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Home My WebLink AboutApplication and WC oF'�'�R �� _ _ �� TOWN OF YARMOUTH Ha�f 0 � � "3 1146 ROUTE 28, SOUTH YARMOUTH,MASSACHiJSETTS 02664-24451 - �. �,, �,a�' � Telephone(508)398-2231, ext. 1241 Health � '�`�6 Fax(508)760-3472 Division To: YarmouthBusinessEstablishments G�yMP�a F,rrr NaosE 2�r+�u2wNT From: Bruce G. Murphy, Director � G3�C'S�OMGD Yazmouth Health Department� �aN '� 2 2��5 Date: November 7, 2014 HEALTH DEPT. Subject: Increase in License/Permit Fees Please be aware that the Yannouth Boazd of Health, under the direction of the Yarmouth Board of Selectmen, has raised a number of license and pernut fees issued tluough the Yarmouth 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 Yazmouth 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 Public WhirlpooUVapor Baths $ 80.00 Tobacco Sales $ 95.00 �. Motels $ 55.00 Food Service 0-100 Seats $ 85.00 $85:00 Food S�rvice 6v�r i00Sea�s -$Yfi0.i3fY 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: $ bo.oo cw+.+«��c . Total fees owed for your establishment: �145�o0 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 springprior to opening" on the application.J BGM/maf . . �18 � a�c��« � TOWN OF YARMOUTH BOARD OF HEALTH�� APPLICATION FOR LICENSE/P , :-2p��0 , JAIN 12 2015 " * Please complete form and attach all necess ° et�hy De " b PT Failure to do so will result in the returYrbf your application ESTABLISHMENT NAME: 0�4mP�p �S�t ;4t��ss ��cAUEAtv'r TAX ID• LOCATIONADDRESS: 13+�i 2o�-c� Z8 So `fR2Mo�rt+Y MA OZ66y TEL.#: 5c�g�-34�-Z61Z. MAILING ADDRESS: s aa�E E-MAIL ADDRESS: OWNERNAME: 7�ME-m� SKO(LDAS CORPORATIONNAME (IFAPPLICABLE): d�-YMP�� F�SN {�ous� �Srtr.utz�at� (n�c. MANAGER'S NAME: TEL.#: MAILING ADDRESS: 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 rivo 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. 2. 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. 2• PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. - — -- . _ __ -- -- -- — 1. _ _ __ ___ _ __ 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 Deparhnent will not use past years' records. You must provide new copies and maintain a file at your establishment. 1. Z• 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-chokuig 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# �{Lo OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# L[CENSE REQUIRED FEE PERMIT# UCENSE REQUIRED EEE PERMIT# B&B $55 _CABIN $55 MOTEL $110 INN $55 CAMP $55 SWIMMINGPOOL$ll0ea LODGE $55 'IRAILER PARK $l05 _WHIRLPOOL $ll0ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# L[CENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �0-100 SEATS $125 _CONTINENTAL $35 NON-PROFIT $30 _>I00 SEATS $200 �COMMON VIC. $60 _WHOLESALE $80 —RESID.KITCHEN $80 RETA[L SERVICE: LICENSE REQUIRED FEE PERMIT# UCENSE REQUIRED FEE PERMIT# LICENSE REQUIRE I <50 sq.ft. $50 >25,000 sq.ft. $285 VENDIN D $25 <25,000 sq.ft. $150 —FROZEN DESSERT $40 _TOBA O $110 xnnqE c�NCE: sts AMOUNT DUE _ $ $ _00 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** ADMINIS'I'RATION Under Chapter 152,Section 25C,Sixbsection 6,the Town of Yarmauth is nerw required to hold issuance or renewal of any license or permit ta operate a business if a person or cornpany does not have a Certificate of Worker's Compensation Insuranca TkIE ATTACAED STATE Wt}]2KER'S COMPENSATION INSITRANCE AFFIDAVIT MLTST SE COMPLETF.D AND SIGN�D, OR C�RT. OF INSI3RANCE ATTACHED OR � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACH�D Toum of Yarrnouth taaces and liens rnust be paid prior to renewal or issuance of your pertnits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LODGING ESTABLISIiMENTS TRAN5IENT OCCUPANCY: For purposes ofthe limitations ofMotel or Hotel use,Transient accupancy shall be limited to the temporary and short term occupancy,ordinarily and customarily associated with motel and hotel use. Transient occupants must have and be able to demonstrate that they maintain a principal place af residence elsewhere.Transient occupancy shall generally refer to continuous occupancy of not rnore than thirty(30)days,and ' an aggregate of not more than ninety(90)days within any six(6)month periad. Use of a guest unit as a residence or dwelling unit shall not be considared transient. fJccupancy that is subject to the cailection of 12aom Occugancy Excise, as defined in M.G.L. c. 54G or 834 CMR 64G,as amended, shall generally be considered Transient. P40LS P40L f}PENING:All swimming,wading and whirlpaols which have been closed for the season mccst be inspected by the Health Department prior to opening. Contact the $ealth Department to schedule the inspection three (3) days prior fa opening. PI,EASE NdTE: People are NOT allowed to sit in the pool area untiI the pool has been inspected and opened. POOL WATER TESTING: The water must be tested for psendomonas,total coliform and standard plate count by a State certified lab, and submitted to the Health Departrnent three (3} days prior to opening, and quazterly thereafter. POdL CLOSING: Every autdaar in graund swimming pool must be drained or covered within seven{'7)days of closing. FOOD SERVIC� SEASONAL FOOD SERVICE OPENING: ' Ali faod service establishments must be inspected by the Health Department prior ta opening. Please contact the Health Department to schedule the inspection three (3)days prior to opening. CATERIlYG POL7CY: .