HomeMy WebLinkAboutApplication and WC OF �Y'�R
�� -=�` q �`�c TOWN OF YARMOUTH He�f
� -._ '._- K `3 1146 ROUTE 28, SOUTH YARMOUTH, MASSACHLTSETTS 02664-24451 -
�. �,r �b� '� Telephone(508)398-2231, ext. 1241 Health
t,��µE Fas(508) 760-3472 Division
To: Yarmouth Business Establishments k i N G s W�t`i T2ti s z �n.y-E c�v p,> ' �
From: Bruce G. Murphy, Director �
Yarmouth Health Department� ����Od�D
Date: November 7, 2014 �t� �'� ��t4
HEALTH DEPT.
Subject: Increase in License/Permit Fees
Please be awaze that the Yarmouth Board of Health, under the direction of the Yannouth Board
of Selectmen, has raised a number of license and permit fees issued through the Yazmouth
Heaith Department, effective January 1, 2015.
Attached is the Yannouth 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 requued 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 86.
Public WhirlpooUVapor Baths $ 80.00
Tobacco Sales $ 95.00
Motels $ 55.00
Food Service 0-100 Seats $ 85.00
Food Service Over 100 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 listed above:
Total fees owed for your establishment: gG �d
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
�. - �31,
a . TOWN OF YARMOUTH BOARD OF HEALTH
��� APPLICATION FOR LICENSE/PE��R�M�.IT -�0� W UkG U S (U14
" * Please complete form and attach ali necessary�"�'o��uments 6y�Dee be
Failure to do so will result in the return of your application' PT
ESTABLISHMENT NAME: � rU s � TAX ID• � �
LOCATIONADDRESS: S Ir� � ��STEL.#: -3 �
MAILING ADDRESS: 5 �
E-MAILADDRESS: B P,t�^uCci �1 �(�r�/�70rJ �/'� ���'J
OWNER NAME:
CORPORATION NAME (I APPLI BLE):
MANAGER'S NAME• �BrP�r`c 2`f'Y'UL'��i TEL.#: ;,,�iyx,/ �
MAILING ADDRESS: ��'nivyi 0
POOL CERTIFICATIONS:
The pool supervisor must be certi6ed 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.
i. ) ,�,4-� ��h5 2. {�1 i 1'��. lTi1/.G1�I�iCd' ---
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 forxn. The Health Department will
not use past years' records. You must provide new copies and maintain a file at your place of business.
l. ��.�� ���Pil�i7S . 2. �7+ LCG LJ' l�
3. r4hd�v1 rPlil� S 4. ��ca. 7or s
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.
l. 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.
l. Z•
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
INN $55 CAMP $55 �SWIMMINGPOOL$ll0ea
LODGE $55 1RAILER PARK $105 _WHIRLPOOL $ll0ea
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
0-100 SEATS $125 _CONTINENTAL $35 NON-PROFIT $30
>100 SEATS $200 COMMON VIC. $60 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.fr. $285 VENDING-FOOD $25
=<25,000 sq.ft. $150 —FROZEN DESSERT $40 _TOBACCO $110
NAMECHANGE: $IS AMOUNTDUE _ $ IIO . 00
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** �1" � �����
�y� 1�f7/c l3�os"�!�
ADMINISI'RATION
Unde^r Chapter 152,Sectioxa 25C, Subseatioia 6,the Tawn of Yarm�uth is nc>w required t�7 hold issuance or renewal
of any license or permit to operate a business if a persan or company does not have a Certificate of Worker's
Compensatian 7nsurance. TIiE ATTACHETI STATE W(?RKER'S COMPENSATTQN IN3UTtANCE
AFFIDAVIT MUST 13E COMPLETED AND SIGNED, UR
C�RT. OF iNSURANCE ATTACFIFD �
OR �
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACH�D
Towta of Yarmouth taxes and liens must be paid prior to renewal or issuance of your petmits. PLEASE CHECK
APPROPRIATEI,Y IF PAID:
YES� NO _
MOTELS ANA OTHER LODGING FSTABLISHMENTS
TRANSIENT OCCUPANCY: For pwposes of the limitations of Motel or Hotel use,Transient occupancy shall be
limited to the temporary and short term occupanoy,ordinarily and custamarily aesociated with motel and hotel use.
Transient occupants nlust have and be able to demonstrate that they maintain a principal place af residenca
elsewhere.Transisnt occupancy shall generally refer to continuous occupancy o£not more than thiriy(30)days,and
an aggregate af not more than ninety(90)days within any six(6)month period. Use of a�uest unit as a residence or
dweiling unit shall not be cansidered transient. Occupancy that is subject to t11e collection of Room Oacupancy
Excise, as defined in M.G.L. c, 64G ar $30 CMR 64C'T,as amended, shall generally be considered Transient.
