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HomeMy WebLinkAboutApplication and WC o�"Y`�R �� ��'`_ '�� TOWN OF YARMOUTH Ha�f � —� { y I 146 ROUTE 28, SOUTH YARMOUTH, MASSACHLJSETTS 02664-24451 � �. �,rr^�„f`.�' x Telephone(508)398-2231, ext. 1241 �����y���on , Fax(508) 760-3472 UtC 1 0 2014 To: Yannouth Business Establishments }-4-AUE rs STDR� HEALTH DEPT. From: Bruce G. Murphy, Director � Yannouth Health Departsnent� Date: November 7, 2014 Subject: Increase in License/Pernut 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 pernut 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 applicafion after Januazy 1,2015. However, if you fully complete the application, and submit it to the Yarmouth Health Department with all required certificarions 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 85•00 ----- -- Fo�d a"�rvice fjver 1�0 3Eats - _ $16e.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: o.pa cAw,�N��c.���., D�SE'R-T Total fees owed for your establishxnent: $�JS.Cb NOTE: To be entitled to pay the current 2014 rates listed above, your business application, food and/or pool certi�cations, 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 a TOWN OF YARMOUTH BOARD OF HEALTH a���0�'/C�D ��� APPLICATION FOR LICENSEfPi��i'#`-20 � ' p ���c�����'° Utt; f 0 (tlt4 " * Please com lete form and attach all necess' o ts b ece ber IS 2014. Failure to do so will result in the retultxi of ydur-appt�ahon'i5 cke��LTH DEPT. ESTABLISHMENT NAME: � ' TA D: LOCATION ADDRESS•��� /i1R/f ��-!'G'�•9' /A2/�eiJfi��' TEL 3G 2 33G MAILING ADDRESS: �.,,,+� � /�7 • C�2.476 E-MAIL ADDRESS: ' OWNER NAME: � ' CORPORATION NAME (IF APPLICABLE): ', MANAGER'S NAME: TEL.#: MAILING ADDRESS: POOL CERTIFICATIONS: The poot 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 currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation (CPR), having one certified employee on premises at a11 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 prov�de 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 fixll-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishxnents, 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 hoars of operation. — _ �' �csr�r�' � 1�� _ _ 2. i. - 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 nd maintain a file at your establishment. i. C �A.P �rs � ��11 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 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' records. You must provide new copies and maintain a �le at your place of business. 1. 2• 3. 4. RESTAURANT SEATING: TOTAL# r)ar✓,r� + vA OFFICE USE ONLY LODGING: UCENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $110 —I1VN $55 CAMP $55 SWIMMINGPOOL$ll0ea. LODGE $55 _TRAILERPARK $105 _WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE P�$RMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQIDRED FEE PERMIT# J_0-100SEATS $125 '�ll��� CONTINENTAL $35 NON-PROFIT $30 . >I00 SEATS $200 1COMMON VIC. $60 . �sVO , _WHOLESALE $SO — —RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT q LICENSE REQUIRED FEE PERMIT# <50 sq.ft. $50 >25,000 sq ft. �z85 �6 —TOBACCO F��D$$10 =<25,000 sq.ft. $150 �FROZEN DESSERT $40 � _ NAME CHANGE: $15 AMOUNT DUE _ $ 225.00 *'*"•PLEASETURNOVERANDCOMPLETEOT}IERSIDEOFFO_R�M***** ��rG� �C ��QV _ . , � ����� 'r°`t����`� .�� � ADMINISTRATION Undex Chapter 152,Section 25C,Subsection 6,the Tawn of Yarmouth is now required to hold issuance or renewal of any lioense or permit ta operate a business if a person or company does not have a Certificate of Worker's Compansatian Insurance. THE ATTACHED STATE VY4I2KER'S COlYIPENSATIdN IATSUItANCE AFFIDAVIT MiTS,TtBE COMPLETED AND SIGIVED, QR - ' ( CERT.