HomeMy WebLinkAboutApplication and WC O� �Y`qR
�� .�`_ �`�� TOWN OF YARMOUTH Ha�f
� � ` { "� ll 46 ROUTE 28, SOUTH YARMOUTH,MASSACHiJSETTS 02664-24451 '
�. �,� �,'� '� Telephone(508)398-2231, ext. 1241 Div sion
`"`"E Fas(508)760-3472
To: Yannouth Business Establishxnents ��MM`IS R�AST B�"'F �������p
From: Bruce G. Murphy, Director � UtC 1 5 2�14
Yarmouth Health Department�
HEALTH DEPT.
Date: November 7, 2014
Subject: Increase in License/Permit 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 Yazmouth
Health Department, effective January l, 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. 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 Yarmouth Health
Department with all required certificarions and worker's compensafion coverage information
(cer[ificate 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 � SS.oO
- Food J'ervice �v�r i00 5eats $160.00
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:
Total fees owed for your establishment: � <35•Ot�
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 cerhfications prior to opening, however, you must note,^
"Will provide in the spring prior to opening" on the application.J
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'a TOWN OF YARMOUTH BOARD OF HEALTH ��'�'����y 5
� � APPLICATION FOR LICENSE/PERMIT -2 ca� s,�t� 1 5 ZU 14
�IK .
�"' * Please complete form and attach all necessary d4�c nt L1y]Jec ber IS PT
Failure to do so will result in the retu,m;of y0tu apgli�a�om ck .
&�^.l Cev.. ...�: z ...
ESTABLISHMENTNAME sm�n�` S ti �.e.e� T XID• ��
LOCATION ADDRESS: 1A�`� (ho��v� �rw� ��- c��Z TEL.#: �75-96 3?
MAILING ADDRESS: �.
E-MAIL ADDRESS: ��S��v G Qr�Sr�-Co w�
OWNERNAME: � �' cw�h..E S%��.
CORPORATION NAME (IF APPLICABLE): �P�S �>ecy<�se� T-�.
MANAGER'S NAME: �tX`�- TEL.#: $S 7 �7a 3d�
MAILING ADDRESS: Sa^M-
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 prov�de 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 establislunent must have at least one Person In Charge (PIC) on site during hours of operation.
__ _ _ - _ . _
L 2.
ALLERGEN CERTIFICATIONS:
All food service establishxnents aze 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.
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 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.
l. Z•
3. 4.
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 $110
—INN $55 CAMP $55 SWIMMING POOL$I l0ea
LODGE $55 TRAILERPARK $105 _WHIRLPOOL $110ea
FOOD SERVICE:
LICENSE REQUIRED FEE RMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
�0-100SEATS $125 �l5-IOS —CONTINENTAL $35 NON-PROFIT $30
>100 SEATS $200 COMMON VIC. $60 WHOLESALE $80
— — —RESID.HITCHEN $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
—<z5,000sq.ft. $l50 —FROZENDESSERT $40 _TOBACCO $110
NAME CHANGE: $15 AMOUNT DUE _ $ I � -pO
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM**"** �"�� �$S`�
C��36�C ����(
'
Ar�Mrrrisa��aTiarr
Under Chapter 152,Section 25C,Subsection b,the Tawn of Yazmqufh is naw required to hold issuance or renewal ,
of any license ar pernut to aperate a business if a persan or company does not have a Certificate of Warker's '
Compensation Insurance. THE ATTACHED STA'TE WOItKER'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, CiR
CERT. OF INSURANCE ATTACHED !
OR
W4IZKER'S C4MP. AFFIDAVIT SIGIVED AND ATTACHLD
T'own of Yannouth taxes and liens musC be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPR4PRZATELY IF PAID:
YES NO
A'I4TELS AND OTH�It LODGING ESTABLISI3MENTS
TRANSIEN'I"OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be
Iimited ta the temporazy and short term occupancy,ordinarily and custarnarily associated with motel and hotel use. �
Transient occupants must have and be able to demonstrate thaC they rnaintain a principal place of residence :
elsewhere.Transient oocupancy shall generally refer to continuous occupancy of not more than thisry(30)days,and
an aggregate of na2 more than ninety{9Q}days within any six{6}month period. Use of a guest unit as a residence az
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. 64G or 830 CMR 64G, as amended, shall genexally be considered Transient.
POOLS
POOL OPENING: All swimming,wad'zng fand whirlpools which have been closed far the seAson must be inspected
by the Health Dapartment priar to opening. Confact the Healtih Departrnent ta sehedule the inspection three(3}
days prior to opening. PLEASE NOTE: People are NOT allowed to sit in the pool area until the pool has been
inspected and opened.
POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and staxidard plate count
by a State certified lab, and submitted to the Heaith Department tlu�ee (3) days priar ta opening, and quarterly
thereafter.
POOL CLOSING: Every outdoor in ground swimming pool must be draitied ar covered within seven(7)days of
closing.
F0013 SEI2VICE
SEASONAL FOdD SERVICE OPENING:
All food service estahlishments must be inspected by the I-Iealth Department prior to ogeaing. Please contact the '
Health Deparhnent to schedule the inspection three (3) days prior to opening.
CATEffiNG POLICY:
Anyone who catezs within the "I'own of Yarmouth mnst notify the Yazmouth Heaith Departrnent bv filing the
required Temporary Faod Service Application form 72 hours prior to the catered event. These forms can be
abtained at the Aeaith Deparhnent,or from the Town's website at we�=w.yannouth.maus under Health I7epartruent,
Downloadable Forms.
FROZEN DESSERTS:
Frozen desserts must be tested by a State certified lab priot to opening and montlily thereafter,wath sample resuIts
submitted to the Health Department. Failure to do so will resnit in the suspension or revocatian of your Frazen
Dessert Permit until the above terms have been met.
