HomeMy WebLinkAboutApplication and WC AF_Y`q�2
�� - _ _;`�� TO WN OF YARMOUTH H��f
� � "3 1146 ROUTE 28, SOUTH YARMOUTH,MASSACHLISETTS 02664-24451 -
�. �,� `.° � Telephone(508)398-2231,ext. 1241 Health
'"`"� Fax(508) 760-3472 Division
To: Yarmouth Business Establishments BoNK�1z.z PA�Ty ZoN6
From: Bruce G. Murphy, Director � ��6����p
Yannouth Health Departrnent�
DEC T 1 2014
Date: November 7, 2014
HEALTH DEPT.
Subject: Increase in License/Permit Fees
Please be awaze that the Yazmouth Boazd of Health, under the direction of the Yarmouth Boazd
of Selectmen, has raised a number of license and pernut fees issued through the Yarmouth
Health Depazlment, effective Januazy 1,2015.
Attached is the Yannouth 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 Yannouth 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 �8.�i.o0
_ Food Service Over Y60 Seats __ �Y6O:OD__ _-_.___._ _ _
Retail Food Service <25,000 sq. ft. $ 80.00
Retail Food Service >25,000 sq. ft. $225.00
Other fees owed but not listed above: ��o.o o �o..noN vi�.
Total fees owed for your establishment: ► 5.00
NOTE: To be entitled to pay the current 2014 rates listed above, your '
business application, food and/or pool certifications, along with worker's
compensation information must be received, or mailed (postmarked) on or
prior to December 31, 2014. [Those establishments which open in the spring will be
allowed to provide food and/or pool certifications prior to opening, however, you must note
"Will provide in the spring prior to opening"on the application.J
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. � TOWN OF YARMOUTH BOARD OF HEALTH G3CSCC,C��MLDD
� � � APPLICATION FOR LICENSI� „
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* Please complete form and attach a11 nece��s atTj�d , j� er 1�SC2014.Z��4
Failwe to do so will result in the ret�of e�p�c�tioa�pa et.HEA�TH DEPT.
ESTABLISHMENT NAME: ar L C TAX D•
LOCATIONADDRESS: (�5�- i 2 TEL.#: Sp$-��5-���
� MAILINGADDRESS: - �26 3 -
� E-MAIL ADDRESS:
OWNER NAME:
� CORPORATION NAME (IF APPLICABLE):
MANAGER'S NAME: �' P�nY' • TEL#: ri 08-��S•I O 10
MAILING ADDRESS: �►1 Qto.+O' 2£Z �!f)Os�vtzi R.tc�u fA�..I p - 0 2 .6�`�
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 - - .
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 Sle at your place 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 C►le at your establishment.
1. 2•
PERSON IN CHARGE:
Each food establishment must have at least one Person In Chazge (PIC) on site during hours of operation.
1. . 2•
ALLERGEN CERTIFICATIONS:
All food service establishments are required to have at least one fixll-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.
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 �le at your place of business.
1. 2.
3. 4.
RESTAiJRANT SEATING: TOTAL#
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQU[RED FEE PERMIT#
_B&B $55 CABIN $55 MOTEL $110
I7VIV $55 CAMP� $55 SWIMMINGPOOL$110ea
_LODGE $55 _TRAILERPAAK $105 WHIRLPOOL $110ea. �
FOOD SERVICE: '
LICENSE REQUIRED FEE PERMIT# LICENSE REQU[RED FEE PERMIT# LICENSE REQUIRED FEE PERMTT#
L�100 SEATS $200 �� �COMMON VIC. $60 �/,�p�z WHOLE3ALE $80
RETAIL SERVICE:
—RESID.KITCHEN $80
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. $I50 =FROZENDESSERT $40 _TOBACCO $110 �
NAMECHANGE: $15 AMOUNTDUE _ $ /55.00 I
*****PLEASETURNOVERANDCOMPLETE�THERSIDEOF�FORM**•*• �t '^ ���V'�� '�,
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ADMINISTRATION
Under Chapter 152; Sectian 25C,Subsection 6,the Towi�of Yarmouth is now required to hold issuance or renewal
of any license or permit to operate a business if a person ar company does not have a Certificate of Worker's
Cosnpensation Insuraccce. TAE ATTACFIED STATE WORKER'S COMPEI�TSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR
CERT. OF INSI3RANCE AT1'ACHED�
OR
WOR.KER'S COMP. AFFIDAVIT SIGNED AND ATTACHED -�'l`
Town of Yatmouth taYes and liens must be paid prior to renewal c�r issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES__�__ NO _
MOTELS AND QTH�R LODGING ESTABLISHMENTS
TRANSIENI'OCCUPANCY: For purposes of the limitations ofMotel or Hotel use,Trans3ent occupancy shall be
limited ta the temporary and short term occupancy,ordinarily and customarily assooiated with matel and hotel use.
