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� � "` y 1146 ROUTE 28, SOUTH YARMOUTH,MASSACHLJSETTS 02664-24451 -
� �.,1��N6�a` � Telephone(508)398-2231,ext. 1241 D vis o
Fas(508) 760-3472
To: Yarmouth Business Establishments Lp gS-(�'� $optr-
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From: Bruce G. Murphy, Director U
Yarmouth Health Department� Utl: L 9 �L��4
Date: November 7, 2014 HEALTH DEPT.
Subject: Increase in License/Permit Fees
Please be awaze that the Yannouth Board of Health, under the direction of the Yazmouth Boazd
of Selectmen, has raised a number of license and pernut fees issued through the Yarmouth
Health Deparhnent, effective January 1, 2015.
Attached is the Yazmouth Business License/Permit Application for 2015. You will note that the
fees listed aze the fees effective January 1, 2015. T'hese fees will be due if you complete and
submit the application after Januazy 1,2015.
However, if you fully complete the application, and submit it to the Yannouth Health
Department with a11 required certificarions and worker's compensa$on coverage informa6on
(certificate of uvsurance 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
Food Service Over 100 Seats $160.00 (,O O
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: � (00.00 Cornr+oN V�c.
Total fees owed for your establishment: $220.00
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 certiftcations prior to opening, however, you must note
"Will provide in the spring prfor to opening" on the application.J
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' LOFiSfE�g6Yt� ,
' a TOWN OF YARMOUTH BOARD OF HEALTH
' ��� APPLICATION FOR LICENSE/PE��T -�2015 ��C I s���D
* P l e as e c o m p l e t e f o r m an d a tt a c h a l l n e ce s s a ry d o�i ��9 b y D e c e m b 1 s . 9 2 0 1 4
Failure to do so will result in the retum'of your applicatron pack .
,_'�-�LTFi �JEP-i .
ESTABLISHMENT NAME: 1 P TAX ID•
LOCATIONADDRESS: TEL.#: ,5=65��-6
MAILING ADDRESS: o
E-MAILADDRESS• Z roL'emOCJ l n� tiE P r �p
OWNERNAME:_ �(�� SNta ��1J DS
CORPORATION NAME (I APPLICABLE): S', d e #t
MANAGER'S NAME: /" � TEL.#:
MAILING ADDRESS: e �
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.
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 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 place of business.
1. Z.
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 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. �/1T� � � i�m a.1CaR�LS�I o� 2.
PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
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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.
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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. '
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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 $I10
INN $55 CAMP $55 SWTMMINGPOOL$110ea.
LODGE $55 TRAILER PARK $105 WHIRLPOOL $110ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
0-100 SEATS $125 CONT[NENTAL $35 NON-PROFIT $30
=>]00 SEATS $200 1 — 4 �COMMON VIC. $60 �S _��D.KITCHEN $80 '
RETAIL SERVICE:
LICENSE REQIDRED FEE PERMIT# UCENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �.
<50 sq.ft. $50 ' >25,000 sq.ft. $285 VENDING-FOOD $25 '�
=<25,000 sq.ft $150 _FROZEN DESSERT $40 TOBACCO $110
NAME CHANGE: $IS AMOUNT DUE _ $ 260.��
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** �C �U`� � Zr�`�
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ADMINISTRA7'ION
x
Under Chapter 152, Section 25C, Subsection 6,the Town of Xannoutt�is now required to hold issuance or renewal
of any license or permit to operate a business i£a person ar cornpany does not have a Cettificafe of Worker's
Campensatian Insurance. THE ATTACAED STATE Vt'ORKER'S COMPENSATION INSUI2ANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR
CERT. OF iNSURANCE ATTACHED ✓
OR
WORKER'S COMP. AFFIDAVI"T SIGNED AND ATTACHED
Town of Yarmouth taxes and liens must be paid priar to renewal or issuance of yoixr permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES_�__ NO
MOTELS AND OTHER LODGING ESTABLISHMENT3
TRANSIENT OCCUPANCYt Far purposes ofthe limiiations ofMotel or Hotel usa,Transient occupancy shall be
limited to the temporary and short term occupanoy,ordinarily and customarily associated with motel and hotel use.
Transaent occupanEs must have and be able to demonstrate that they maintain a principa] place of residence
elsewhere.Transient occupancy shall general ly refer to continuous occupancy of not more than thirty(30)days,and
an aggregate of not more than ninety(90)days within any six(6)manth period. Use of a guest unit as a residence or
dweTling unit sha11 not be eonsidered transient. Occupancy that is subject to the collection of Room 4ecupancy
Excise,as defined in M.G.L. c. 64G or 830 CMR 54G, as amended, shall generally be considered Transient.
POpLS
POOL OPENING:All swimming,wading and whirlpooEs which have been closed far the season must be inspected
by the Health Deparhnent prior to opening. Contact the Health Deparkmeut to schedule the inspection three(3)
days prior to opeuing. PLEASE NdTT: People are NOT allowed to sit in the poal area until the paol has been
inspected and opened,
POOL WATER TESTING: The water must be tested for pseudamonas,total coliform and standard plate count
by a State certified Iab, and submitted to the Health Departrnent three (3} days prior to opening, and quarterly
thereafter.
PQOL CLf}SING: Every outdoar in graund swimming poot must be drained az covered within seven{7)days of
olosing.
FOOLI SERVICE
SEASONAL FOOD SERVICE OPENING:
All food service establishments must be inspected by the I-Ieaith Departsnent prior ta opening. Please contact the
Health Departrnent to scheciule the inspection three (3)days pzior to opening.
CATERTNG POLICX:
Anyane who caters within Yhe Town of Yarmouth must notify the Yarmouth Health Department by frling the
required Temporazy Food Servaca Applicatian farm 72 hours priar to the catered event. These forms can be
obtained at the Health Department,or fram the Tawn's website at www.varmouth.ma.us under He;alth Deparhtient,
Downloadable Forms.
