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Home My WebLink AboutApplication and WC oF'Y`9R �� .� . �''�� TOWN OF YARMOUTH Boazdof y G, Health ��--� = ��`� 1146 ROUTE 28, SOUTH YARMOUTH, MASSACHUSETTS 02664-24451 " �.�`s,�. ��';'� Telephone(508)398-2231, ext. 1241 Health rA t�E Fax(508) 760-3472 Division �� u S/ To: YazmouthBusinessEstablishments Suewi�`i , ,�m„� 2� ��y,�� L�tiF� From: Bruce G. Murphy, Director � p[��[�OC�I�D Yarmouth Health Department� Utl; U 2 [U14 Date: November 7, 2014 HEALTH DEPT. Subject: Increase in License/Permit Fees Please be awaze that the Yarmouth Boazd of Health, under the direction of the Yannouth Board of Selectmen, has raised a number of license and permit fees issued through the Yarmouth Health Department, effective January l, 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 �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 Public WhirlpooUVapor Baths $ 80.00 Tobacco Sales $ 95.00 Motels $ 55.00 Food Service 0-100 Seats $ 85.00 $ 85.00 Foa3 Service Over l OC 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 listedabove: $ (Qo. oo coKkoN v�c. Totai fees owed for your establishment: �I�kS UO 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 prlor 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 springprior to opening" on the application.J BGM/maf S�Bw � TOWN OF YARMOUTH BOARD OF HEALTH ��p�v]�DD �� APPLICATION FOR LICENSE ERMIT -2 1 �,�`�� `�� ,�� i��t4 * Please complete form and attach all neces o um n s y Dece be Failure to do so will result in the return of your application p cke H��TH DEPT. ESTABLISHMENT NAME: y �-��-�...T L��S� v TAX ID: 5/4-M LOCATION ADDRESS: �S/ CS',Ov 7� Z F TEL.#: L/7 L�(� i l�(� MAILING ADDRESS: �,�7 G'�ok S�s9 L"'Lr�i,00� �.a o z6� 7 E-MAIL ADDRESS: /� q�o c c�r�a � �a�rc�e`-.v�i` O WNER NAME: �r�o..� /�/',�✓JrR,��✓2._. CORPORATION NAME (IF APPLICABLE): C�i// �v� —.��vc , MANAGER'S NAME: �� f�i9��to�Av�� TEL.#: 6<�66f/�79 MAILING ADDRESS: B`"7 7D�u�/� L��- „ ,�l��....3.;0�� Z�v .� 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 Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one fixll-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. i.�f�� I,aST�i��v,e� a. 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: l�`' C/a-�.� iF �t/�>� .—�tii/;'� rj� I�'C- ut}4ll �N SiY�.�'SAFi 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 Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# oZ S� OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $110 INN $55 CAMP $55 SWIMMING POOL$110ea. _LODGE $55 TRAfLER PARK $105 WHIRLPOOL $110ea. FOOD SERVICE: ' LICENSE REQIDRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �0-100 SEATS $125 - �-O (o CONTINENTAL $35 NON-PROFIT $30 _>]00 SEATS $200 �COMMON VIC. $60 -l-#�2- _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 <25,000 sq.ft. $I50 _FROZEN DESSERT $40 TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE _ $ I�5.O`Cl �a *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** 7'<<-�� `,��'�� c��-� rs�y ��/��f ADMINISTRATION CTnder Chapter 152,Sectioti 25C,Subsection 6,the Town of Yannouth is now required to hold issuance or renewal , o£any.licanse,or permit to oparate a business if a person or company dc�es not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE W{}RKER'S CQMFEi�SATIQN INSURANCE AFFYDAVIT IYIUST BE COMPLETED AND 3IGNELI, OR CF,R7". OP INSURANCE ATTI1CHIiD OR WORKER'S COMP. AFFIDAVIT SIGNED ANI)A'1"I`ACHF,II'�f Tawz� of Yannoufh taxes and liens rtiust be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES � NC} MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCIJPANCI': For purposes of the limitations ofMotel or Hotei use,Transient