QUTSIDE CAFES:
Outside cafes(3.e.,outdoor seating with waiteriwaitress service),must have prior approval from the Board of Health.
OUTDQCIR COOKING:
Outdoor cooking,preparation,ar display of any food product by a retail or faad service establishment is prohibited.
NQTICE:Permits run annuaily fram January 1 to December 31. 1T IS XOUR RESI'QNSIBTLITY TO RETCTRN
THE COMPLETED RENE;WAL APPI,ICATION(S) AND R.EQUIRED FEE(S) BY DECEMBER 15, 2014.
ALL RENQVATIONS TO ANY FOOD F,STA$LI3HIVIEPdT, M R P40L {i.e., PAINTING, NEW
BQUIPIv1ENT, ETC.), MUST BE KEPORTED TO D APP ED BY T BOARD OF HEALTH PRIOR
TO CONIMENCEMENT. RENOVATIONS MAY I R A SITE P
DATP,: �} �� /Uj SIGNATURE:
PR1NT NAME & TITLE: �� Cj t �,U '
x��. urosna �
� The Commonwealth ofMassachusetts
Department oflndustrialAccidents
O�ce oflnvestigations
' 1 Congress Street, Suite I00
Boston, MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Auplicant InformaHon Please Print Le¢iblv
Business/Organization Name:
Address:
City/State/Zip: Phone #:
Are you an employer?Check the appropriate bos: Business Type(required):
1.❑ I am a employer with employees(full and/ 5. ❑Retail
- __ Fr=�_-tin�e)k _ _. _- -- - - - __ 6. �] RestauranUBaz/Eating Establishment
2.❑ I am a sole proprietor or partnership and have no 7, � Office and/or 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 o�cers have exercised 9. ❑ Entertainment
their right of exemption per c. 152, §1(4), and we have 10.Q Manufacturing
no employees. [No workers' comp. insurance required]*
4.❑ We are a non-profit organization, staffed by volunteers, 11.� Health Caze
with no employees. [No workers' comp. insurance req.] 12.❑ Other
•Any applicant t6at checks box#1 must also fill out the section below showing their workers'compensation policy infotmation.
"If The cotporete officers have exempted themselves,but the cocporation has other employees,a worke:s'compensarion policy is roquired and such an
organization should check box#1.
I am an employer that is providing workers'compensation insurance for my employees. Be[ow is the po[icy information.
Insurance Company Name:
Insurer's Address:
CiTy/State/Zip:
Policy#or Self-ins. Lic. # Expiration Date:
Attac6 a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
-- Failure to sesure caverage assequized�anderSection25A ofMGL�.152�an lead to th€img4sition of criminal penalties_of a _
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 $250.0 day against the violator e advised that a copy of this statement may be forwazded to the Office of
Investigations o e DIA fo ' su ce c rage verification.
I do hereby certi nd the pai a penalties o perjury that the information provided above is true and correci.
Si ahve: Date: � ��
Phone#:
Official use only. Do not write in this area,to be completed by city or town officiaL
City or Town: Permit/License#
Lssuing Authority(circle one):
1.Board of Health 2. Building Department 3. City/Towa Clerk 4.Licensing Board 5. Selectmen's Oftice
6.Other
Contact Person: Phone#:
www.mass.gov/dia .
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
INFORMATION PAGE
AGENT NO 3020 OFFICE NO 3020
MARK SYLVIA INSURANCE AGENCY LLC
004 MAIN ST
CENTERVILLE MA 02632-2976
�
FARM FAMILY CASUALTY INSURANCE COMPANY 5oa-a2a-oaao
NCCI COMPANY NO. 76727
POLICY NO 2007W6070
TTE�1k�I..1.;:::Il�i5LTR�}3 INSURED AND MAILING ADDRFSS: ADJUST RENEWAL
TRS ENTERPRISES INC����� EFFECTIVE 7/24/74
DBA TIMMY'S ROAST BEEF
788 ROUTE 26
W YARMOUTH, MA 02673-4660 .
THE INSURED IS CORPORATION
Workplaces covered by this policy:
ST WP N0. ADDRESS OF WORKPLACE RTG.BUR NO. INTRASTATE NO.
MA 07 198 MAIN ST 345867
� WEST YARMOUTH MA
� �,-:�Yi��`�.:�.�..�_.�`+���:.::: .�_.,;' �:�:: ��..: �::; : : �.: :, .; ..:: � :�•:
The policy period is from �/za/uto �/za/t5 12:01 A.M. Standard 1Yme at the insured's ma;lin� address.
I��I � '�t�'�i�. , _ ; -
A.Workers Compensation Inswance Part One of the policy applies to the Workers Compensation Law of
the state listed here: Mp
B. Employers Liability Insuranc� Part 'I�vo of the policy applies to work in each state listed in item 3.A.
The limits of our liability under Part 1�vo ar�
Bodily Injury BV ACGdont Bodily Injury BY Disease Bodlly In�ury By Disease
S 700,� each accident S 500,000 policy Ilmk Z 100,000 each employee
C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: All states
except the stat� designated in item 3.A. of the information page and ND, OH, WA, and WI'
D. This policy includes these endorsements and schednles:
wc o0 00 oos wc oa aa o�a wc o0 0> >a wc o0 oa �s wc o0 oa �a wc o0 oa zza
WC 20 03 07 WC 20 03 02A WC 20 03 03D WC 20 04 05 WC 20 06 01A
CopyrigAt 1967 Netional Comcil INSURED COPY pgp�ED O7/lO/14
m Componeation Inearum
wc o0 00 oi w Issuing Office - PO Box 656 • ALBANY, NEW YORK 12201-0656