�oaLs
P40L OPENING:All swimming,wading and u�hirlpoals�uhich have been closed for the season must be insgeeted
by the Health Department prior to opening. Contact the Health Depat�trnent to schedule the inspection three (3)
days priar to opening. PLEASE 1vOTE: People are NQT allowed to sit in the paol area until khe pool has been
inspected and opened.
POOL WATER TESTING: The water must be tested i'or pseudomouas,total coliform and standard plate count
by a State certified lab, and submitted to the Health Department ttu-ee (i) days prior to opening, and quarterly
thereaftar.
POOL CLOSING: Every outdoar in ground swimn�ing poal rnust be drained ar covered within seven{7)days of
closiilg.
FO011 SERVICE
SEASONAL FOCID SERVICE OPENING:
All food service establishments must be inspected by iha I Iealih De partmenk prior fo opening. Flease contaet the
Ilealth Deparlrnent to schedule tha inspectian three (3)days prior to a�aening.
CATERING POLICY:
Anyone who caters within the Town of Yarmouth must notify the Yarnzouth Health Department by filing the
requared Temporary Faod Service Application Iorm 72 hours priar to the catered event, These forms can he
obtamed at the Health I)epartment,or from the Town's website at www.yaxmouth ma.us under Health Departn�ent,
Do��nloadable Forms,
FROZEN DF:SSERTS:
Frozen desserts must be tested by a State certified lab privr to opening and 7nonthly thereafrer,with sample results
submitted to the Healfh Deparhnent. Failure to do sc� will result in the suspension or revocatlon of yout Fr�zen
Dessert Permit until the above tercns have been met.
C3IITSIDE CAFES:
Outside cafes(i.e.,outdoor seating with waiter/w�itress secvica),must have prior approval from the Bot�rd of Health.
CIUTDOOR COOHING:
t)utdoor cooking,preparation,�r display of any faod product by a retail nr food service establishment is prohibited.
NiDT,ICE:Permits run annuaIly from 7anuary I to December 31. IT IS YOLTR RESP�DNSIBILITY TO RETURN
T�iE CQMPL�TED RENEWAL APPLICATit}N(S}AND REQUIRED FEE(S}BY DF.,CEMBER I5, 2014.
ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAIN7'ING, NEW
EQUIPM�N7', ETC.},MUST BE REPORTBI}TO AND APFRO VEI7 BY THE B(7 AKD OF HEALTH PRIOR
TO COMMENCENIENT. RENOVATIONS MAY REQiJIRE A SITE PLAN.
DATIi: ��`-��—�SIGNATURE:
t'RINT lYAME& TI1'LE:_;��������_.yP�_ ,�tsyt��__��� C/
Rcv. (3li?}tt4 �
>
� The Commonwealth ofMassachusetts
Department of Industrial Accidents
Office of Investigations
1 Congress Street, Suite I00
Boston, MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Le�iblv
Business/Organization Name: w� V�-f�, � ��'�e�
Address: �����( s �r���
City/State/Zip: �'a rma����� /�!�- �a6>� phone#: �o��-�6 2—�353�
Are ou an employer? Check the appropriate box: Business Type(required):
1.,� I am a employer with employees(full and/ 5. ❑ Retail
or part-time).* 6. ❑ RestauranUBaz/Eating Establishment
2.❑ I am a sole proprietor or partnership and have no 7. � Office and/or Sales(incl. real estate, auto, etcJ
employees working for me in any capacity.
[No workers' comp.insurance required) 8• ❑ Non-profit
3.❑ We are a corporarion and iu 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 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'u workers'compensation policy information.
**If the corporate o�cers have exempted themselves,but the corporafion has other employees,a workers'compensation policy is required and such an
organization should check box#1.
I am an employer that is provid�i/ng� workers'compens/ation insura/n�ce for my employees. BeLow is the policy information.
InsuranceCompanyName:L�p�/'�[.� /yf�Uq! �I7,S `O.
Insurer'sAddress: e�D /��Jg l�7/ 0�� L� �s a99 �a/�QY�Y�L/e ��.
City/State/Zip: /,IJ>�i'nj�ri� j`J'J� �JgR /
Policy#or Self-ins. Lic.# L.C)G�31 c3�.d(D,� ��� Expiration Date: �S'�3 -aOA,S
Attach a copy of the workers' compensation policy declarafion page(showing the policy number and expiration 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-year 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
InvestigaUons of the DIA for insurance coverage verification.
I do hereby certify,under the pains and pena[ties ofperjury that the information provided above is true and correct.