T'ransient occupants must have and be able to demonstrate that they mainiain a principal place of residence
eisewhere.Transient occupancy shall generaily refer to continuous occupancy af not mare than thirty(34)days,and
an aggregate of not more than nznety(90)days within any six(6)month period. Use of a guest unit as a residence or
dwelling unit shall not be considered transient. Occupancy that is subject to the collection of Room Occupancy
Excise, as defined in M.G.L. c. 64U or 830 CMR 64G,as amended, sha11 generally be eonsidered Transient.
POOLS
POOL 4PENING:All swimrning,wading and whirSpools wl�ich have been clased for the season must be inspected
by the Health Depariment prior to opening. ConYact the Health Deparcment ta schedule the inspection three(3)
days prior to opening. PLEASE NOTE: People are NQT allowed to sit in the pool area until the paol has been
inspected and opened.
POQL WATER TESTING: The water mnst be cested far pseudomonas,tatai coliform and standard piate count
by a State certified lab, and submitted to the Health Department three (3) days pxior to opening, and quarterly
theraafter.
PO4L CLOSING:Every outdoor in ground swimming poo)must be drained ar cavered within seven{'7}days of
closing.
F�OI) SFRVICE
SEAS4NAI.FOtJD SERYFCE OPENING:
All food service establishrnents must be inspected by the Health Depaztment prior to opening. Please cnntact the
Health Department ta schedule the inspection three (3}days prior#o apening.
CATERING POLICY:
Anyane who catars within the Town of Yazmauth must notify khe I'armouth Health Department by filing the
requzred Temparary Food Service Applicatian forrn ?2 houzs prior to the catered event. These farms can be
obtained at the Health I�epartment,or fram the Town's website at www�aamouth.ma.us under Health Department,
Dowxiloadable Forms.
FRQZEN DESSERTS:
Frozen dessarts must be tested by a State certified lab prior ta opening and monthiy thereafter,with sampie results
submitted to the Health Department. Pailure ta do so will result in the suspension or revocatipn of your Frozen
Dessert Permit until the above terms have been met.
OUTSIDE CAFL�`S:
Uutside cafes(i.e.,outdoor seating with waiter/waitress servioe),must have prior approval from the Board of Health.
OUTDdOR COOKYNG:
Outdoor cooking,preparation,�r display of any food product by a retail or faod service establishrnent is prohibited.
NOTICE: Permits run annually frorn January 1 to December 31. IT IS YOUR I2ESPONSIBILITY TO RE"tC.JRN '
THE COMPLETF.D RENEWAL f�PPT.ICATION(S}ANI7 REQLIIRIs`D FEE(S}BY I3BCEMBER 15,2d14.
ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAIN'T1NG, NEW
EQUIPMENT, ETC.}, MU3T BE REPt}RTED TO AND AI'P OVEI�BY THE BOARD C?F HEALTH PRIOR
TO COMMENCEMENT. RENOVATION3 MAY REQUIRE SITE PLAIV.
DATfi�����q� } _l� SIGNATURB: ,
PR1NT NAME& TITLE: pyt.,t ��jdta,�..�L�.�—._ �
Rev_]11U3t14 �
�
� The Commonwealth of Massachusetts
Department of Industrial Accidents
O�ce of Investigations
' 1 Congress Street, Suite 100
Boston, MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Annlicant Information Please Print Legiblv
�I� Business/Organization Name: L
; ��
Address: �,�� Qp�� 2A I�s T�
City/State/Zip: ct9, 26 3Phone#: $Off - ���- 101 O .
