HomeMy WebLinkAboutApplication and WC � 3
OF�Y'`�R
�.� �` _ �� TOWN OF YARMOUTH Hathf
� =. �` "� 1146 ROUTE 28, SOUTH YARMOUTH, MASSACHLJSETTS 02664-24451 - �
�. 4,� �cMe�.W :� Telephone(508)398-2231,ext. 1241 Health
r FaY(508) 760-3472 Divisio
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To: YazmouthBusinessEstablishments Li� CA600SE Utl; 1 5 2��4
From: Bruce G. Murphy, Director � HEALTH DEPT.
Yannouth Health Department�
Date: November 7, 2014
Subject: Increase in License/Permit Fees
Please be awaze that the Yazmouth Boazd of Health, under the direction of the Yarmouth Board
of Selectmen, has raised a number of license and permit fees issued through the Yazmouth
Health Department, effecUve 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. 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 Yarmouth Health
Department with a11 required certifications and worker's compensation coverage informafion
(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 ��5.oa
FoocrService Over 100 Seats $160.Ofl
Retail Food Service <25,000 sq. ft. $ 80.00
Retail Food Service>25,000 sq. 8. $225.00
Other fees owed but not listed abovei p.00 r-a-o� ac�s�
Total fees owed for your establishment: 2 ,o0
NOTE: To be entitled to pay the current 2014 rates listed above, your
business application, food and/or pool certifications, atong with worker's
compensation information must be received, or mailed (postmarked) on or
prior to DeCember 31, 2014. (Those establishmends which open in the spring will be
allowed to provide food andlor pool certifications prior to opening, however, you must note
"Will provide in the spring prior to opening"on the application.J
BGM/maf
• a TOWN OF YARMOUTH BOARD OF HEALTH p����d��
��� APPLICATION FOR LICENS /F, ��� �'' �t� '� S ZU14
3�7� � �
* Please complete form and attach all neces�y� 'en�s by D 'm er IS 2014.
Failure to do so will result in the retum of your apptcahon pa et. HEALTH DEPT.
ESTABLISHMENT NAME: ID: sa«-.e—
LOCATION ADDRESS: Qt TEL.#: y
MAILINGADDRESS:I(l �Inr��v�} � h�n� �L}�p,V�n�iC,�l1 O!F M� C3ZI��IIo
E-MAIL ADDRESS: L l � ��
OWNERNAME:, �n. n io l�v.o ('�„r q Ah � Ilnnr»c« 2C..Vl0.�f �t�
CORPORATIONNAM (IFAPPLICABL :�n�al �xDYcsS LI.C.
MANAGER'S NAME: AC 1 TEL.#: d3 ib
MAILINGADDRESS:jh N?v dv nii 1�oY�, M�1 c�2.ia4 �0
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 Cazdiopulmonary 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 aze required to have at least one full-time employee who is certified as a Food
Protecfion 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.� ACc�t o li v�a �nY Y� carA�(l Z•
PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
1. _ 2: C,L� � I h�i tt7 a n .
3, Mur��� l�� n�e,,rlc�.r� � 1 .
ALLER CERTIFI TIONS:
All food service establishments aze 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 establis ent.
1. �
HEIMLICH CERTIFICATION :
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 certificarions 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# O
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT tk
B&B $55 CABIN $55 MOTEL $110
INN $55 CAMP $55 SWIMMING POOL$l l0ea.
LODGE $55 TRAILERPARK $105 _WHIRLPOOL $ll0ea.
FOOD SERVICE:
LICENSE REQUIRED FEE P RMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# ��
�0-100SEATS $125 �!S—/0'� _CONTINENTAL $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.q $50 >25,000 sq.ft. $285 �Q Q _TOBAC O FOOD$$�O �.
—Q5,000 s .ft. $150 �FROZEN DESSERT $40 U
NAME CHANGE: $l5 AMOUNT DUE _ $ I�05.�
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** �`'t'�-�� � ��`oO
c�-� z373 ������`�
` . �
ADMINISTRATIdN
Under Chapter 152,Section 25C,Subsection 6,the Town of Yarmouth is naw required to hold issuance or renewal
of any license or permit to oparate a business if a persan or company does not have a Certificate of Worker's
Compensation Instcraztce, THE ATTACHED STATE WOI2KER'S CC?MPENSATION IiVSUTtAiV'CE
AFFIDAVIT MUST SE COMPI,ETED AND SIGNEll, OIi
CF,RT. QF iNSURANCE f1TTACBED� '
OR ',
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yazmouth taxes and liens must be paid prior to canewal or issuance of your permits. PLEASE CHECK
APPROPRIA"I'ELY IF PAID:
XES� NO _
MOTELS AND OTH�R LODGING ESTABLISHMENTS
TRANSIENT OCCUPANCY: For purposes oi'the limitations of Motei or Hotel use,Transient oacupancy shall be
limited to the temporary and short term occupancy,ordinarily and customarily associated with motel and hatel use.
