HomeMy WebLinkAboutApplication and WC o�'�qR
�� -�" s �`�o TOWN OF YARMOUTH Ha�f
� --:.. :�- �`� ll46 ROUTE 28, SOUTH YARMOUTH,MASSACHLJSETTS 02664-24451 -
N 4�r�AiME�,� $ Telephone(508)398-2231, ext. 1241 D v s�'on
Fas(508) 760-3472
To: YarmouthBusinessEstablishments S�sTP�c.��DC���
From: Bruce G. Murphy, Director �
Yarmouth Health Department�
Date: November 7, 2014
Subject: Increase in License/Permit Fees
Please be awaze that the Yazmouth Boazd of Health, under the direction of the Yannouth Boazd
of Selectmen, has raised a number of license and permit fees issued through the Yazmouth
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 applicafion after Januazy 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 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
Motels $ 55.00
Food Service 0-100 Seats $ 85.00
Food Service Over i00 Seats $160.00
Retail Food Service <25,000 sq. ft. $ 80.00 C�.OU
Retail Food Service>25,000 sq. fr. $225.00
Other fees owed but not listed above: �_
Total fees owed for your establishment: � 80,pp
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
i�n`�.�
"Will provide in the spring prior to opening" on the application.J
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. �Usr PicxED CnF`rs
� TOWN OF YARMOUTA BOARD OF HEALTH G3�C�C�M�DD ,
��� APPLICATION FOR LICENSE/PE IT -201 �
�, ., ��st�t� �S 4 =
* Please complete form and attach all necessary�ocuments by D em��'1� �ld�.
Failure to do so will result in the return of your applicatio packet.
HEALTH DEPT.
ESTABLISHMENTNAME: LL TA D•
LOCATION ADDRESS: /3 I�/f�,0�/ S��k�'rrirr-�I�2f"�l�`-TEL.#: 3�a���S--G2aof
MAILING ADDRESS: �a 1 Lv./ /w � , U/4��� o�iif-/1Z�9- 6�7.5�
E-MAILADDRESS: ( n-�Gd-Ir`Nrb� TUS`I-Pi cICe�S Cdn.�
OWNER NAME: ��r���c1�n�
CORPORATION NAME(IF APPLICABLE):
MANAGER'S NAME: /�- r� TEL.#: SOtP- G3� - oZ
MAILING ADDRESS: � O
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.
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_. _ _ _ _ _ -
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1. 2.
Pool operators must list a minimum of two employees currently certified in basic water safety, standazd 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 file at your place of business.
1. Z•
3. 4.
FOOD PROTECTION MANAGERS - CERTIFICATIONS:
All food service establishments 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�ot 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 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-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:
UCENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
B&B $55 CABIN $55 MOTEL $110
I]V1V $55 CAMP $55 SWIMMINGPOOL$IlOea
LODGE $55 TRAILERPARK $]OS _WHIRLPOOL $ItOea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
0-100 SEATS $125 —CONTINENTAL $35 NON-PROFIT $30
>I00 SEATS $200 COMMON VIC. $60 WHOLESALE $80
— —AESID.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
�<25,000 sq.ft. $150 . . Iti-C1�7(n —FROZEN DESSERT $40 _TOBACCO $110
NAME CHANGE: $15 AMOUNT DUE _ $ I�JC�. OC�
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*****
ADMINISTRATIQN
Under Chapter 152,Section 25C,Subsectiori 6,the Town of Yarmouth is naw required to hold issuance or renewal
of any license or perniit to operate a business if a persan or company does npt haue a Certiftcate of Worker's
Compensation Insurance: THE ATTACHED STATE WOI2Kl.R'S COMPENSAT'ION INSUI2ANCE
AFF'IDAVIT MIJST SE COMPLETED AND SIGNED, UR
CER1'. QF iNSURAN{"E ATTACHED �
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Toum of Yarmouth taxes and liens rnust be paid pr;or to renewal t�r issuance of your permits. PLEASE CHECK
APPROPRIA'CELY IF PAID: �
YES NO
VIOTELS AND OTHER I.ODGING ESTABLISI3MENTS
TRANSIENT OCCIJPANCY: For pucposes ol'the limitations ofMotel or Hotei use,Transient occupancy shall be
limitad to the temporary and short term occupancy,ordinarily and custornarily 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 aecupancy shall generally refer ta continuous occupancy a f not rnore than thirry(34)days,and
an aggregate of not more than ninety(90)days within any six(6)month period. tJse af a guest unit as a residence or
dwelling unit shalI not be considered transient. Qccnpancy that is subject to the callect3on of Raom Occupancy
Excise,as defined in M.G.L. c. 64G or 830 CMR 54G, as amended, shall generaliy be considered Transient.