Are ou an employer?C6eck the appropriate boz: Business Type(required):
1.� I am a er with 2. emp(oyees (full and/ 5. ❑ Retail
� � or tune .* 6. ❑ RestaurantBaz/Eating Establishment
F 2.❑ I am e proprietor or parmership and have no �, � Office ancUor 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. �Entertainment
their right of exemption per c. I 52, §1(4), and we have 10.❑ Manufacturing
no employees. [No workers' comp. insurance required]*
4.❑ We aze a non-profit organizafion, staffed by volunteers, 11.❑ Heakh Caze
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 workeis'compensation policy i¢folmation.
**If the coiporate officeis have exempted themselves,but the corporation has other employees,a workers'compensaTion policy is required and such an
organizalion should check box#1.
I am an employer that isproviding workers'compensation insurance for my employees. Below is the policy information.
Insurance Company Name:
Insurer's Address:
City/State/Zip:
Policy#or Self-ins.Lic.# Expiration Date:
Attach a copy of the workers' compensation policy declaration page(showing the policy nnmber and ezpiration date).
_ Failur�to secs�e�overa�e a�reg�ire�l_undet Section 2�A of MGL c. 152 o�n lead to the imposition of criminal_genalries Qfa ___ _
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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify,unde the pains and penalties ofperjury that the information provided above is true and correct.
Si ature: Date: �l
Phone#: ���� � � �� - ��(� .
Officia[use only. Do not write in this area,to be completed by city or tawn official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2. Building Department 3. City/Town Clerk 4.Licensing Board 5. Selectmen's Office
6.Other
Contact Person: Phone#:
www.mass.gov/dia
Clier�t#:307366 BONKERZ
ACORD,� CERTIFICATE OF LIABILITY INSURANCE °"'�"""°""'"'
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THIS CERTIFlCATE IS ISSUED AS A MATTER OF INFORMAiION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMAi1VELY OR NEGATNELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW.THIS CERTIFICATE OF�INSURANCE DOES NOT CONSTITUTE A CONTRACT BEiWEEN THE ISSUING INSURER(S),AUTHORIZED
REPRESENTATNE OR PRODUCER AND THE CERTIFlCATE HOLDER.
IMPORTANT:H Lhe certiflcate holder is an ADDfiIONAL INSURED,Me poliry(ies)must be endorsed.H SUBROGATION IS WAIVED,aubjeM to
the terms and cond'N'ons of the policy,cerlafn policles may require an endorsement A statement on thls eerdficste does not conTer rights to the
certiflcate holder in lieu of such endo�sement(s).
%tODUCER �E, Anne Sanzo
HUB Intemational New England YMONE r�$_�5�7BG3 � �,: 5pg�qq5-0136
265 Orleans Road ,���: anne.sanzo�hubinternational.wm
NoRh Chatham,MA 02650 �NSURER(S�AFFORpM1GCOVEFNGE wucs
508 945-0446 �N��RA:Philadelphia ins
INSURED �N��e:AIM
Bonkers Party Fun Zone LLC
657 Rte 28 r+sunve c:
West Yartnouth,MA 02673
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IMSURER F:
COVERAGES CER7IFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVEBEENISSUED TOTHE INSURED NAMEDABOVE FORiHE POLICYPERIOD
INDICATED. NOTNITHSTANDING ANV REQUIREMENT, TERM OR CONDRION OF ANV CONTRACT OR O7HER DOCUMENT WRH RESPECT TO WHICH THIS
CERTIF�CATE MAV BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BV THE POLICIES DESCRIBED HEREIN IS SU&IECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. �IMITS SHOWN MAV HAVE BEEN REDUCED BY PAID CWMS.
INSR POLICY EFF POLICY FJ� ��
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DESCPoPIION OF OPERATION8/LOGA7qN5/VEHICLES(Apxh ACORD 101.Atltlltlo�W Remaike Schetlule,if man space is requi�etl)
CERTIFICATE HOLDER CANCEILATION
Town of Yarmouth SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELIED BEFORE
THE E%PIRATION DATE iHEREOF, NOTICE WILL BE DELNERED IN
1746 Route 28 ACCORDANCE wrrH n�e roucr PROVISION3.
South Yarmouth,MA 02664
AUi1qRRED REP�SENTAi1VE
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ACORD 25(2070/05) � p}� The ACORD name and logo are reglstered marks of ACORD
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