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Home My WebLink AboutApplication and WC o�'YAR �� --�" p �[ TOWN OF YARMOUTH BHa�°f � :» .�- � "� 1146 ROUTE 28, SOUTH YARMOUTH, MASSACHIJSETTS 02664-24451 - �. ��, �,a�' � Telephone(508)398-2231,ext. 1241 Health �"`"E Fax(508) 760-3472 Division :'`:b To: YannouthBusinessEstablishments KiN65 U?A`t T2-usT From: Bruce G. Murphy, Director � (�C�,C�OC�IGDD Yannouth Health Department� UEC 0 5 '[014 Date: November 7, 2014 IiEALTH DEPT. Subject: Increase in License/Permit Fees Please be awaze that the Yannouth Boazd of Health, under the direction of the Yarmouth Boazd of Selectmen, has raised a number of license and permit fees issued through the Yannouth 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 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 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 (2; � I b0 .00 Public WhirlpooUVapor Baths $ 80.00 Tobacco S�les $ 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: 1�0.p0 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 andlor pool certifzcations prior to opening, however, you must note "Will provide in the spring prior to opening" on the application.J BGM/maf ��4��s � � TOWN OF YARMOUTH BOARD OF HEALTH �� APPLICATION FOR LICENSE/PERM�T�?�Q��oi Utl: U 5 CU14 �e c.rc. * Please complete form and attach all necessary document�by Decemb IS DEPT. Failure to do so will result in the return of your application pack ESTABLISHMENT NAME• I�l �7a s a.� / u S�" TAX ID: 0 LOCATION ADDRESS' 6 LF np �i � 4rr>,.��. v�}67j TEL.#: S'v�-36a 3S31r MAILING ADDRESS: ru- E-MAILADDRESS: �'�e ��-c� �T �`D4�mo�t�G.rw�iP• c�M OWNERNAME: ✓h� s '�./�; ru � CORPORATION NAME (IF A LICABLE): MANAGER'S NAME: 13c-ia n Pc��-v cc-i TEL.#: �"� MAILING ADDRESS: s�r� � 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. i. � �� n� 2. l� i �c �runye'� 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 61e at your place of business. 1. 3 C-Y�- �l�rf S 2, )''I��Ae. G'-i rzt rlG e� 3. t�run on � E�'J ib� 4. LiSc� 1 orrtg FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishxnents 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 Heaith 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. 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 far 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# OFFICE USE ONLY LODGING: L[CENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $110 INN $55 CAMP $55 �SWIMMINGPOOL$IlOea I – � 9 G�{0 LODGE $55 TRAILERPARK $105 WFIIRLPOOL $ll0ea. � FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 _CONTINENTAL $35 NON-PAOFIT $30 >100 SEATS $200 COMMON VIC. $60 WHOLESALE $SO —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 V ENDING-FOOD $25 =<25,OOOsq.ft. $150 —FROZENDESSERT $40 _TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE _ � 2zo -oa *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** �G �� rC�B. C�� -�i�75— ,�jos�i�l ADiVIINISTRATION Under Chapter 152, Section 25C, Subsection 6,t11e Town of Xazmouth is now required to hold issuance or renewal of any ticense or permit to operate a business if a person or company does not have a Certificate af Worker's Compensation Insurance. TI�E AT'I'AC'HED 5TATE WOItK�R'S CC7MPENSATION INSUILANCE AFFIDAVIT MiJST BE COMPLETED AND SIGNED, OR CERT. OF IN5URANCE A'I'TACIIED qR �. WORKER'S COMP. APFIL7AVIT SIGNED AND A'I'TACH�,D Town of Yannouth taxes and liens must be paid p 'or to renewal or issuance of your permits. PLEASE CHECK APPROPI2IATELY IF PAID: 1'ES NO _ 1VIOTEL5 AND OTHFR I.ODGING FSTABLISHMENTS TRANSTENT OCCUPANCY: For purposes of the limitations ofMotel or Hotel use,Transient occupancy shall be limited to the temporary and short term occupancy,ordinarily and customarily associated with motel and hotel use. Transient accupants must have and be able to demonstrate that they maintain a principal place of residence elsewherE.Transient occagancy shall generally refer Co continuous occupancy of not rnore than thirty(30)c�ays,and an aggregate o£not more than ninety(90)days within