occupancy shall be limited to the temporary and short term accupancy,ordin<�rily and customarily associated with motel and hotel use. Transient accupants must have and be able to demonsirate that they maintain a principal place of residence elsewhere.Transient occupancy sha11 generally refer to continuous occupancy of not more than thirry(30)days,and an ag�regate af not more than ninety(90)days within any six(6)month period. Use of a guest unit as a residence or dweiling unit shall not be considered transiant. {Jccupancy that as subject ta tl7e collection of Roam Occupancy Bxcise, as defined in M.G.L. c. 64G or $30 CMR 64G, as amended, shall generally be considered Transient. roaz,s POdL QPEIVINCi:A11 swimming,wading and whirl��ools Fvhich 1?ava beez�closed far the seasan must be inspected by the Health Department prior to opening. Contact Yhe Health Department to schedule the inspection three (3) days priar to opening. PI.EASE I'�O"I`E: Peapte are NC}T allowed to sit in the pool area until the poal has been inspected and opened. PQOL WATER'1'ESTING: The water musY be tested f"or pseudomonas,total coliform and standard plate cvunt by a State certified lab, and submitted to the Health Departrnent three (3) days prior to opening, and quarterly thereafter. PQOL CLOSING: Every outdoar in ground swimming pooi must be drained or covered within seven(7)days af closing. FOOI) SERVICE SEASONAL FOC►D SERVICE OPENING: All food service estab(ishments must be inspected by the I�ealth Department prior to opening. Ptease contact the Health Departrnent to schedule the inspectian three{3) days prior to apening. CATERING POTsICX: Anyone who caters within the Town o£ Yarmouth rnust notify the Yarmouth Health Department by filing the requzred Temporary Foad Seruice Appiicatian form 72 haurs pz7ar ta the catered event. These forms can be abtained at the Health Department,or frorn the Town's website at www,varmouih.ma.us under Health Department, Downloadable Forms. FROZEN DESSERTS: Frozen desserts must be tested by a State certified 1ab prior to apeiling and rnonthly thereafter,with sample results submitted to the Heatth Departrnent. Failure to do so will resuIt in the suspension or revocation of your Frozen Dessert Permit until the above Lerms have been met dUTSIDE CAFFS: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Boazd of Health. OUTAOOR COCIKING: Outdoor cooking,preparation,or display of any food product t�y a retail ar food service esiablishment is prohibited. NOTICE; Permits run annually from January 1 to December 31. I`x IS YOUR 12ESPONSI$ILI'CY TO RETIIRN THE COMPLETF,I} RENEWAL APPLICATION{S}AND REQCJIRE.I}FEE(S}BY DECEMBER 15,2Q14. ALL RENOVATIONS Tt7 ANY FOdD ESTABLISHNIENT, MOTEL OR P(3dL (i.e., PAINTING, NEW �QUIPMENT, ETC.},MUST BE I2EPORTED TO A APP OVED BY THE ARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY UT A SIT AN. DATE: 1�/ /�' SIGNATCJRE: , PR1NT NAMB�Y: TITLE: ,�11a,�� — � ' oera..�✓"k _---_.. 3Lev. 11103174 ' ` � The Com�reonwealth ofMassachusetts Department oflndustrial Accidents Office of Investigations I Congress Street, Suite 100 Boston, MA 02I14-20I7 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Le¢iblv Business/Organization Name: l.f�//� ��vL� �,vc C��d �� OLr��oy Address: �.�� 0�� Z� City/State/Zip: ��j9��p� Q2�6 � Phone#: 6/ 7 66 C/ /2 7� Are�n employer? Check the appropriate bos: Business Type(required): 1. I am a employer with��employees(full and/ 5. ❑ Retail or part-rime).* 6. �estauranUBaz/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] 8• ❑ Non-profit 3.