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� —� ' `3 1146 ROUTE 28, SOUTH YARMOUTH,MASSACHiJSETTS 02664-24451 - �
�. 4,rr �e`� $ Telephone(508)398-2231, ext. 1241 Div son'
"`"E Fa7c(508) 760-3472
To: Yannouth Business Establishments pcE%N S�c�act �oc� lm- � �� ���r��
From: Bruce G. Mtuphy, Director � u�� u 3 ��14
Yannouth Health Department�
HEALTH DEPT.
Date: November 7, 2014
Subject Increase in License/Permit Fees
Please be awaze that the Yazmouth Boazd of Health, under the direction of the Yannoutlt 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 Yannouth Bus� ess License/Permi pplication for 2015. You will note that the
fees listed aze the fees effecti e January l, 2015. ese fees will be due if you complete and
submit the application after Jan , .
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) 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
Foou Service Over 100 SeaYs $16G.00
Retail Food Service <25,000 sq. ft. $ 80.00 $ {3�.U�
Retail Food Service>25,000 sq. ft. $225.00
Other fees owed but not listed above:
Total fees owed for your establishment: � f3 0.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 ahe 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
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� � TOWN OF YARMOUTH BOARD OF HEALTH � c `�
��� APPLICATION FOR LICENSE/P�E��I����<��d°� pE�' �,5 ZU I i
�'"' * P l e a s e c o m p l e t e f o r m an d a t t a c h a l l n e ce s s a o c u m e n t s b y D e c e m r I S 2 0 1 4.
Failure to do so will result in the return of your applieation pac et. LTH DEPT.
Ocean State Job Lot of S. Yarmouth.. Inc.
ESTABLISHMENTNAME: d/b/a Ocean State Job Lot #206 TAXID:
LOCATIONADDRESS: 1080 Rt. 28 Yarmouth Plaza TEL.#: 508-394-1386
MAILING ADDRESS: 375 Commerce Park Road, North Kingstown, RI 02852
E-MAILADDRESS: Permits@OSJL.com
OWNERNAME: Ocean State Jobbers, Inc.
CORPORATION NAME (IF APPLICABLE):
MANAGER'S NAME: Diane White TEL.#: 508-394-1 386
MAILINGADDRESS: 375 Commerce Park xoa�3, North x� ngstnwn , uT n�st5�
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 cunently 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 Aealth Department will
not use past years' records. You must provide new copies and maintain a £►le at your place of business.
1. 2•
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 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 Diane White 2. Kenneth Cowap
ALLERGEN CERTIFICATIONS:
All food service establishments are required to have at least one fuil-time employee who has Allergen certificaUon,
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 estabiishment.
1. Z•
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 a11 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' rewrds.
You must provide new copies and maintain a file at your place of business.
L 2•
3. 4.
RESTAURANT SEATING: TOTAL #
_ , — — . __
aF�ICE�J3E ONLY -
LODGING:
LICENSE REQUTAED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERM[T#
B&B $55 CABM $55 MOTEL $110
INN $55 CAMP $55 SWIMMINGPOOL$ll0ea.