Signature: Date:
Phone#:
Official use only. Do not write in fhis area, to be comp[eted by city or tawn officiaL
City or Town: Permit/License#
Lssuing 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
12/5/2014 5:20:07 AA1 PST (GMT-8) FROM: 100005-TO: 18664757959 Page: 2 of 2
AC Ro v' CERTIFICATE OF LIABILITY INSURANCE °"'�`�'
,vs�2o,n
THIS CERTIFlCATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGiR3 UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE �ES NOT AFF�RMATNELY OR NEGATNELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTRUTE A CONTRACT BEfWEEN THE ISSUING INSURER(S), AUfHORIZED
REPRESENTATNE OR PRODUCER,AND THE CERTIPICATE HOLDER.
IMPORTANT: H the cerl'fii�ate holder is an ADDRIOWIL INSURED,the polky�iea) muat be endorsed. N SUBROGATbN IS WANED, subjed to
the terms and conditione o(the polity,eartain polieiae may require an endonement. A statameM on this eeRi("kate does not eoMar righffi to tha
certiTicffie hWder fn lieu of aueh endorsdnen s .
PROOUCER HUB INTERNATIONAL NEW ENGLAND LLC E:
299 BALLARDVALE STREET � F�
WILMINGTON, MA01887 "� "°'
e�
INBUR BAFFOROWGCOVEMGE IWCO
neuxnw: LM Incvanm Co orallon 33600
1X8�� NBUREAB:
KINGS WAY TRUST
64 KINGS CIRCUIT nsunFnc:
YARMOUTH PORT MA D2675 nsunERo:
NSWtERE:
Y RF:
COVERAGES CERTIFICATE NUMBER: 225q6977 REVISION NIIMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED B�OW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICV PERIO�
INDICATED. NOTWRHSTANDING ANY REQUIREMEN7,7ERM OR CON�RION OF ANY COMRACT OR OTHER DOCUMEM WITH RESPECf TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCR6ED HEREIN IS SUBJECf TO ALL THE TERMS,
IXCLUSIONS AN�CANDITIONS OF SUCH POLJCIES.LIMRS SHOWN MAY HAVE BEEN REDUCED BY PAID CIAIMS.
�� 1TVEOFN9URANCE � BR vOu��� PWoICYEFF N LICTFJ� ��
LlR
COMh�RCULGElERALLIRBLIfY Eqq{p��� g
CLAIMS�.IAOE ❑OGGUft $
YED D�(M me parsm) $
PHiSON4L8ADVIWURV 8
G@l'LAGC�RECA7ELIMRAPPLIESPER: GEIJHtALRGGREGA7E $
PoLIGY❑�� �LOC PROWCTS-COMPIOPAGG $
OTHER: s
nur0uoei�uneurr � S
aavwto eooi�viruunv�rerpermml S
Al10NT�� 3CfEWlEO BOOILVINJURV(PxetdtlBM) S
AUT03 AUTOS
HIP�NVf03 AUT S�ED PerecfitleM A E
$
UMBREl1AWB OCCUfi EACFIOCCURRENCE $
��$V� CIFIMS�dADE AGGREGAIE S
D RETENfION S
A wowcEnseoMve�snnoN WCS-31S-32b630-024 5/13/2014 5H3/2015 � y�A� ER
AM EAVlAY9B'WBRfIY
ANYPROPR�IIXWqR1NEPoE%EWTNE v�N E.L.EACHACCO@!f S SOOOOO
OFFICEfLMEMBERIXCLl1Om'! �N/A
(MantlamryinNl� E.LDISEASE-EAEMPLOVE S SOOOOO
If ec;tlerabeuntler
o�scniPriaooFoaewmoNsm� E.LDISEASE-PoLICYLIMR S 500000
DESCRP110N OF OPEMTIONB/IDCATIOMS/VEXICLES(ACORD 107,Atl0ltlonal Remarke SchebJe,my be atladietl It more ryaze Is reqWren)
Workers compensation insurance coveraga appl les only to Uie wakers compensation laws�Uie slate of MA.
This certifcate cancels end supetsedes all previously issued certiTicales,only as tliey ralate to workers'compensation coveraga
CERTIFICATE HOLDER CANCELLATION
TOWN OF YARMOUTH SH W LD ANY OF 7HE ABOVE DESCRIBED POUCIES BE GWCELLED BEFORE
THE EI�IRA710N DA7E THEREOF, NOTCE WILL BE �LNERED M
HEALTH DEPARTMENT ACCORDANCEIMhITiEPOLICVPROVISIONS.
1146 ROUTE 28
SOUTH YARMOUTH MA 02664
AVIIIORI�REPREBENrNiNE t ,�� ��
/ 1
�- /
LM Insurance C ation �, �'
�7986-2014 ACORD CORPORATION. All rlghts reserved.
ACORD 25{2014/O7) 7he ACORD�me and logo are registered marks of ACORD
Ceai n0.: Z25<69]J Cii[nx COoe: 14506)0 Lury Gacfield 12/5/201< B:U:42 AH �[ST) eagc 1 of l