�nyone who caters within the Town af Yarmouth rnust notify the Yarmouth Health Department by filing the reqwred Temparary Food Service Application form 72 haurs priar to the catered event. These forms can be obtained at the Health Department,ar frarn the Town's website at www.varmoixth.ma.us under Health Department, Downloadabie Forms. FI20ZEN BESSEI2TS: Frozen desserts must be tested by a State certified lab prior to apening and monthly thereafter,with sample results submitted to the Health Department. Failure to do so will result in the suspension or revocatian of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. OUTDOOR CO(}HING: Qutdoor cooking,prepazatian,ar display of any food prociuct by a retail or food service establishment is prphibited. NOTICE:Permits run annually from January 1 to December 3 i. IT IS YO[TR RESPONSIBILITY TO RETtJRN "i'HE COAhPLETED RENEWAL APPLICATION{S)AND REQUIR�D FEE(S}BY DECEMBER i5, 2414. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTTNG, NEW BQUIPMENT,ETC.}, MUST$E I2EP�RTED TQ ANI}APPROVEI7 BY THE Bt?ARI?OF HEALTH PRIOR TO COMMENCEMBNT. RENOVATTQNS MAY REQUIRE A SITB PLAN. DATE: STGNATLJRE: PRINT NAME& TITLE: ftev_ llN3tl4 � A�� SPA DA'IE(MM/DDA'YYY) CERTIFICATE OF LIABILITY INSURANCE R095 3/24/2015 THIS CERi1FICATEiS ISSUED AS A MATTER OF INFORMA770N ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.TMIS CER7IFlCATE DOES NOT AFFIRMAiiVELY OR NEGATIVEIY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CER77FICATE OP INSURANCE DOE$NOT CONSTITUTE A CONTRACT BEiWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If ihe eertlfieate holder is an ADDPTIONAL INSURED,ths polley(fes)must be endoraed. H SUBROGATIONIS WAIVED,subJect to!he terms and eondkbns oi the polley,eertaln pollGes may nquire an entlorsement. A sfatemeM on lhis certlNcate does not conTer Mghts to the certllieate holder lo Ileu of such endorsemeM�s). � cwrncr w�ne NUMBER ONE INSURANCE AGCY INC/PHS �°acHO."i»,�ny (866) 967-8730 i�.�a (888) 993-6112 088171 P: (866) 467-8730 F: (888) 443-6112E�s ' - � 301 A*dDDS- PARK DRIVE wsmca�s�rac«,o�e�co�w,cE wuc,�t CLINTON NY 13323 wsimEaa: Twin City Fire Ins Co aisua� .,�� iruweta: insursErsc: '. OLYMPIA FISH HOUSE RESTAORANT, INC. s�sxeeio 1341 ROUTE 28 �r+ene: ' SOUTH YARMOUTH MA 02664 i�mmr: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: I THIS IS TO CERTIFV THAT THE POlIC1ES OF INSURANCE LISTED BEIOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD ' INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CON7RACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS ' CERTIfICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POIICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAV HAVE BEEN REDUCED BV PAIU CLAIMS. INSB lYPEOFLVSpRANC6 ADOL S(/BR PoLKYNUNBEA PoL(CFEFP !OLlCYHAT LIMRS COMMERCULLGENERALLIA&LffY EACH OCCURRENCE ' CLAIMS�MADE ❑OCCUR DAMAGETORENIED S � PREMISES Ea omainenm) MED EXV(My me panwi) PERSIXJFL&ADV INJURY GEN'L AGGREGATE LIMIT APPLIES PER: GENEML AGGREGATE "'.. Y�7ECT�� ... . _. PRODIKTS-Ca1AP/9PAfd; ... OTHER: y AUfOMO&lE IIABILRY COM&NED SINGLE LMIT (Ea a�ddeip . ANV AUTO BpDILV INJURV(Perparson) $ ALLOWNED SCNEDULED BOD2YINJ�R��PoreMCen�� 5 AUTOS AUTOS H�REOAUTOS NON-0WNED PROPERTYOAI.NGE � AUT0.S (Peractltlmq 5 . UMBRELLA LIAB OCCUR EACH OCCURRENCE EXCESS IIpB CLAIMS-MADE pC�GREGpTE 5 oeo aErwrpr1 S woxaecsrn.vrexs��wH ven o1w � MDHWLOYGRSGL182/iY X STRIUIE ER �. ANYPROPRIETOWPARTNERIIXECUi1VE YM E1.EACHACCIDENT SZOO� OOO OFFlCERIMEMBEREXCLUDED? A (MmdaroryfnNp � W� OS WEC TJ3961 09/19/2015 09/19/2016 E.LDISEASEEAEMPLOYEE 51�� 00 �. If yes.tlescribe ur�tler E.L.DISEASE.POLICY LIMIT 5�j Q Q .. DESCRIPTIONOFOPERATIIXJSbebw � OOO � DESCPoPIIDNOFOPERATIONS/LOG�110MS/VENICIESIACOPD101.ACUtlo�wlRemvbBrJMCUM.nuYbeMNCMEHmara[P�bnOuliM) . .. . ..... �-.—. �, � '_��_� ___� � Those usual to the Insured's Operations . !. r p / ( q[ i h�i\ V G. L l�f.J ; . CERTIFICATE HOLDER CANCELLA770N SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED .. BEFORE THE EXPIRATION DATE THEREOF,NO710E WILL BE '��.. DELNERED IN ACCORDANCE WITH THE POLICY PROVISIONS. '� Yarmouth Town Hall A�7NOR�OREPRESEMTA7IVE 1146 ROUTE 28 �aZ "'7� �/ _. ' SOUTH YARMOUTH, MA 02664 �`t � �1988-2014 ACORD CORPORATION.All rights reserved. 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