any six(6)month period. Use of a guest unit as a residence or dwelling unit shall not be considered transiant. Occupancy that is subjeet to the cc�IlecCian of FCoom Occupancy Excise, as detined in M.G.L. c. 64G or $30 CMR 64G, as amended, shall generally be considered Transient. POOLS PQOL QPENING:A(1 swimming,wading and whiripools which have been ciosed for ihe season must he inspected by the Health Department prior to opening. ConCact Yhe fiealth Department to schedule the inspection three (3) days prior to opening. PLEASE NOTF,: People are NOT allowed#o sit in the pool area until the poal has been inspected and opened. POC1L WATER TESTING: The water must be tested far pseudomonas,total colifonn and standard plate caunt by a State certified Iab, and submitfed to the Heafth Dapartrnenf tluee (3) days prior to opening, and quarterTy thereafter. P4fJL CLOSINfx:Every outdt�or in ground swiinm3ng paoi must be drained ar covered within seven(7)days af closing. FOOD SFRVICE SEASONAL FOOD SERVICE OPENING: All food service establisbments must be inspected by thz Heatth Department prior to opening. Please cantaot the kiealth Department to schedule the inspcction tlu�ee (3) days prior to opening. CATERING P4LICY: Anyone who caters within the Town of Yarmouth must noti,fy the Yarmouth HeaIth Department by filing the required Temporary Food Service Application larm 72 hours pz•iar to the catered event. These forms can be obtained at the Health Departmant,or fram the Town's website at www.yarmouth.naa.us under Health Department, I7ownloadable Forms. FROZEN DESSERTS: Frozen desserts must be tested by a State certified 1ab prior to apening and monthly thereaftar,with sample results submitted to the Hea2th Department. Failure to do so will resutt in the suspension or revocatian of your Frozen DesserE Permit untii the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Boazd of Health. OUTDOQR COOHING: Qutcipor cooking,preparation,or dispIay of any food product by a retail or food service establishment is prohibited. NOTTCF: Permits run annually from January 1 to December 31. I'C IS YOUR RESPONSIBILI'I'Y TO RETURN THE COMPLETEI} RENEWAL APPLICATION{S)AND REQUIREI}FEE{S} BY DECEMBER 15, 2024. ALL RENOVATIONS TO ANY POOD ESTABI,ISHMEI�T, MO'I'EL OR FOOL (i.e., PAIN7'ING, NEW EQUIPMENT, ETC.}, MI3ST BE TtEPQR"i'ED TO AND APPROVBI)BY TI-IE BOARD OF HEALTFI PRIOR TO COMMENCEMENT. RENOVATIONS MAY FtEQUIRE A SITE PI,AN, r�A�r�E: /�- � �1^�sz�NA�ru�: . PRINT NAME&TITLE: Rev.11f03114 V � The Commonwealth ofMassachusetts Department of Industrial Accidents Office oflnvestigations I Congress Street, Suite I00 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Auplicant Information Please Print Le¢iblv �"`'L�C�..EI'" Business/Organization Name: �' ,� � � ,�! Address: , ° ; ` s n'I 'yJ� City/State/Zip: Y'v�76� f oY7 ��°��hone #: �pA'- �loa- 3� ,3j Are you an employer? Check the appropriate boa: Business Type(required): 1,� I am a employer with employees(full and/ 5. ❑ Retail or part-Ume).* 6. ❑ RestaurantlBaz/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 aze a corporation and its officers have exercised 9. ❑ Entertairunent their right of exemprion per c. 152, §1(4), and we have 10.0 Manufacturing no employees. [No workers' comp. insurance required]* 11.0 Health Caze 4.❑ We are a non-profit organization, staffed by volunteers, _ with no employees. [No workers' camp. insurance req.] 12.�Othec_ _ _ •Any applicant thaz checks box#I must also fill out the section below showing their workers'compensation policy information. **If the cospornte officers have exempted themselves,but the corporation has other employees,a workers'compensafion policy is required and such an organization should check box#1. I am an employer that is providing wolrkers'compenLsaBon insurance fo/r�my employees. Be[ow is the policy information. InsuranceCompanyName: LI�eY"7L1 ///t!