FI20ZEN DESSERTS:
Frozen desserts must be tested by a State certified lab prior to opening and rnonthly thereafter,with sample results
submitted to the Health Department. Failure to do sa will result in the suspension or revooation of your Frozen
Dessert Permit uutil the above terms have been met.
dUTSIDE CAFES:
Qutside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth.
OUTDOOR COOHING: '
Outdoor cooking,prepazatian,er display ofany faod product by a retail pr food service establishment is prohibited.
N4TICE: Permits run annually frorn 7anuary 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLTTED RENEWAL APPLICA'I'I4N(S)AND REQUIRED FEE{S)BY DECEMBEIZ 1S, 2014.
ALL RENdVATIQNS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUTPMENT, ETC.},MUST BE REPOItTED T'd AND APPRO VED BY THE BOARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY RE UIRF A SITE PLAN.
DATE:��/� �SIGNATUI2E: �����„�„'
PRINT NAME& TITLE: f ;Q � C'g�f�y�, ��P yy����
Rev. 11l03(l4
� _ � The Commonwealth ofMassachusetts
� Department of Industrial Accidents
OJfice ofinvestigations
I 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/OrganizationName: L� � 6 2 s �-
Address: UI � S �
City/State/Zip: �} �Fhone #: � 7�� �y�o
Are you an employer? Check t appropriate box: Business Type(required):
1.❑ I am a employer with employees(full and/ 5. ❑ Re il
or part-time).* 6. estauranUBaz/Eating Establishment
2.❑ I am a sole proprietor or partnership and have no 7, � Office ancllor Sales(incl.real estate, auto,etc.)
employees working for me in any capacity.
[No workers' comp.insurance required] $• ❑ Non-profit
3.❑ We aze a corporation and its officers have exercised 9. ❑ Entertainment
their right of exemprion per c. 152, §I(4), and we have 10.❑ Manufacturing
no employees. [No workers' comp. insurance required]* 11.❑ Health Caze
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'compensa[ion policy infotmation. �
**If the cocpomte officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is Iequired and such m
organ'vation should check box#I.
I am an emp[oyer that is providing wo�kers'compensation insurance for my employees. Below is the policy information.
InsuranceCompanyName: ����TW-��_ ��C�A-A�T-S l,�C'. (�rp�1P it� C
Insurer's Address: IV � � ��( �� �c�c�. 'q 3 c�-�
City/State/Zip: ��C4�/I'M�e� . � �} O�o��SS
Policy#or Self-ins. Lic. # I�') `{�S(L-��•9 a I� 4 Expiration Date: � � 7 I r�2���J'
Attach a copy of the workers' compensation policy declaration 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 crimina]penalries of a
fine up to $1,500.00 and/or one-yeaz imprisonment,as well as civil penalties in{lie 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 forwazded to the Office of
Invesrigations of the DIA for inswance coverage verificarion.
I do hereby cenify,under the pains a penalties ofperjury that the information provided above is true and correct
�
Si ature: ' Date:
Phone#: � S` 7 7i7 - d�d!O
Ojficial use only. Do not write in this area,to be comp[eted by city or town official
City or Town: Permit/License#
Issuing 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 ',
WORKERS CAMPF.NSATION .4I�ID E[�ffIAYERS LIABILITY INSURANCE CERTIFICATE
�,/ INFORMATION PAGE RENEWAL A(�2Effi+I�N'P
i Producer: Agent# 932
MA Retail Merchanta WC Group Inc. Dowling fi 0'Neil Inaurance Agency
PO Box 859222-9222 PO Box 1990
Braintree, MA 01285 Hyannis, MA 02601
(Carrier Code: 34355) ; Certificate �: 014005030290114
IPr3or Certificate #: 014005030290113
i
1. The Employer: The Lobeter Boat Restaurant
Azzaro Yarmouth, LLC
Mailing Address: 681 Main Street
�toute 28
�lest Yarmouth, MA 02673
Fein:
Other workplaces not shown above: Type of Business: Corporatioa
SBB SCHEDULE OF OPSRATIONS Risk ID:
2. The certificate peiiod is from 12:01 a.m. o� 1/�1/2014 to 12:01 a.m. on
1/O1/2o15 at tlie inaured's mailing address.
3. A. Workers Compensation Coverage: Part One o£ the certi£icate applies to the
Workers Compen�ation Law o£ the atatea listed here:
MA
8. Employera Liability Coverage: Part 1tw o£ the certificate applies to work in
each state lieied in Item 3.A. The limits o£ our liability under Part �tvo are:
Bodily Injury by Accident S 500.000 each accident
Bodily Injury by Disease S 500_000 certificate limit
Bodily Injury by Disease $ 500.000 each e�ployee
C. Other States Coverage:
D. This certi£ica�e includea theae endorsements and schedules:
WCOOODOOA(04/92) WC000310(04184) WC000414(07/90} WC000422A(09/08) WC200301(04/84)
WC200302(OS/86). WC200303B(07/94) WC200405(06/O1) WC200601(06/92)
4. The contribution for this certiPicate urill be determined by our Manuals of Rules,
Classif3cations, Rates and Rating Plans. All information required below is subject
to verification and change by. sudit.
Classifications I Code Contribution Basis Rate Per ' Eetima#ed
No. Total Estimated $100 0£ Annual
Annual Remuneration Remuneration Contribution
SEE SCfIEDULE �F OPERATIONS
Total Estimated Anclual Contribution 2,682.00
M3nimum Contribution $ 266.00 Expense Constant $ .00
WC 00 00 01 A Issue Dlate: 1/27/2014 Countersigned by
I