HomeMy WebLinkAboutApplication and WC ��°�_��'�� TOWN OF YARMOUTH BHadhf 4
� -:., :_- � `j ll46 ROUTE 28, SOUTH YARMOUTH, MASSACHLJ5ETTS 02664-24451 -
�. ���rACXt�e�' � Telephone(508)398-2231,ext. ]241 Divsi n
Fax(508) 760-3472
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To: Yannouth Business Establishments cavE Cos� ('Q�cr�e2y UE� �9 ?Q 14
From: Bruce G. Murphy, Director � HEALTH DEPT.
Yarmouth Health Department�
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 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
Departrnent with a11 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 .00
Food Seivice Over 100Seats $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: _,� ��p,pp co rMo N J�c. j
Fko�z��KS�X
Total fees owed for your establishment: � s.00
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
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� � � TOWN OF YARMOUTH BOARD OF HEALTH � � °
� APPLICATION FOR LICENSE/PE T,,2 1 � `v` �
= p �F��i`���� '. Utl; U� LU14
* Please com lete form and attach all necessa do u en b' ece �er IS 2014.
Failure to do so will result in the return of you�r appticafion p cke . DEPT.
ESTABLISHMENT NAME: � w TAX ID:
LOCATIONADDRESS: �-tG,e��e � on,_ � S . r/A✓w�v� TEL.#: i?�4'-�394'-i3yU0
MAILING ADDRESS: S A-..�,� ��
E-MAIL ADDRESS: e�r-va,..,�. .,--
OWNER NAME: /�,-. �9-�3
CORPORATION NAME (I APPLICABLE): � �U( r,,,��d.,,.,�u� , LL�
MANAGER'SNAME: �✓),-� �/,�v+1 �TEL.#: 5?r -7 e-s
MAILING ADDRESS: e a� S, �✓.. o
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 tlus form.
1. 2.
Pool operatars must list a minimum of two employees cunentiy 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 ptace of business.
1. Z.
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. ,��✓�-� � A7��3 2.��✓r�....- ��'C w✓
PERSON IN CHARGE:
Each food establishment must have at least one Person In Chazge (PIC) on site during hours of operation.
L - -�-- ----- - - -
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 �le at your establishment.
1. �/t�v1 ��,/r S 2. �7`i-,-•^ �o...� S�r�7/�
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 ail times. Please list your employees trained in anti-choking procedures below and
attach copies of employee certifications to this form. The Health Deparhnent will not use past years' records.
You must provide new copies and maintain a file at your place of busiaess.
1. 2•
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$110ea.
LODGE $55 _TRA[LER PARK $105 _WHIRLPOOL $110ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PER[vIIT# LICENSE REQUTAED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
10-100SEATS $125 -�1���9�h —CONTINENTAL $35 NON-PROFIT $30
>100 SEATS $200 . COMMON VIC. $60 � : �7� 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,OOOsq.ft. $150 TFROZENDESSERT $40 �0.� _TOBACCO $ll0
NAMECHANGE: $IS AMOUNTDUE _ $ G.Z� 1L
�
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** �p��C� L`���[ 7
� - � ��CI�S�.'G �Z/�/���
ADIYIINISTRATION
Under Chapter 152, Section 25C, Subsection b,the Tawn of Yarmauth is naw required to hold issuance ar renewal
af any license or permit to operate a business if a person or company does not have a Certi£icate of Worker's
Compensation Insurance. THE ATTACHED STATE WORK�R'S COMPENSATION INSUI2ANCE
AFFIDAVIT MLIST BE COMPLETED ANI} SIGNF,D, OR
CERT. OF' INSURANCE ATT�CI-iED ✓'�
OR
WOIZKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yannouth taa{es and liens must be paid prior to renewal ar issuance of your permits. PLEASE CHECK
APPR4PRIATELY iF PAID: /
YES �/ NO
MOTELS AND t)THER I,4DGING ESTABLISHMENTS
TRANStENT OCCUPANCX: Far purposes oPthe limitatians of Motel ar Hotel use,Transienf accupancy sha11 be
limited to the temparary and short term occupancy,ardinarily and cvstomarily assaciated cvith motei and hotei use.
Transient ocoupants rnust have and be able tc� demonstrate that they maintain a princip�l place of xesidence
elsewhere.Transi,ent accupancy shall generally refer to continuous occupancy ofnat more than thirty(36}days,and
an aggregate of not mare than ninety{94}days withiu any six{6)month period. Use af a guest unit as a residence ar
dwelling unit shall not be considered transient. Occupar�cy that is subject to the collection of Room Occupancy
Excise, as defined in M.G.L. a 64G or $30 CMR 64G, as amended, shall generally be considered Transient.
POOL5
PO4L OPENING:All swimming,wading and whirlpools wkuch have been closed f'or the season must be inspected
by the Health Department prior to opening. Contact the Health Departrnent ta schedule the inspection three(3}
days prior to opening. PLEASE NOTE: People are NQT allowed to sit in the pool area until the pool has been
inspected and opened,
POOL WATER TESTING: The water must be tested for pseixdomanas,total coliform and standard plate count
0y a StaYe certified lab, and submitted to ihe Health Deparhnent three {3) days prior to opening, and quaRerly
thereafter.
POOL CLOSINC: Every outdoor in ground swimming pool must be drained or cUvered within seven(7)days of
closing.
FdC1D S�RVICE
SEAS�NAL FOOD SERVICE OPENING:
All food service establishments must be inspected by the Health Departmex�t prior to openiug. Please coutact the
IIealth Depaxtment to schedule fhe inspection three (3) days prior to opening.