`OF INSIJRANt;E ATTACHBD�es OR WORKER'S COMP. AFFIDAVIT SIGNED AN17 ATTACHT�D�S Toun7 of Yarmouth taxes and liens rnust be paid prior to renewal or issuance of your perrnits. NLEASE CHBCK APPROPRIATEI.Y IF PAID: XES � NO MOTELS AND OTHER LODGING ESTABLISHMENTS ' TI2ANSIENT QCCUPANCY: For purposes of the limitations of Motel ar Hotel use,Transient occupancy sl�all be limited ta the temporary and shart term occupancy,ordinarily and customarily associated with matel and hotel use. Transaent occupants musY have and be able ta demonstrate that they maintain a principal place of xesidence elsewhere.Transient occupancy shall generally refer to cantinuous occupancy of not more than thirty(30)days,and an ag�regate o£not more than ninety(90)days wiYhin any six(6)month period. Use of a�uest unit as a residence or dwelling unit shall not be considered transient. dccupancy that is subjeot to the collectian af Room Oceupancy Lxcise, as defined in Nf.G.L. a 64Cr or&34 CMR 64G, as amended, sha11 generally be cansidered Transient. POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed far the season musi be inspected by the Health Department prior to opening. Contact the TIealth DeparGment to echedule the inspection three(3) days prior to openin�. PLEASE NOTE: Peaplc are N4T allawed to sit in the pool area until tha poof has been inspected and apened. POOL WATER'I'ESTING: The watez must be tested for pseudamonas,totaJ coliform and standard plate count by a State certified tab, and submitted to the Health Department three (3} days ptior to opening, and quarCerly thereafter. 1't}OL CLOSING: Every outdaar in ground swimming poal must be drained or coverad within sevan{7)days af closing. FO011 SF.I2VICE , ,, . SEASONAL FOdD SERVICE OPENINC>: All faod service establishments must be inspected by the Health Department prior to opening. Please contact the Health Department to schedule the inspection three (3)days prior to opening. CATERING PQLICY: Anyane who caters within Yhe Town of Yaamouth must notify the Xarmouth Health Department by filing the required Temporary Faod Service Application farm 72 hours priar ta the catered event. These forms can be abtained at the Health Department,ar fram the Town's website at www.varrnoath.ma.us under Health Department, I�ownioadable Forms. _ k'RO'LEN DESSERTS: Frozen desserts must be tested by a State certified lab prior to opening and rnonthly thereafter,with sarnple results submitted to the Heatth Department. Failure to do so wilI resuIt in the suspension or revocation of your Frozen Dessert P�rmit until the above Yerms have been met. OUTSIDE CATL`S: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. (?UTDOCIR COOKING: Outdoor cooking,prepazation,or display of any food product by a retail or faod service establishment is prahibited. NOTICEs Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBII.ITY TO RETCTRN THE COMPLETEI}RENEWAL APPLICATION(S}AND REQUIREI3 FEE(S}BY DECE1ffB�R 15, 2414. ALL IZENOVATIONS TO ANY FOQD ESTABLISHMENT, MQTEL OR POOL (i.e„ PAINTING, N�W EQUTPMENT,ETC.},NIUST BE REPC}RTBI}T4 AND APPROVED BY TITE B(7A OF HEALTH PRiOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SI , P N. DATE: /a2 ' f"aA�`� SIGNATURE:._� PRINT NAME 8c TITLE: �/*/rs �l� Rev. 3 t103134 �. i � The Commonwealth oJMassachusetts � Department of Industrial Accidents � Office of Investigations 1 Congress Street,Suite 100 � Boston,MA 02114-2(JI7 www.mass.gov/dia Workers' Compensation insurance Affidavit: General Businesses A�plicant Information Please Print Le�ibiv BusinesslOreanizarion Name: Charles Clark D B A Hallet's Store Adclress: 139 Main Street City/State/Zip: Yarmouthoort Ma.02675 Phone �: �8 362 2402 Are you an employer?Check the appropriate bos: Business Type(required): l.❑ I am a employer wich employees(full and,- 5• ❑ Retai� or part-time)." 6. ❑ Restaurant/FtariEating Establishment 2.❑ I am a sole proprietor or partnership and have no 7, � q�ce and/or Sales(incl.real zstate,auto,eta) employees working for me in any capacin. [Vo workers' comp. insurance requiradj 8� ❑ �on-profit 3.❑ We are a corporacion and its officers have exercised 9. ❑ Entertainment their right of exemption per a 152, §1(4),and we hava �0.