❑ We are a corporation and its officers 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 *My applicant that checks box#1 must also fill out the section below showing the'u workeis'compensation policy infotmation. **If the corporate officers have exempted themselves,but the corporatlon has other employees,a workers'compensation policy is requimd and such an organization should check box#I. I am an employer that isproviding wo�rkejrs'compensation insurance for my employees. Be[ow is thepo[icy information. Insurance Company Name: [ ' /L/�- Insurer'sAddress: 333 � (yf/ F3Af�l City/State/Zip: ( '�1iG,o/��i.,,o,cs �� Policy#or Self-ins.Lic. # �C �p 7�0 �/p 7 '� Expiration Date: ��/ /.� Attach a copy of the workers' compensation policy declaration page(showing the policy nnmber and ezpiration 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 forxn 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 c ify,un er the pains and pe Iti s ofperjury that the information provided above is true and correct. Si ature: Date: �� S` Phone#: 6 � Official use only. Do not write in this area,to be completed by city or town officiaL City or Town: Permit/License# Issuing Authority(circle oae): 1.Board of I3ealth 2. Buildiug Department 3. Ciry/Towa Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone#: www.mass.gov/dia � . . . . . � . . AND .��iPId3YHRS LIABILITY BOLICY .INFORMATION PAGE - RENEWAL��OF��FflC 4 30764072 Pdicp Numba F�art pC�cy Pe[bd , 'Ta � CoYetageNPto�idad BY � �g�.Y ' an WC 4 36764072 06/01/lA OSI01125 CONTI23ENTAL CASU'ALTY CO 0?0390580 � ` Na�ned lnntidd And Addroas , �` �ITEM Chill Line Inc � . .�.. ..�. . S&S133ROGtN fr� BROWN OF CT. 2NC. . . . . 1_ . �87 TONEL7, LANE � � � � �BF�RNSTABLE, MA 55 CAPITAL� BLVD. , STE. 162 �. � � OCRY EI7.L . ��CT Q546? � . . 02630 FEIN N[7MBER: NCCI CARRIER CODE NO: 10243 O'FHII2 WORR PI,ACES N6T SHOWN AROVS: SEfi A2TACHID SCHEDULE{S� YOU AR� A - CORPp#2ATION/S y, ppI,ICY PII2IOD- 06t01114 Tfl 06(01115 12:01 AM STANDARD TIME AT TfIE � � : � INSQREDS MAILING ADDRESS. � . . � 3A� PART ONE 4F TF[IS POLICY APPLZE9 TQ T1iE WORKEEtS COMPENSATIQN LAW AND ANY � � OCCIIPATIONAL DISEASE LAW OF EACH OF THE 9TATES LISTED HERE: � NSA. 3B. PART 2'Y70 OF TfI25 POLICY APPLIES TO EMPLOXERS �LIABILITY INSIIRANCE FOR W012R � : IN SACH STATE LZSTED IId ITF2I 3A: TAE LIAtITS OF LZABILITY ARE: �� BQDILY BJJIIRY BY ACCID�PIT � $100,000 EACH� ACCIDENT � .� BODII,Y ZNJIIRY RY DSSEASE $500,Q00 POLICY L7MZT � . m BODILY INJURY BX� DISEASE $100,000 EACH EMPLOYEE � . � $ 3C. PART R'HREE OF TFIIS�P9LZCY APPLZES TO pTIiER STATES, IF ANY, I,ZSTED REitE: . g ALi. STATES F.BCEPT AR, ND, OA, WA, WY AND STATES DESIGNATBD IN ZTEM 3A OF Tt£E ZNFdRMATIdN PAGE_ 3D. THSS POLICY INCLIIDES THESE ENDORSEMENTS AND SCHEDIILHS: SHB ATTACHED SCAEDIILES --------"-------------------`---'--------------'----------------'-------- � 4. 'PHE PRSMIOM FOR TFIIS P4LICY WILI, BE DETER2fSN&D BY OUR MANtJAL OF 12ULES, CLASSTFICATIONS, I2ATES, AND RAT7NG PLANS. ALL INFORMA2ION REQIIIRED HELOW IS SUH3fiCT TQ YEFkSFICATIOSF AND CIiANGE BY ADDIT. � � � AD�7i7STMENT OF PREMIOM� SHALI, BE M111?E: AT POLICY E%PIRATION � CLASSIFICATIOt3 OF OPSHATIONS � &ST ANNOAL PREMIIIM � SEE ATTACHED $1,103 HREMIUM DISCODNT 0 `< E%PE�ISE CONSRANT 338 � TERRORISM PREMIUM 29 � � MZNZMIIM PF2S6IiF7M $219 TRTAL ESTIMATED ANNUAL PRF•ASIUM . $1,474 �. — TOTAL STATE TABES/ASSESSMENTS/S'URCHARGES $38 � � TOTAL EST441T&L> COST $1,508 � � DEPOSIT PREMTUM $1,470 . . � � ACCOIINT NQMBBR: 3019092053 � � DATE OF ISSUE: 04/07/14 — POLICY ZSSUItIG OFFZCB: FARMIN61'dR � . � COIINTERSIGNID BY � = DATE AIITHORIZED AGENT �� WC000041 P-33398-E (ED. 6187) � � �� 9e�.+.C+�..n �°"��.,""_ dl�lYM�[ . �t�e{�y . . . . . - i�\AVA� . . .. .. . . . .. . . . . ..... . . . .. .. ..... .. _.... - . ..