CATERING POLICY:
Anyone who caters within the Tawn of Yarmouth must notify the Yannouth Health Departsnent by filin� the
requrred Temporary Food Service Application form 72 hotzrs prior to the catered event. These £orms can be
obtained at the Health Departmant,ar from the Town's website at wwwyarmauth.ma.us under Heaith I�epartment,
Downloadable Farms.
FROZEN DESSERTS:
Frozen desserts must be tested by a State certified lab priar to opening and monthly thereafter, with sample results
submitted to the Health Department Failure to do so will result in tl2e suspension or revocation of your Frozen
Dessert Permit until the above terms have been met.
OUTSIDE CAFES:
Outside cafes{i.e.,outdoar seating with waiterlwaitress service},mnst have prior approva]fron�the Board af Health.
OUTDt70R CCIOKING:
Outdaor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited.
NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR ItESPONSIT3ILI"1'Y TO RETL7R,�T
THE COMPI.ETED F2ENEWAL APPLICATICIN(S) AND T2EC�UIRE,D FEE(S) SY DECEMBER 15, 2Q14.
ALL RENOVATIONS TO ANY FOOD ESTABLISFiMENT, MUTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT, ETC.), MUST BE TtEPQRT'ED 'f0 AND AFPROVED BY THE BOARD QF HEALTH PRIOR
TO CdMMBNCF,MENT. RE;NOVATIflNS MAY REQUIRE A 5I1'E PL.Aiv'.
DATE: SIGNATURE: j��r`�,._ "'�,,� �C'�,..i
,
PRTNT NAME & TITLE:___ i�� f•yl .� � V�i � µ„-e�..�
Rev. li/03/14 �
� The Commonwealth ofMassachusetts
Department of Industrial Accidents
Office oflnvestigations
I Congress Street, Suite Z00
Boston, MA 02I14-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Le¢iblv
Business/OrganizationName: �'�✓�/�e Z� �-c,.�.,,-�„/
�
Address: j /r�-,a�a�.�c �,i%-..� � ��i
City/State/Zip: S- �/�wv,il'1. , rl'i� ��i (� y Phone#: S'L fl ' 3 9 k ' Q`1 oU
Are you an employer? Check the a ropriate box: Business Type(required):
1.� I am a employer with�employees(full and/ 5. ❑ Retail
or part-fime).* 6. [v]�RestauranUBaz/Eating Establishment
2.❑ I am a sole proprietor or partnership and have no �, � pffice 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. I 52, §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.] 12.0 Other
•Any applicant that checks box#1 mus[also fill out the section below show'vig their workers'compensation policy iaformation.
*'If the cocporate officets have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an
organization should check box#I.
I am an emp[oyer that is providing workers'compensation insurance for my employees. Be[ow is the policy information.
Insurance Company Name: �slr.����.•,_ 4- d {$/G��
Insurer's Address: 9�3 Zw✓-h�,o�rG. �G��
City/State/Zip: ��,y.�,,,? v1�! w O,�(��
Policy#or Self-ins.Lic. # Lv�L 5?,�.3-a,�i 9 y S�o/`>� Expiration Date: O S�Ol��j�
Attach a copy of the workers' compensation policy declaraHon page(showing the policy number and expiration date).
Failure to_secure_c_overage 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 WOI�K 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 verification.
I do hereby certify, under the pains and penalties ofperjury that the information provided above is true and correct.
Sienature: ����- �Q�� Date:
Phone#: � � ' �` r�S ��3
Offcial use only. Do not write in fhis area, to be completed by city or town officiaL
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of HealtL 2. Building Department 3. City/Town Clerk 4.Licensing Board 5. Selectmen's Office
6. Other
Contact Person: Phone#:
www.mass.gov/dia
Client#:45428 2CCCR1
ACORD,., CERTIFICATE OF LIABILITY INSURANCE DATE�MMI�OIYYYY)
10I2312014
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER�S),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed.If SUBROGATION IS WAIVED,subject to
the terms and conditions of the policy,ceRain policies may require an entlorsement.A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER CONTACT
NAME:
Dowling&O'Neil °"o"E-� —508 775•1620� � �F"" 5087787218
Insurance Agency ,E maa� EX`�: --__ i iu°,"°e
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9731yannoughRd., POBox1990 INSURER�S�AFFOR�INGCOVERAGE NAICp
Hyannis,MA 02601 'ixsuRER A:Safety Indemnity
INSUREO iHsurseR e:Associated Employers Insurence
Cape Cod Creamery, LLC
5 Theatre Colony Road INSURER C:
South Yarmouth� MA OZSG4 �NSURERD:
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INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVEBEENISSUED TOTHE INSURED NAMEDABOVE FORTHE POLICYPERIOD
INDICATED. NOPNITHSTANDING ANV REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAV BE ISSUED OR MAY PERTAIN, THE INSUR4NCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLIGES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
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LTR INSR WVD POLILYNUMBER MMIDOIYYri MMIDDIYYYY � LIMITS
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DESCRIPTIONOFOPERATIONSbelow I E.L.DISEASE-POLICYLIMIT SSOO�OOO
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DESCRIPTION OF OPERATIONS/LOGATIONS/VEHICLES�Attach ACORO 101,Atltllllonal Remarks Schetlule,if more space is raquiretl)
Insurance coverege is limited to the terms,conditions,exclusions,other limitations and endorsements.
Nothing contained in the certificate of insurance shall be deemed to have altered,waived,or extended the
coverage provided by the policy provisions.
CERTIFICATE HOLDER CANCELLA710N
Town of Yarmou[h SHOULD ANV OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
1146 Route 28 ACCORDANCE WITH THE POLICY PROVISIONS.
South Yarmouth, MA 02664
AUTHORIZEO REPRESENTATIVE
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