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Home My WebLink AboutApplication and WC �o��'_�Y---`�R,� � � � TOWN OF YARMOUTH Bo�dof �_� � Health ��— -�'�+�`� 1146 ROUTE 28, SOUTH YARMOUTH, MASSACHUSETTS 02664-24451 - �.� �,� t�'��:� Telephone(508)398-2231, ext. 1241 Health ��„a l"`"E Fa�c(508) 760-3472 Division G3C�C�L OC�/C�D To: Yarmouth Business Establishments (�r>,� T�k� c„�s i��' UEC U 8 ZU14 From: Bruce G. Murphy, Director Yarmouth Health Department HEALTH DEPT. Date: November 7, 2014 Subject: Increase in License/Permit Fees Please be awaze 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 Depaztment, 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 �davit) nrior 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 Sa1es $ 95.00 Motels $ 55.00 Restaurants 0-100 Seats $ 85.00 g .�J Restaurants Over 100 Seats $160.QQ 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: �b0,00 cov,MoNV ic. Total fees owed for your establishment: ��45.Ob 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 springprior to opening" on the application.J BGM/maf � � SIN� �� `✓'�� a � TOWN OF YARMOUTH BOARD OF HEALTH - �� APPLICATION FOR LICENS�/flERMIT - 2��(5`� �C�; ,�� (U i 4 ''' * Please complete form and attach all necesSar�cidnen#s'by De mber I S 2014. Failure to do so will result in the retturi of�you�app�icatio�i ac ALTH DEPT, ESTABLISHMENT NAME: L3(� S 1 L`� y Fl j CCI i C I N� TAX ID: �� -� LOCATION ADDRESS: 5�14 R�iJTE 7i`6 W - iZMovi H _ M � TEL.#: �5��-��1 �� ( `� S�- MAILING ADDRESS: E-MAIL ADDRESS: P gP�1-1 A— 6 0 � kl o'f M Gl i l, .. �o N� OWNERNAME: �g,ReuA So� Iti�f �uR RoEN CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: TEL.#: MAILING ADDRESS: POOL CERTIFICATIONS: The pool supervisor must be certiTied 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 Cazdiopulmonary 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 HeaUh Department will not use past years' records. You must provide new copies and maintain a file at your place of business. l. 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. YII�G �� IL l�EOP�RMP � 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. �' i � � �- � � �� '�'G�-} �{ �� 2. ALLERGEN CERTIFICATIONS: All food service establishments aze 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. Y i N G �-.(� l� ��C� �I� M P� 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 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. i.y � ov� RRf�`f� �'D`�A-N� S�N`�D �N 2, pI�R ��} R So�1 �L�ie�t�} �n�rJ 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 I1V1V $55 CAMP $55 SWIMMINGPOOL$]l0ea _LODGE $55 TRAILERPARK $]OS WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �0-100 SEATS $125 ' ( -C� CONTINENTAL $35 NON-PROFIT $30 >100 SEATS $200 �COMMON VIC. $60 ��{ _WHOLESALE $SO —RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQIDRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# q >25,000 sq.ft. $285 VENDING-FOOD $25 —<Z5,000 sq.ft. $150 _FROZEN DESSERT $40 TOBACCO $ll0 NAME CHANGE: $15 - AMOUNT DUE _ $ 1Q '�j.GGf �^ *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** r��' � Y i °V'�� E`��t' LO(o�3 IZ�Oq�� ADMINISTRATICIN Under Chapter 152, Saction 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any Iicense or �7ermit to operafe a business if a person or company does not have a Certificate of Worker's Campensation Insuraizee. THE ATTACFIED STA1'E W012K1?,R'S COMPENSATION INSURANCE AFFIDAVIT MLJST SE COMPLETED AND SIGNEll, UR CERT. OF INSIJRANCE ATTACHED, OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHGD Town of Xarmouth taxes and liens must be paid priox to renewal ar issuance of yot�r permits. PLEASE CHFCK APPROPRIATELY IF PAID: YES NQ MOTELS AND O"TH�R LODGING ESTA,BLISHMENTS TI2ANSIENT OCCUPANCY: For purposes of the limitatiotas of Motel or Hotel use,Transient occupancy shall be limited to the temporary and shart term occupancy,ordinarily and eustc�marify associated with matel and hotel use. 1'ransient accupants 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 thiriy(30)days,and an aggregate c�f not more than ninety(90)days within any six(6)month period. Use of a guest unit as a residence or dwelling unit sha11 not be eansidared transient. Qecupancy that is subject to the c�llectian of Room Oecupancy Bxcise, as defined in M.G.L. c. 64U or$30 CMR 64G, as arnended, shall generally be considered Transient. 1'OOLS P40L CiPENING:All swianming,wading and whiripools which have been ciosed£ar thc season must be inspected by the Health Department prior to apeni,ng. Contact Che Health Depaz�tmenY to achedule the inspection three(3) days priar to opening. PI.,EASE 1V4TP: People are NOT allowed ta sit in the pool area un#il the pool has been inspected and opened. POOL WATER'1'ESTING: The water must be tested for pseudomonas,total coli£orm and standard plate count by a State certified lab, and submitted to the Health Department three (3} days prior to apening, and quarterly thereafter. POOL CL4SING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days af closing. FO011 SFRVICE SEASONAL FOOD SERVICE OPENING: A11 faad service establishments must be inspected by the I�ealth Departmeni prior ta opening. Please con#act the Health DcpartmenY to schedule the inspection three (3) days prior Yo opening. CATERING POI.ICY: Anyone who caters within the Town oP Yarmouth rnust notify Ghe Yarmouth HeaIth Department by filing..the required Temporary Foad Service 1�,pplication forn� 72 haurs prior to the catered event These forms can be obtained�t the Health Department,or from the Town's website at www.yazmouth.ma.us under Health Department, Downloadable Forms. �ROZEN DES3LBTS: Frozen desserks must be tested by a State certified lab prior to opeixing and monthly thereafter,with sarnple results submitted to the Health DeparCment. Failure to do so will result in the saspension or revocation af your Frozen Dessert Permit until the ahove terms have been met. OUTSIDE CAFF`.S; Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval fronn the Board of Health. OUTDOC/R COOHITVG: Outdoor cooking,preparation,or display of any food product by a retail ar food service establishment is prahibited. __ _ _ _ . _ NOTICE: Permits run annually from January 1 to December 3 i. IT IS YOUR RESPONSIBILITY TO RETTTRN THE COMFLETk�;D RENE'sWAL APPLICATION(S)ANL}REQUIRL;D FEE{S}BY DEGEMBBR 15, 2014. ALL RENOVATIONS TO ANY FOOD ESTABLISH:�iENT, iv1dTEL OK P�OL (i.e., PAINTING, NEW BQUIPMENT, ETC.}, MUST k3E F2EPORTED 'Cd AND APJ?Rt7VEi? BY TF[E BOAI�D OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY FLEQUIRE A SITE PT,AN. DATE: �2—�—2 0� �[ �GN�ATIrRE:G � s i � PRINT NAME& TITLB: Rev.1 it4311A � The Commonwealth ofMassachusetts Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Le�iblv Business/Organization Name: �j�S�l. l(-�� 1 Ci�l( S 1 N � Address: �j"�� UT� 2�5 City/State/Zip: +iv�s i oo i pz6 33 Phone #: �db' - � �I � - � � f� Are you an employer? Check the appropriate box: Business Type(required): L[� I am a employer with 3 employees(full and/ 5. ❑ Retail or par�time).