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Home My WebLink AboutApplication and WC �°��`�Q TOWN OF YARMOUTH Boazdof �, - _g [ Health ��—_ _ _ � `j 1146 ROUTE 28, SOUTH YARMOUTH,MASSACHLJSETTS 02664-24451 Heal � `,��LMfEO� � Telephone(508)398-2231,ext. 1241 Division Fa�c(508)760-3472 R�c��od�� To: Yannouth Business Establishments 7o��e TR-�-��f ZZ-7 Utl: 1 5 Z��4 From: Bruce G. Murphy, Director HEALTH DEPT. Yannouth Health Department Date: November 7,2014 Subject: Increase in License/Permit Fees __ Please be aware 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 Yarmouth Health Department, effective January 1, 2015. Attached is the Yazmouth Business License/Permit Applica$on 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 l, 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 �davit) arior 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 Whirlpool/Vapor Baths $ 80.00 Tobacco Sa1es $ 95.00 Motels $ 55.00 _ � Restaurants 0-100 Seats $ 85.00 Restaurants Over 100 Seats $160.00 Retail Food Service <25,000 sq. ft. $ 80.00 80 .Od ' � Retail Food Service>25,000 sq. ft. $225.00 Other fees owed but not listed above: Total fees owed for your establishment: 9 0.00 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 springprior to opening" on the application.J BGM/maf . . - �a�R Ta�#�UuZ, � . TOWN OF YARMOUTH BOARD OF HEALTH ��-.-. �� APPLICATION FOR LICENSE/PERMIT -2015 utC "I 5 2ui4 " * Please complete form and attach all necessary documents by Decem er I S 2014. Failure to do so will result in the return of your applicarion pa et.HEALTH CE�T. ESTABLISHMENT NAME: � TAX ID: -/ �' LOCATION ADDRESS: /� xF TEL.#: `�`F ��oa MAILING ADDRESS: V 1 P E-MAILADDRESS: l e.CQ OWNER NAME: l CORPORATION NAME (IF APPLICABLE)i�l�j2,Q, T�� S'f?r�PJ� 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 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 provide new copies and maintain a file at your place of business. I. n1 A a. 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 establisk�ment 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 haue 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. , 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-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 file at your place of business. 1. 2• 3. 4. RESTAURANT SEATING: TOTAL # N14 OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $110 I7V1V $55 � CAMP $55 SWIMMINGPOOL$110ea LODGE $55 _TRAILERPARK $105 _WHIRLPOOL $ll0ea FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 _CONT[NENTAL $35 NON-PROFIT $30 —>100 SEATS $200 COMMON VIC. $60 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 �S—n3Z —FROZENDESSERT $40 _TOBACCO $110 � NAME CHANGE: $15 AMOUNT DUE _ $ I� •****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM"****�! �a��d�� L�L-(�U207o�Sa070 ��/'W'� ADMINISTRATION Under Chapter 152,Section 25C,SubsecUon 6,the Town af Yarmouth is now required to hold issuance or renewal of any license or pernpit to operate a business if a persan or company does not have a Certificate of Worker's Compensation Inswance. THE ATTACHED STATE WOItKER'S Ct?MPENSATION IN8U12ANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF iNSURt1NCE ATTt1CHED �/ OR WORKER'S COMP. AFFIDAVIT SIGNED AND A'1'TACHED Towta of Yarrnouth ta�ces and liens rnust be paid priox to renewal or issuance of your permits. FLEASE CHECK APFROPRIATELY IF PAID: / YES i/ N4 MOTELS ANA OTHER LODGING ESTABLISHMENTS TRA.14iSIENT OCCUPANCY: Forpurposes oftl-.e lir:litations ofMotel or Hote]use,Transient c�ecupancy sha11 be limited to the temporary and short term occupancy,ordinarily and customarily associated with matel and hotel use. Transienl accupatzts must