❑ Manufatturing no employees. [No workers' comp. insurance required]* �1.❑ Health Care 4.❑ We are a non-profit organization,staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.0 Ocher "Any applicsnt that checks box tFl musi also fill out the section below stwwing iheir workers'compensation poiicy information, � "«If the cnrp�rate o�cers have esemp[<d thtmStives,bm the corporarion has other employees.a�rorkers'compensazion policv is required and such an organization should check box q l. I am an employer that is providing workers'compensation insurance jor my employees. Below is the policy iaformotion. Insurance Company Name: LOVEQUIST- MURRAY INS AGGY INC Insurer's Address: �q� MATN cT CitylState Zip:_ WEST DENNIS MA 02670-0038 _'_ _i_ Policy#or Self-ins. Lic.# SBP 1065339 Expiration Date: 12�13/2015 Attac6 a copy of the worken' compensation poficy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL a li2 can ]ead to the imposition of criminal pena(ties of a fine up to S L�OO.00 and/or one-year imFris�nment,as well as civit penalties in the form of a STOP WORK ORDER and a fine of up to 5250.00 a day against the violator. Be advised that a c y of this statement may be fonvazded to the Office of Invosfigations of the DIA for insurance coverage verificatio /do hereby certify, r th ain nd pena of p r that the injormation provided av is true and correct. $jlenature: D t : Phone#: Officia!use only. Do not wrtte Jn this urea,to be completed by cin•or lown o�ciaL City or Town: Permit/License# [ssuing Authortty(circle one): 1. Board of Health 2. Building Department 3. City�"l'own Clerk 4.Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone#: wNlv.msss.gov%dia ,acoRO� CERTIFICATE OF LIABILITY INSURANCE DATE(MWOU/YYYY) �..� is�s�zoi4 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICA7E HOLDER. iHIS CERTIFICA7E DOES NOT AFFIRMATIVELY OR NEGA7IVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERi1FICATE OF INSURANCE DOES NOT CONSTITUiE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holtler is an ADDITIONAL INSURED,the policy(ies) must be entlorsed. If SUBROGATION IS WAIVED, subject to the terms antl contlitions of the policy,certain policies may require an entlorsement. A statement on this certificate dces not confer rig�ts to the certificate holder in lieu of such endorsement(s). PRODUCEH NAMEA T Catherine Murrap CIC The Oceanside Iasurance Group PHONE �SOH)3JH-ZZBZ F� .(508)]60-2211 E-MAIE :C8Lb2IlIIe@OC28R81[�01DSUS8pC2.COID PO S08 3S INSUHERS AFFOflDINGCOVFAAGE NAICi West Deanis MA 02670 INSUREflACaIDbrl(I e 19771 INSUpED INSUflEH B: (,`ALRi.RS CLARR INSUflFA C: 139 MAIN ST INSUflERD: INSUpER E: � YARMOUTHPORT MA 02675-1713 INSUflEHF: COVERAGES CERTIFICATENUMBERCL3412503577 REVISIONNUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LIS7ED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BV THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSfl PpLICY EFF POUCV EXP �Tq TVPE OF INSUqANCE PpLICY NUMBER MM�DD/YYY MINDD/YYY LIMRS GENEflAL LIABILfiY EACH OCCURRENCE $ 1�OOO�OOO COMMERCIALGENER4LLIABILITV PREMISES Eaoccurrence $ SO�OOO A CLAIMS-MAOE �OCCUR BP1065339 2/13/201412/13/2015 MEDEXP(Anyoneperaon) $ $���0 PERSONALBAOVINJURY S S�OOO�OOO GENER4L AGGREGATE E 2�OOO�OOO GEN'LAGC�REGATELIMITAPPLIESPER: PRODUCTS-COMPIOPAGG E 1�000�000 B POLICY PRQ �O� s AUTOMOBILE LIABILITY CA MB�IN�E�D,SINGLE LIMIT a ANV AUTO BODILY INJURV(Perperson) $ ALLOVJNED SCHEDULED BODILVINJURV(Peraccitlen� S AUTOS AUTOS � HIRED AUTOS NON-OWNED PROPERTV DAMAGE $ AUTOS PeracrJtlem S UMBRELLALIAB OCCUR EACHOCCURRENGE 5 EXCE$$LIAB CL41MS-MADE AGGREGATE E DE� RETENTIONS y WOHKEfl$COMPENSHTION WCSTATU- OTH- ANDEMPLOYEH$'LIABILITV Y�N ANY PRdPR1ETOfLPARTNER/EXECUTIVE OFFICEWMEMBEREXCLUDEO? � N/A E.LEACHACCIDENT $ (WnAatory in NH) E.L.