POCILS
POQL OPENING:All swimming,wading and whirlpaols which have been closed far the season must be inspected
by the Health llepartment priar to opening. ConYact the Health Department to schedule the inspectian three(3)
days priar ta opeaing. PLEASE NOTF: People are NOT allacved to sit in the poaI area until the paol has been
inspected and opened.
POOL WATLR TESTING: The water must be tested for pseudomonas,tota(coliform and standard plate count
by a State certified lab, and submitted to the Health Department three (3) days prior to opening, and quarcerly
thereafter.
POOL CLOSING: Bvery outdaar in ground swimming paol must be drained or covered within seven(7)days of
closing.
— - _
FO011 S1:RV CC�
SEASONAL FOOD SERVICE OPENING:
All food service establislunents must be inspected by the Health Deparhnent priar ta opening. Please contact the
Health Department to schedule Yhe inspection three (3)dt�ys prior to opening.
CATERING POLICY:
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the
requared Temparary Foad Service Applicatian farm 72 hours priar to the catered evcnt. These forms can be
abtained at the Health Department,or from the Toum's website at�,vww.varmouth.ma.us under Health Department,
Downloadabte Forms.
FROZEN DESSERTS:
Frozen desserfs must be tested by a State certified lab prior to opezung and rnonthly thereafter,with sample results
submitted to the Health Department. Failure to do so witl result in the suspension or revocation of your Frozen
I7essert Permit unti] the above terms have been met.
QUTSIDE CAF�.`S:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval frorn the Board of Health.
QUTDOQR COOHING:
Outdoor cooking,preparation,or dispIay of any faod product l�y a retail or food service establishment is prohibited.
NOTICE:Permits run annually from January I to December 3 l. IT IS YOUR RESPONSIBILITY 7'0 RETCJRN
THE COMPLETEI}RENL;WAL APPLICA'TION{S} AND REQI7IREI}FEE(S}BX DECEMBER 15, 2014.
�LL RENOVATTONS TQ ANY FOOD �STABLISHMENT, NIOTEL OR POOL (i.e., PAINTINU, NEW
EQUIPMENT, ETC.}, I+rfUST BE REPORTED TO AND APPRdVED BY TFTE BQARD OF HEALTH PRIOR
't`O COMMENCEMENT. RENOVATTONS MAY ItEQUIRF A SITE PLAN.
DAT�: l � l���?��_SIGNATURE: `���.�,� ��
7 f
z=�vT Na��� TI�rzE: C-�`Sl� {M�� I i N�� ���s.��
Rev. fI7G3t14
� ' � `t `� The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
I Congress Street, Suite I00
Boston, MA 021I4-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
AAplicant Information Please Print Legiblv
Business/Organization Name: 5�st �I��f� C L,�i e—
Address: �� l�->�� �t b W 5-E- U�hf v�n o cJ`(�-� o�lt� I,�/l� �Z�� �
City/State/Zip: Phone #: `.�b � ^ 3�e�- — C>�O�
Ar,.e,�°u an employer? C6eck the appropriate box: Business pe(required):
1.LI I am a employer with�employees (full and/ 5. etail
or part-time).* 6. ❑ RestauranUBazBating 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 o�cers have exercised 9. ❑ Entertainment
their right of exemption per c. 152, §1(4),and we have 10.❑ 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#I must also fill out the secflon below showing[heu workers'compensarioa policy infoimatiou.