have and be ahle to damonstraTe thaY they maintain a principal plaee of residence elsewherc.Transient occupancy shall generally refer ta continuous occupancy ofnot mare than thirty(30)days,and an aggregate of not more than ninety(90)days within any six(6)month period. Use of a guest unit as a residence ar dwelling unit shall not be considared transient. Occupancy that is subject to the cpllection of Raom Occupancy �xcise, as defined in M.G.L. c. 64G or $30 CMR 64G, as amended, sl�all generally be c:onsidered Transient. POOLS PQOL OPENING:A[1 swimming,wading and whirlpools which have been ctased for the seasan inust be inspecEed by the Health Department prior to opening. Contact ihe Health Departmeni to schedule the inspection three(3) days priar to opening. PLEASE NOTE: People are NOT allo�ued to sit in the pool area usztil the pool has been inspected and opened. POOL WATER TESTING: The water must be tesied for pseudomanas,total coliform and standard plate oount by a State certified lab, and submitted to the Health Department three (3) days prior to opening, and quarGerly thereafter. P40L CL4SING: Every outdoor in graund swimmi�tg pool must be drained or covered within seven{7)days af closing. FOOD SERVICE � - � SEASONAL FOdD SERVICE OPENING: All food service establishments must be inspected by the I3eaith Deparfinent prior to opening. PIease contact the Health Department ta schedule the inspection three(3) days prior ta apening. ' CATERING POLICX: Anyone who caters within the Town of Yaamouth rnust notify the Yannauth HeaIth Department by filing the required Temporary Food Service Application farm 72 hours prior to the catered event. These farms can be obtained at the Health Department,or from the Tawn's website at www.yazrnouth.ma.us under Health Department, Downlaadable Forms. FROZElY DESSERTS: Frozen desserts must be tested by a State cerCified lab prior to opening and monthly thereafter,with sample results submitted to the HeaTth Department. Failure to do so wili result rn the suspension or revooation of your Frozen Dessert Permit untii the above terms have been met. C3UTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval frorn tha Board ofHealth. OUTDOCIR COOHING: Qutdoor cooking,preparation,or display of any food product by a retail or fnod service establishment is prohibited. NOTICE:Permits run annuaIly from January T ta December 31. IT IS YOLTK RESPONSIBILITY TO RETtJRN THE COMPLETEI3 RENEWAL APPLICATZON{S)AND REQUIRF:D FEE{S}BY DECEMBER 15, 24i4. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINT7NG, NEW EQUIPMENT,ETC.),MUST BE REPOIZTED TQ AND AFPROVED BY THE B{7ARD OF HEALTH PRIt}R TO COMMENCEMENT. RENOVATIONS MAY ItEQUIRE A SITE PLAN. DATE: ��c'�lc�0f� SIGNATURE: �cd.J1tAQ..e o �.�_e�0—�2.4— PRINT lYAME& TITLE:�t��Cc(t�i'�p 1(1l�'O('L,�G' x�. urasna �� t� The Commonwealth ofMassachusetts Deparlment of Industrial Accidents Office ofinvestigations � I Congress Street, Suite I00 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legiblv Business/Organization Name: �(QL62� TiQ��, C�71R.e�S, Address: �7� 1/(l��C) Pf'�(,t)UL- City/State/Zip: �{ a�3�� Phone#: �5�. �� (. �CX�S Ar,�e y, o�u an employer? Check the appropriate box: Busines�,Type(required): 1.L�' 1 am a employer with l�employees(full and/ 5. [�-�etail or part-time).* 6. ❑ RestaurantJBaz/Eating Establishment 2.� t air,a sole proprietor or gmtaership and have iro — �,°� Office 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. 152, §1(4), and we have ]0.❑ Manufacturing no employees. [No workers' comp. insurance required]* 11.❑ Health Care 4.❑ We aze a non-profit organizarion, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.