LODGE $55 TRAILER PARK $105 _WHIRLPOOL $110ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSG REQUIRED FEE PERMIT# LICENSE REQUIRfiD 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
�<Z5,000 sq.ft. $150 ��=�� —FROZEN DESSERT $40 _TOBACCO $110
NAME CHANGE:� $15 AMOUNT DUE _ $ I SZJ.OO
�
� *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** ��"��� � ����•�
c:�'C-� �1�0 LO 12�w�i`f
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ADMINISTRATION
iJnder Chapter 152, Section 25C, Subsectiota 6,the Town af Yarmouth is naw required ta hold issuance or renawal
of any license or permit to operate a business if a person or company does not have a Certificate of Worker's
Compensation Znsuranee. TI3E ATTACHED STA7'E WQI2KER'S C01YI�'ENSATION INSURANCE
AFFTDAVIT MUST BE COMPLETFD AND SI(�NED, OR
CGRT. OF IN4URAN(:E ATTACHED X
OR
WORKER'S COMP. AFFTDAVIT SIGNED ANil ATTACHED X
Town of Yazmouth taxes and 11ens must be paid prior to renewal or issuance of yonr permits. PLEASE CHECK
APPROPRIt1`I'ELX IF PAID:
YES X NQ
MOTELS AND OTHER LODGING FSTABI.I3HMENTS
__ _ -TRAI�T�IENT O�CUPANCY: For purposes ofthe limitations of Motel or Hotel use,Transient occupancy shall be
fimited to the temporary and short term occupancy,ordinarily and customarily associated witt�motei and l7t�tei us�:
Transient occupants must have and be able to demonstrate that they maintain a principal place of resideuce
elsewhere.Transient occupancy shall generally refer to continuous occupancy of not rnore than thirty(30)days,and
an aggregate of not more than ninety(90}days within any six(6)month periad. Use of a guest unit as a residence or
dwelling unit shall nat be eonsidered transient. Occupancy that is subject to the collection of Room Oceupancy
�xcise, as defined in M.G.L. c. 64Cr or 830 CMR 64G, as anaended, shall generally be considered Transient.
POOLS
POdL OPENING:Ali swimming,wadii�g and whirlpools which have been ciosed for the season must be inspected
by the Health Departrnent prior to apening. Contact the F�ealth Departrnent to sch�dule the inspectian three(3)
days prior to agening. PLEASE N4TE: People are NC7T allowed to sit in the poal area witil the paol has baen
inspected and opened.
POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count
by a Stata certified lab, and submitted to the Health Department three (3) days prior to opening, and quarierly
thereafter.
POC3L CLOSING: Every outdoor in ground swimming pooi must be tlrained or covered within seven(7)days of
closing.
FIJOD SERVTCE
SEASONAL FOOD SERVICE OPENING:
F�ll food service establishments must be inspected by the I-Iealth Depariment priar to apening. Please contact The
Health Depaztment to schedule the inspectian thsee (3) days prior to opening.
CATERiNG POLICY;
Anyone who caters wSthin the Town of Yarmouth must notify the Yarmouth Health Department by filing the
reqwred Temporary Poad Service Appiicatian farm 72 haurs prior ta the caterad event. These forms can be
obtained at the Health Department,or from the Town's website at www.yannouth m,a.us under Health Deparhnent,
Downloadable Farms.
FRO'LEN DESSFRTS:
�'rozen desserts mustbe Yested�y a Sta�e certified lab prior to uperling and rnonthly Che��afTetZvith satnple resuits
submitted to the Health Department. Failure to do so will result in the suspension or tevocation of your Frozen
Dessc�rt Permit until the abave terms have been met
OI77'SIDE CAFES:
Qutside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior appr�oval from the Boazd ofHealth.
QUTDOOR COOHING:
Outdoor cooking,prepazation,or dispIay of any food product by a retail or faod service establishment is prahibited.
NOTICE:Parmits run annually from 7anuary I to December 31. IT IS'YOUIZ RESl'ONSIBILITY TO RETURN
THE COMPLETED RENI,WAL APPLICATIQN{S) AND REQUIRFI}PEE(S}BY DECEiU1BER 15, 2414.
ALL RENOVATIONS TO AN�' FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT, ETC.), ML3ST BE R.EPURT�D'I'O AND APPRQVEI)BI' THE BOAKD{?F HEAI.TH PRIOR
7'O COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
I7ATE: 12-3-14 SIGNATURE:���,,,�,t� �'�� ��
, �y.�'
PRINT NAME& TITLE: Elaine M. Gagne, Licensinq Manager
R.ev. 1 I1Q31t4
s� The Commonwealth of Massachusells Print Form
� , DepartmentoflndustrialAccidents
�� Office of Investigations
� �� ' �; I Congress Street, Suite 100
, ��� Boston, MA 02114-2017
���'" www.mass.gov/dia
Workers' Compensation Insurance AfSdavit: General Businesses
Applicant Iuformation Please Print Leeiblv
Business/OrganizationName: Ocean State Jobbers , Inc.
