days within any six(6)month period. Use of a guest unit as a residenoe or dwelling unit shall not be eonsidered transienT. Occupaney that is subject to the collectian�f Roorn Occupancy �xcise, as defrned in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient. PO4LS P40L OPENING:AJ 1 swimming,wading and whiri�aoCs which hava been ciosed far the season must be inspected by the Health Department prior to opening. Contact the Nealth Deparlment to achedule the inspection three (3) days prior to opening. PLEASE NOTE.: Peogle are NOT ailowed ta sit in The poal arca until the pool has been inspected and opened. POOL WATER TES'CING: The water must be tested 1"or pseudamonas,total coliforni and standard plate count by a State certified lab, and submitted to the Heaith Department three (3} days prior to opening, and quarterly tl�ereaftex. POOL CLOSING: Every outdoar in ground swimming pool rnust be drained or covered within seven{7)days of alosing. FOOD SERVICE SEASONAL FOOD SERVICE OPENING: All food service establishme:nts must be inspected by t'he Health Department prior ta opening. Please eontact tt7e Health Deparfinent to schedule Yhe inspection three (3) days�rior to openu�g. CATFRTNG PflLICY: Anyone who caters within the Town o.f Yarmouth must notify the Yazmauth Health Department by filing the requued Temparary Food 3ervice Applicatian form 72 hours prior to the catered evant. These forms can be obtained at the Health Department,or from the Tawn's website at www. armouth.ma us under Health Deparhnent, Downloadable Forms. FROZEI�i DESSERTS: Frozen desserts must be tested by a State cerfified lab prior to opening and monthly thereafter,with sarnple results submitted to the Health Department. Failure to do so will resutt in the suspension or revocation of your Frozen Dessert Permit unYil the abave teuns have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waitariwaitress service},must have prior appxoval frorn the Board o1'Health. OUTDOOR COOHING: Outdoor eooking,preparation,�r display of any food product by a retail or foad service establishmenT is prohibited, NOTICE: Permits run annually frorn January 1 to December 31. IT IS YdUR I2ESPQNSIBILI`1'Y TO RETURN THE COMPLETED RENL�WAL APPLICATION(S}AND R�.QUIRED FEE(S} BY DECEMBER 15,2U14. ALL RENOVATIdNS TO ANY Fd4D EST�BLISHMENT, MOTEL OR PQOL {i.e., PAINTING, NEW F,QUIPMENT,ETC.}, MUST BE REPQRTED"I'O AND APPROVED BY THE BOARD UF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQ RE A DATZ:__��I-'t � SIGNATURE: P T NAME& TI'TLE:��rt' -��. �" `'v \ Rev.11143t14 � � The Commonwealth ofMassachusetts Department oflndustrialAccidents Offzce oflnvestigations I Congress Street, Suite 100 Boston, MA 02114-20I7 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses A licant Information se Print Le ibl Business/Organization Name: �-��- Address: � City/ ate/Zip: Phone #: ' ` Are y u an employer? Check the appropriate box: Business Type(required): 1. I am a employer with employees (full and/ 5. ❑ R i or�ut-time).*_ 6. estauranUBazBating 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 are a corporation and iu o�cers have exercised 9. ❑ Entertainment their right of exemprion per c. 152, §1(4), and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]* I I.❑ Health Care 4.❑ We aze a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.❑ Other *Any applicant that checks box#I must also fill out the section below showing the'v workets'compensarion policy information. **If the cocpornte officers have exempted[hemselves,but the corporation has other employees,a workers'compensation policy is required and such an organizaUon should check box#1. � I am an employer thaf is prov'din,g�worke 'compe tion insurance for my employees. Be[ow is the policy information. Insurance Company Name: � ^ y�. Insurer's Address � P p 2� b City/State/Zip: 2�� oV� 0 'C�JQ� � Policy#or Self-ins. Lic. # C —� ' � Expira6on Date: �(� ` � l� Attach a copy of the workers' compensation policy declaration page(showing the policy number and eapiration date). Failure 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 $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 forwarded to the Office of Invesrigations of the DIA for insurance coverage verification. I do hereby rtify,under ains and pena ies of perjury that the information provided above is true and correct. Si ature: Date: �-/- � Phone#: ' — Offzcial use only. Do not write in this area,to be completed by city or town officiaL 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.'.IYI. Mutual A.I.M. MutualInsuranceCompany Massachusetts Employers Insurance Company New Hampshire Employers Insurence Company INSURANCE COMPANIES Associated Employers Insurance Company RENEWALPROPOSAL WORKERS' COMPENSATION TEL.# (800) 876-2765 — LEASE MAKE REMITTANCE TO Date OS/22/2014 W A..M. Mutual Insurance Co � i dddWW��/ P O.Box 4070 - �� urlington,MA 01803-0970 i Bass River Pizza � / IMPORTANT: COVERAGE WILL NOT BECOME Cape Crust LLC V EFFECTIVE UNTIL YOUR POLICY EFFECTNE 1311 Route 28 � DATE. South Yarmouth, MA 02664 �� . PLEASE PAY THE TOTAL AMOUNT DUE SHOWN BELOW NO LATER THAN: INSURED September 23, 2014 Schlegel&Schlegel Insuranc rokers Inc payment of the deposit premium will constitute 34 Main Street Rt 28 the employer's acceptance of and agreement to West Yarmouth,MA 02673 the terms and conditions of the policy. PRODUCEFOFRECORD � Current Policy Expiretion Date 10/13/2014 � Renewal Policy EHective Date 10/13/2014 - Renewal Policy Number VWC-700-6016196-2014A � Estimated Total Rates Per Estimated Annual Premiums CODE qnnual $�OOof /' NO Remuneration Remun- Subjectto AllOther eration Modification SEE EXTENSION OF INFORMATION PAGE TOTAL ESTIMATED ANNUAL PREMIUM 1,797.00 TOTAL MA ASSESSMENT x%, DEPOSIT PREMIUM 1,797.00 DEPOSIT ASSESSMENT TOTAL AMOUNT DUE 1,797.00 FOR COMPANY USE ONLY NET AMOUNT OF CHECK Placing Office: 100-109-2 Initial&Date � AP 4921 (9-89) 54 Third Avenue• P.O. Box 4070• Burlington, MA 01803-0970•Tel: 781.221.1600/800.876.2765 • FaX; 781.270.5599 BRIDGEWATER• BURLINGTON . CONCORD, NH • HOIYOKE . MARLBOROUGH sponsored byAssociated Industries ofMassachusetts