**If the cotporate officers have exempted themselves,but ihe corporation has other employees,a workers'compensation policy is requ'ved and such an
organization should check box#I.
I am an employer that is providing w�,o/rkers'pcampensation insurance for my employees. Be[ow is the policy information.
InsuranceCompanyName: l"l� f'L� f l,�l � f�ei�'7Q�� T1� �l' � �9/�Ov�� .L� �/
Insurer's Address: �� /O � X �� �� �� — �� �'}
City/State/Zip: 4�rG-!n frf � � y � � / �- �j
Policy#or Self-ins.Lic. # � � ���J �� �-����� /� � E�cpiration Date: ��� ��'�� ��
Attach a copy of the workers' compensation policy declaration page(showing the policy nnmber and espiration date).
Failure tn secuce coverage as require�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 forwazded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify,under the pains and penalties ofperjury that the information provided above is true and correct.
C '
Si�nature: �� Date• ���Z� ���
Phone#: �6 �,���—�/��� �
Officia[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 Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmeds Office
6. Other
Contact Person: Phone#:
www.mass.gov/dia
WORKERS �OMPENSATION AND II+IPLOYERS LIABILITY INSURANCE CERTIFICATE
INFORMATION PAGE RENEWAL AGREII�NT
Producer: Agent� 826
MA Retail Merchants WC Group Inc. Sullivan Insurance Group, Inc.
PO Box 859222-9222 One Chestnut Place
Braintree, MA 01285 Worcester, MA 01608
(Carrier Code: 34355) Certificate 4i: 014005031589114
Prior Certificate 4l: 014005031589113
1. The Employer: Dennis East International, LLC
Mailing Address: 221 Wi11ow Street
Yarmouth Port, MA 02675
Fein:
Other workplaces not shown above: ltjpe o£ Business: Limited T,iability Co
SEE SCfIEDULE OF OPERATIONS Risk ID:
2. The c rtificate period is from 12:01 a.m. on 1/O1/2014 to 12:01 a.m. on
1 at the insured's mailing address.
3. A. W rkers Compensation Coverage: Part One of the certi£icate applies to the
W rkers Compensation Law oP the states listed here:
MA
B. Employers Liability Coverage: Part n,*o o£ the certi£icate applies to work in
each state listed in Item 3.A. The limits o£ our liability under Part 7.4ao are:
Bodily Injury by Accident $ 500.000 each accident
Bodily Injury by Disease $ 500.000 certificate limit
Bodily Injury by Disease $ 500.000 each employee
C. Other States Coverage:
D. This certificate includes these endorse�ents and schedules:
WCOOOOOOA(04/92) WC000310(04/84) WC000406A(08/95) WC000414(07/90) WC000422A(09/08)
WC200301(04/$4) WC20030Z(OS/A6) WC200303B(07/99) WC200405(06/O1} WC200601(06;92)
4. The contribution-for this certificate will be determined by our Manuals o£ Rules,
Classi£ications, Rates and kating Plans. All in£ormation required below is subject
to verification and change by audit.
Classifications Code Contribution Basis Rate Per Estimated
No. Total Estimated $100 0£ Annual
Annval Remuneration Remuneration Contribution
SER SCfIF1)iTLE OF OPERATIONS
Total Estimated Annual ConY.ri.bution .16,964.00
Minimum ContriLution $ 339.00 Expenr,e Constant $ .00
WC 00 00 O1 A IsSue Date: 1/29/2014 Countersigned by ___.___
SCHEDULE OF OPERATIONS FOR: PAGE: 1
Dennis East International, LLC Certificate #: 014005031589114
221 Willow Street Fein:
Yarmouth Port, MA 02675
OTHER WORKPLACES:
Four Corners International Ventures, LLC
221 Willow Street
Yarmouth Port, MA 02675
Fein:
Just Picked LLC
7-13 Willow Street
Yarmouthport, MA 02675
Fein:
Dennis East International, LLC
225 White' s Path
South Yarmouth, MA 02664
Dennis East International, LLC
Corner Rt 6 and Willow St.
Yarmouthport, MA 02675
WC 00 OU O1 A