�ISEASE-EA EMPLOVE $ Ifyes,tlescn0e under DESCRIPTION OF OPERATIONS below EL DISEASE-POLICV LIMIT $ OESCflIPTION OF OPEflATIONS/LOCATIONS/VEHICLES(Atbc�ACOflD 101,AtlEidonal Remarks Sc�etlule,if more space is requiretl) Certificate of Insurance for Workers Compensation to follow directlp from assigned risk carrier. CERTIFICATE HOLDER CANCELLATION (SOH)76O-4H30 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIHA710N DATE THEHEOF, NOTICE WILL BE DELNEHED IN ToTdn of YaimOuth ACCORDANCE WRH THE POLICY PROVISIONS. Attn: Board of Health 1146 Route Z$ AUTHORQEDqEPflESEMATIVE South Yarmouth, MA 02664 C Murray CIC/MC �',�, �"�` n��m�"'y`� ACORD 25(2010/OS) O 1988�2010 ACORD CORPORATION. All rights reserved. INS096 i�mnns m Thc OCl1Rfl namn and Innn nru rmictnrul mnr4e nf ACl1RIl �CdRL]r S �j �'� i�`-.�s�` 4'�t � � . --�" P ..�, �_ �.�u , � �.��#�� 12/8/2014 ' 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, E%TEND OR ALTER THE COVERAGE AFFORDED BV THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETNEEN 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 endorsetl. H SUBROGATON IS WAIVED,subject W the terms and conAitions of the policy,certain palicies may require an entlarsement A shlement on this c rtficale tices not eonfer righis to Ne certificate halder in lieu of such endorsements�s) PROOUCER CONTACT NAME: Lovequisr Murray Insurance Age�cy �n"c n�,m�wc (508)698-2282 �ac No.:i PO Box 38 A RIES5 W. DCMIS�MA OZCI�IO PRODIICER CIISTOMER IO#' INSURERS AFFORDING COVER4GE NAIC# ixsuReo iNsuReR a At�antic Charter Insurance Company VDAC 44326 Chades Clark �NSURER B: Hallettes Srore INSURER C 139 Main Street INSURER D: Yarmouthport,MA 02675 INSURER E: INSURER F: COVERAGES: CERTIFICATE NUMBER: REVISION NUMBER: 7HI515 TO CERTIFV iHAT THE PO�ICIES OF INSURANCE LI57ED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICV PERIOD INDICATEp. NOTWITISTANDING ANY REOUIREMENT,TERM OR CONDITON OF ANV CONiFNCT OR OTHER DOCUMENT WIiH RESPECT TO WHICH h115 CERTIFICATE MAV BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY T1E POIJCIES DESCRIBF�HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BV PAID CLAIMS. �N3R TYPE OF INSURANCE ADUL suev POLICY NUMBER POLICV EFFECTNE VOLICV EXPIRATION L1MIT5 LTR ixsa �yyp pATE(MMIDOIn) DATE�MMIDD/W) (InTlwusaiM) GENERALLIABILITY ACHOCcuRRErvcE $ COMMERCIhL GENERAL LIABIUTY AMNGE TO RENTEO PREMISES �� IEe occurtence) E CV.IMSMADE ❑ OCCUR MEDEXF(Myanepereon) $ PERSONAL6NDVINJOFY § ENERhLhGGREGATE § GEN'LAGGREG4TELIMITNPPLIESPER'. PROOUCTS-COMP/OGAGG $ POLICY ❑Pq0.1ECT ❑ LOG hUTOMOBIIELIABILITY COMBINEOSINGLELIMIT E ANY AUTO IEa Accitlem� BODILV INJURV ALLONMEDAUi03 IPerperson) E SCnEDULEDhUTOS ❑❑ BODILYINJURV E (EaNcuEent) HiREDAUT05 PROPERN DAMqGE g NON-0WNDEDAOi03 (EaAcdEan�) NMBRELLA ❑ OCCUR EACHOCCURRENCE b IJA61LItt EXCESSUA6 CIA�MSmnOE AGGREGATE E DEOUCTIBLE ❑❑ E REfENTION $ ORNERHLOMGENSATIONAND WCVOIOGSOOI O4�OIIZOI4 OA�OUZOIS X STATUTORY OTHER A EMPLOYERS'LIABILIN LIMRS NNVPROPRIETOR/PnRTNER/EXECUTIVE Y�� IOO�OOO OFFICE(LMEMBER E%QOOED4 � N/A � policy Coverage State:MA EACH ACCI�ENT $ MmCMory in NH ifyea.CeurioeuneerSPECNLPROVI510N5eelo-x DISEASE-POLICVLIMIT E SQQ,QQQ The workers'compensation policy d s not provide coverage for I18IICS CIBPI(. DISENSE-EACH EMPLOVEE S ���,0� OTHER ❑❑ DESCftIP110N OF OPfRl1TOH5ILOLRTONYJEXICLES�AtlaeM1 ACORD t0i MtlifiaW ftem��ks SCM1NuIe,if mwe spac�ia�puiretl) ��' r . . . . . ,s " .,.,��''��'.� .c�+ �, .-L �"i"�,`�,x,,"c��^�Z a���u .'�3k���k.'_��.-.'�'r'.e:�:'�`�'t SHOULD ANV OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE TO�yp Of Y3tIri0UYI1 EXPIRATION DATE THEREOF,THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 1146 Route 28 ]2 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT SOLLSh Y31'IIIOUt}t, MA OZGG4 BUT FFULURE TO DO SO SHALL IMPOSE NO 08LIGATION OR LIA8ILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. UTXORIZEDREPRE9ENTATIVE /� � ACORD 25(2009/09) A1 BN14BJ / '_. .� Page t ot� CERTIFICATE HOLDER COPY ��988-2009 ACORD CORPORATION. All rigMs mxrveG.