/UC/� �,j'J��, (;0• Insurer'sAddress: C�0 �� ,f��/ /�� L�C; G2�9 �9��CLY'l.3�Ul�/� ON • City/State/Zip: �t��17'I�`Y,V�r�Dj�o �7'1� D� S�R / Policy#orSelf-ins. Lic. # Lc�C53� S �3aD�o3 00�� ExpirationDate: Ul_—�3' D�5 Attach a copy of the workers' compensation policy declaration page(showing the policy number and ezpira6on 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 form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Invesrigations of the DIA for insurance coverage verification. I do hereby c ' ,und the pains and penalties ofperjury that the infarmation provided above is true and correct. Si ature: Mu�4 �q q ,� Date: �a" � �� Phone#: cSGi R - 3(0 � - 353 Official use on[y. Do not write in this area,to be completed by city or town ojficiaG City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2. Building Deparhnent 3. City/Town Clerk 4.Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone#: www.mass.gov/dia 12/5/2014 5:20:07 AM PST (GMT-8) FROM: 100005—T0: 16664757959 Page: 2 of 2 '`�G�� CERTIFICATE OF LIABILITY INSURANCE °"'�`""�°°""""' �v�zo�n THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHiS UPON THE CERTIFlCATE HOLDER.THIS CERTiFICATE DOES NOT AFFIRMATNELY OR NEGATNELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTRUfE A CONTRACT BETWEEN THE ISSUING INSURER�S), AIlTHORIZED REPRESEHTATNE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: M the cert�cate holder is an ADDRIONAL INSURED,ffie pdiry(ies)must be endorsed. H SUBROGATION IS WANED,aubjed to the te�ms and eonditio�of tha poliry,eertain polieiae may require an endorsament. A statement on this cert�eate does not eoMer righte M U�e certifieate holder in lieu of aueh endorsrnen a . aaooucen HUB INTERNATIONAL NEW ENGLAND LLC �E; r 299 BALLARDVALE STREET vxor� � No WILMINGTON, MA 01887 � �ooness: WSUR S AFFnPUP1GC0VERAGE WUC! xcun�nw� LMlicvanco ora[ion 33600 INSWtED f18URER8: KINGS WAY TRUST 64 KINGS CIRCUIT "$""ER�: YARMOUTH PORT MA 02675 r�sunERo: NSURERE: NSNtERF: COVERAGES CERTIFICATE NUMBER: �5q6977 ftEVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSUR4NCE LISTE�BELOW HAVE BEEN ISSUED TO THE INSURED NAME�ABOVE FOR THE POLICY PERIOD INDICATED. NOTWRHSTANDING ANY REQUIREMENT,TERM OR CANORION OF ANY CONTRAC7 OR OTHER DOCUMENT WITH RESPECf TO WHICH THIS CERTFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRBED HEREIN IS SUBJECf TO ALL THE 7ERM5, IXCLUSIONS AN�CONDRIONS OF SUCH POUCIES.LIMRS SHOWN MAY HAVE BEEN REDUCED BY PAID qA1M5. ItBR DL 6R POLICYEFF Pol1CTEXP �� iTVEOFNSUWWCE POIICYNUN9ER MM9 MMNO/YYYY ��$ COMMERCLLLGENERALIUBLRY EACHOCd1RRENCE S QHIM3#1ADE �OCCUfi $ 4EDEJ�(Myme0enm) $ PERSONALBAOVINIURV $ GEN'LAG(YiEGA7ELIMRNPPLIE3PER: GEN6tALAGGREGAIE S PoLIGV��p7 �LOC PROOl/CT5-COMP/OPAGG $ OTHER: S AUTOMOBILE W1BlRY I I I $ i nl nrrvurto eooaviwumrye�peBm� E nuov,�o scr�ou�o eoni�viwurtv�arbaem� 3 AUTOS AUTOS DAMpGE NON-0NMED MIR�AUfOS p�ps Po�eeatlerM1 = S UYBREW WB OCCUR EACH�G$iRENCE $ Ex�E88 uNB CLAIMSiAADE AGGREGRIE S DEO RETENf10N g A wowcerss eorvrx�sAnox WCS315-320630-024 5/13/2014 5N 3/2015 � �A� E�- AMENpIAYFRB'tJABLL1TY Y/N nnrrRORzieT«vaaarnewExecur� e.�.Encr�nccmarr S 500000 OFFlCElLMEMBERE%CLIAm9 �Y N/A � (��d�n'�� E.LDISEA3E-EAEMPLOVE E rJOOOOO Ityss,descrbeinder E.L.OISEASE-PoLICVLIMR $ 5000�� OESCRIPTION OF OPERATIONS Eabw OESCRP110NOFOPEMTIONBILOCnnOXS/VBUClEB (pCOR0101,AmltlonalRemarb6cnetlule,rerybeaWeneel(maeepaeelsrepJntl� Workars compensation insurance coverage appl ies onty to tha workers compensatlon laws of Nie state of MA. This certifpte pncels and supers�es all previously issued cert�cates,only as riiey relate to workers'compensation coverage CERTIFICATE HOLOER CANCELLATION TOWN OF YARMOUTH �a1LD ANV OF TiEABOVE DESCRIBED POLICIES BE CANCELLED BEFORE HEALTH DEPARTMENT 'ME EI�IRATION DA7E THEREOF, NOTICE WILL BE DELNERED IN 1146 ROUTE 28 ACCORDANCE WITiTHE POLICY PROVISIONS. SOUTH YARMOUTH MA 02664 „�„��o�P��.� �,�A'.,- �Qd�.. LM Insurance C oration � @� � �1986-2074 ACORD CORPORATION. All Aghffi reserved. ACORD 25(2011/01) The ACORD name and logo are reglstered marks of ACORD [ERT NO.: 215469)J CLIENi COOE: 14506I0 LucY Ga[fieLd 12/5/l01< B:l):E3 AM (EST� Paqe 1 of 1