* 6. Q RestaurantlBaz/Eating Establistunent 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 10.0 Manufacturing no employees. [No workers' comp. insurance required]* I 1.0 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#1 must also fill out the section below showing their workers'compensation policy information. •"If the coiporate officers have exempted themselves,but the corpora6on has other employees,a workers'compensarion policy is required and such an organization should check box#I. I am an emp[oyer that isproviding workers'compensation insurance for my employees. Be[ow is thepolicy information. Inswance Company Name: ��}j�i (a- 21V �'v�q U�' F C'�0 M P A N Y Insurer's Address: p_Q (�0� �� -F � , City/State/Zip: M 1 N N G A (� 0 L15 _ �1 �} J 5�-1 �� — 01�{ � Policy#or Self-ins. Lic. # �v C-2�-20�O o�1{ �2 - K� o Expiration Date: _� - � I - 2o I � Attach a copy of the workers' compensation policy declaration page(showing the policy number and ezpirafion date). Failure tosecure coverage as required under Section 25A of MGL c. 152 can lead to the imposi6on 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 Investigations of the DIA for insurance coverage verificarion. I do hereby certify,under the pains and penalties ofperjury that the informarion provided above is true and correct. S�i�nature: �S`T �l Date• � z-- S`� 2J ��f Phone#: Official use only. Do not write in this area,to be comp[eted by city or tawn afftcial City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2. Building Department 3. City/Towu Clerk 4.Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone#: www.mass.gov/aia NOTICE � NOTICE TO TO EMPLOYEES �, EMPLOYEES The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 1 Congress Street, Suite 100, Boston, Massachusetts 02114-2017 617-727-4900 — http://www.state.ma.us/dia � As required by Massachusetts General Law,Chapter 152, Sections 21, 22 &3Q this will give you notice that I(we)have provided for payment to our injured employees under the above-mentioned chapter by insuring with: Acadia lnsurance Company NAME OF INSURANCE COMPANY P.O.Box 59143,Minneapolis,MN 55459-0743 ADDRESS OF INSURANCE COMPANI' WC-20-20-005412-00 07/31I2074 POLICY NUMBER EFFECTNE DATES Kerry Insurance Agencylnc PO Box1945, North Eastham,MA 02657 (508)255-8000 NAME OF INSURANCE AGENT ADDRESS PHONE# PRACHASOMKITCHARON 594 MAIN STREET,WESTYARMOUTH, MA02673 EMPLOYER ADDRESS 7/31/2014 EMPLOYER'S V✓ORKERS' COMPENSATION OFFICER(IF ANl� DATE MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the ser- vices provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the NAME OF HOSPITAL ADDRESS TO BE POSTED BY EMPLOYER Berkley Massachusetts Workers' Campensation insurance Pian Acadia lnsurance Company NCCI Carrier Cpde 33391 Administered by 6erktey Assigned Risk Services A��3(�a��R�S�{�ER��E�J P.O. Box 59143,Minneapoli9,Minnesota 55459-0143 Phone(605)945-2144 Fax(866)215-SN8 Toll Free(800)634-4569 www.berkleyassignednskcom policyservices{a�berkieyrisk.com ENTITYAND LOCATION SCHEDULE 1. The Insured: NOrmal A/R Policy Number: WC-20-2p-005412-00 Risk iD: 0891489 PRACHA SQMKITCHARON Tax ID#: F dba: BASIL THAI CUtSINE 594 MAIN STREET Policy Periad: From: 7l3112014 WEST YARMOUTH, MA 02673 To: 7/31/2015 Endorsement Eff. Date: 7131t2814 Date of Mailing: 7/37/2014 Entity Information: (nsured Neme: pRACHASOMKITCHARON ,X�individual � Pertnership Federal ID N�mber: �_�Corporatian �Other UIC Number: dba: BASILTHAI CUISINE 5$4 MAIN STREET WEST YARMOUTH, MA Q26T3 Aaencv Name and Address Kerry(nsurance Agency tnc PO Box 1945 � North Eastham, MA 02651 wcssoso