Address: 375 Commerce Park Road
City/Sfate/Zip: North Kingstown, RI 0285�hone #: 401 —295-2672
Are you an employer?Check the appropriate boz: Business Type(required):
l.� I am a employer with +4 �Q00 employees(full and/ 5. � Refail
or part-time).* 6. ❑ Restaurant/BadEating 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] 8� ❑Non-profit
3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment
their right of exemption per a 152, §1(4), and we have �0.❑ Manufacturing
no employees. [No workers' comp. insurance required]* �� � Health Care
4.❑ We are a non-profit organization,staffed by volunteers,
with no employees. [No workers' comp. insurance req.] 12.❑ Other
*Any applicant that checks boz#1 must also fill out the section below showing their workers'compensation policy information.
•*If[he corporete offce�s have cxempled themselves,but[he wrporation has mher employees,a workers'compensation poGcy is required and such an
organiza[ioo should check box t#1.
/am an empl�yer that is providing workers'compensation insurance far my employees. Be%w is the policy information.
InsuranceCompanyName: Safetv National Casualtv Corp.
Insurer'sAddress: 1832 Schuetz Road
City/State/Zip: St. Louis, MO 63146
Policy#orSelf-ins. Lic.# LDC4047223 ExpirationDate: 10-1 -2015
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failu:e to sewre coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penal[ies of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up m$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of[he DIA for insurance coverage verification �
/do hereby cer.(ijy, under the painps and pe alties ofperjary that the informa[ion provided above is true and correcG
Sienature� ��In.t_3 ���1 �..� Date' / 1--��` ��+
�..
Phone#: 401 -295-2672
Officia[use on[y. Do not write in this area,lo be completed by city or town officiaL
City or Town: PermiULicense#
Issuing Aufhority(circle oue): � � � � � " �
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
� Clienl#:7T567 OCEANSTASS
ACORD�. CERTIFICATE OF LIABILITY INSURANCE °"'�'""�°°"""'
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THIS CERTIFlCATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIg
i CERTIFICATE OOES NOT AFFIRMATVELY OR NEOATNELY AIAEND,EXTEND OR ALTERTHE COVERA6E APFORDED BY THE POLIqES
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, ceRMeate holder in Ileu of aueh andoreament(s).
' VROWCER N,�, Sandy Banigno
Starkweather&Shapley N, 6,,;4014353600 � N,.401431�9678
P��X� � . sbenigno�ntarshep.com
Providence,RI 02907-0549 '
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Oeean State Jobbers,lnc.
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S75 Commerce Park �
North i0ngstown,RI 02852 INSURERO: �
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INDICATED. N07WITHSTANOMG ANY REWIREMEM, TERM OR CONDRIONOF ANV CON7RACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS �
CERTIFlCATE MAY BE 133Um OR MAY PERTNN, 7HE INSURANCE AFFOR�ED 8Y THE POLIqES �E6CRIBED HEREIN IS SUBJECT TO ALL THE TERM9, '�,
EXCWSIONS AND CONDITIONS OF 9UCH POIJGES. LIMIiS SHOVJN MAY HqVE BEEN REDUCED BV PAID CWMS. j
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CERTFICATEHOLDER CANCELLATON �
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THE E1�IRATION DATE THEREOF, NOTICE VYILL BE �ELNERED @J
375 Commerce Park ACCORDANCE WITH trie roucr rfeowswNs. -
North qngstown,RI 02852
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�7988-2070 ACORD CORPORATION.All�Iphta Raervad.
ACORD 25(2010l05) 1 pf 1 The ACOR�name and logo ere regisbred marks of ACORD
#5626250/M624120 SSB