❑ Other *Any applicant that checks box#I must also fill out the section below showiag the'v workers'compensation policy information. •*If the corporete officers 6ave exempted themselves,but the corporation has other employees,a workers'compensatioa policy is requ'ved and such a¢ � organization should checkbox#L � . � I am an employer that is providing workers'compen�sa}t,io�,n insurance for my employees. Below is the policy information. Insurance Company Name:�T/L�` L=C'/ Insurer's Address:(�/1P C �K�J�l�1�+ Y�C[z�, �� L City/State/Zip: /�.C�� U+1-�--i 1V `I � ��D Policy#or Self-ins.Lic. #4'��(�r�� Expirarion Date: I � oZ-� (`J Attach a copy of the workers' compensation policy declaration page(showing the po6cy nnmber an ezpiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposirion of criminal penalties of a fine upto$t,500.00 andlor one-yeaz imprisanment��s wel�a�eivil penalties�rrihe fetm of a STQg WO��I�BFRa�d afine . 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 Investigations of the DIA for insurance coverage verifica6on. I do hereby certify,under thepains andpenaUies ofperjury that the information provided above is true and correct. Signahue•`�2Q--�1__��Q A /Q,BL.!�— � . Date: /02 I c�aOl�{ Phone#: �-��.��. '�{� Official 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 O�ce 6.Other Contact Person: Phone#: www.mass.gov/dia �`'�� CERTIFICATE OF LIABILITY INSURANCE °A�`v'�a,°3""' TH19 CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFER9 NO RIGHTS UPON THE CERTIFICATE HOLOER THI9 CERTIFICATE DOE9 NOT AFFIRMATIVELY OR NE6ATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POlIC1E3 3 BELOW. THIS CER7IFICATE OF INSURANCE DOES NOT CON9TITUTE A CONTRACT BETWEEN THE ISSUINf3 INSURER�S�, AUTHORI2ED � REPRESENTATNE OR PROOUCER AND THE CERTIFICATE HOLDER c � IMPORTAN : I ths certiflcab holder is an ADDITIONAL INSURED, the polley�ias)must b�endoraad. If SUBROGATION 19 WAIVED,sub�eet W �' the terms and eonditlona W the polley,certaln polleiss may require an endonemaM.A afafemeM on Nls eertifleate don nM coMer Aghb W tM ,m—r ceNflwb ho1Wr in Ileu M aueh endonemaM�a�. � — c vnooucen r�in�rNe.�T � '_�o AOn 0.15k Sel'V1C25 CEIIVdI� IIIC. (B66) 283J322 F� 800-363-0105 `y Grand aa0�ds MI oFfice � �•��k q;c.r»,; 171 Monroe AVenU@, N.W. e.w11L � $Ult@ $25 nOORl8E: _ �rand aapids nI 49503 u5n INSUREiyB)AFFOROIN6 CpyERAG! NAIC� inwnEo ixsupepa nrch insurance Company 11150 oollar rree stores, inc. wsunene: x� specialty xnsurance co 37885 500 Volvo varkway Chesapeake vn 23320 USA �Nsun�RC: INSIWEII IX INSUpER E INBUpFA F: COVERAGES CERTIFICATE NUMBER:570052256828 _ REVISION NUMBER: THIS IS TO CER7IFV THAT THE�POLICIES OF INSURANCE LISTE BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLIGY PERIOD INOICATED.NON/RHSTANDING ANV REQUIREMENT,TERM OR CONDRION OF ANV CONTRACT OR O7HER DOCUMENT WRH RESPECT TO WMICH THIS CERTIFICATE MAY BE ISSUED OR MAV PERTAIN,7HE INSUR4NCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT 70 ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POIICIES.LIMRS SHOWN AMY HAVE BEEN REDUCED BV PAID CLAIM3. 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E�o�sewsE-vaicrw.xr Y1.000�000_ DESCFIPf10N OF OPERATIONS babr ._ . _ , . _ . . __ . . ._ __ _._ . ... .____.. __.. . '._ . oescwvna/w ovewwnoxs�wc�Tare i v�es I�n�cano im.amwaw n«wia een.aa..r ma.ww r na+�.a� � � � •:� � �� CERTIFlCATE FiOLDER CANCELLATION y� sHou.o nNr av nie neove uExn� vouc�s ee caxcatEu eesone nle �iax onre n�eneos. nonce wiu ee o¢rv�m w ncco�axce wrtn n� vaucr vnov�sione. �., AUTN)F�D NEPI�SBiTATNE «l1 VGfYIV/6LM�N/ ��J1�µ ACORD 25(2010J05) The ACORD name and logo aro �988-2010 ACORD CORPOItAT10N.All righh reaerved. registered marks of qCORD