Transient occupants must have and be able to demonsttate that they maintain a principal place of residence
elsewhere.Transient occupancy shall generally refer to continuous occupancy o£not rnare 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 or
dwelling unit shall not be considered transient. 4ccupancy that is subject to the coflectian of Raom Oceupancy
Excise,as defined in M.G.TI. c. 64G or$30 CMR 64G, as amended, sha11 generally be considered Transient. '
POOLS
POOL QPENING:AI2 swimming,wading and whirlpools which have been closed Por the season must be irrspec�ted
by the Health Deparhnent prior to apening. Contact khe Health Departrnent to schedule the inspection three(3)
days priar to opening. PLEASE NOTL;: People are NOT allowed to sit in the pool area until the pool has been
inspected and opened.
POOL WATLR TESTING; The water must be tes#ed f'or pseudomonas,tota!coliform and standard plate count
by a State certified lab, and submitted to the Health Department three (3) days prior to opening, and quarterly
thereafter. '
POfiIL CLOSING: Every outdaar in ground swimmmg pool must be drained or cavered wiihin seven{7)days of
olosing.
FOOI) SERVICE
SEASONAL FOOD SERVICE OPENING:
A11 food service establishments must be inspected by the I Iealth Depariment prior to opening. Please contact the
Health Deparlment to schedule the inspection three{3) days prior to opening.
CATERIIVG POLICY:
Anyone who caters within the Town of Yarmouth rnust notify the Yarn7outh Health Department by filing the
required 'I'empo Food Service Applicatian form 72 hours priar to the catered event. These forms can be
abtained at the H�h Department,or frorn the Tuwn's website at www.yarrnouth.ma.us under Health Department,
Daumloadable Forrns.
FROZEN DESSEIZTS:
Frozen desserts must be tested by a State certified lab prior to opening and monthly thereafter,w'tth sarnple results
subm3tted to the Health Department. Failure to do so will result in the suspension or revocafion of your Frozen
Dessert Permit until the abc7ve teuns haue been met
dI3TSIDE CAFES:
Outside cafes(i.e.,outdoor seating witl�waiter/waitress service),must have prior approval,from the Board o£Health.
OUTDOOR COC}HING:
Outdoor oaoking,preparation,or display of any food product by a retail or food service establishment is prohibited.
NOTICE:Permits run annuaIly from 7anuary 1 to December 31. IT IS YOUR RESPONSIBILITY TO RE"Pt7RN
THE COMPLETBI}RENEWAL APPLICATION{S)AND REQUIR�I3 FEE(S}BY DECEMBER 15, 2014.
ALL RENOVATIONS TU ANY POQD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT,ETC.), MUST BE REPORTED T4 AND APPROVEU BY THE BOAIZD OF HEALTH PRIOR
TO COMMENCEIvIENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
DATr: �1� i,�q� !i-{ SI('iNATURE:
PRINT 1VAME & TITLE:
. Kev. 711Q3f I4 ��� �./���n� hy�i� n '' �.
� � U W I�x.+r
� The Commonwealth ofMassachusetts
Department of Industrial Accidents
O�ce ofinvestigations
' I Congress Street, Suite 100
Boston, MA 02114-20U
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Aaalicant Information Please Print Legiblv
Business/Organization Name:
Address:
City/Staxe/Zip: Phone#:
Are you an employer? Check the appropriate box: Business Type(required):
1.❑ I am a employer with employees(full and/ 5. ❑ Retail
or part-time).* 6. ❑ Restaurant7Baz/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 officers have exercised 9. ❑ Entertaiiunent
their right of exemption per c. 152, §1(4), and we have 10.❑ Manufacturing
no employees. [No workers' comp. inswance required]* I 1.❑ Health Care
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 51l out the section below showing the'v workers'compeasation policy infotmation.
**If the coxporate officexs have exempted themselves,but the corporation has other employees,a workers'wmpensation policy is required and such an
orgauizaaon should check box#].
I am an employer that is providing workers'compensation insurance for my employees. Below is the po[icy information.
Insurance Company Name:
Insurer's Address:
City/State/Zip: �
b
Policy#or Self-ins.Lic.# Expiration Date:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and espiration date).
Failure to secure coverage as reguired under Section 25A of MGL a 152 can lead to the imposiUon of criminal penalries 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$250.00 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 verification.
I do hereby ' ,under the pains and pena[ties ofperjury that the information provided above is true and correct.
Si ature: Date: - �
Phone#:
Official use on[y. Do not write in this area,to be comp[eted by city or town offtciaL
City or Town: Permit/License#
Issuing Authority(cirde 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
TRAVELERS/�, WORKERS COMPENSATION
ONE TOWSR SQOARE AND
&nnxaonn, CT 06163 EMPLOYERS LIABILITY POLICY
TYPE V INFORMATION PAGE WC 00 00 01 ( A)
POLICY NUMBER: (IEUB-1A37070-A-14)
RENEWAL OF (IEOB-1A37070-A-13)
INSURER: TEIE TRAVELERS INDENaiITY COMPANY OF CONNECTICUT
�. NCCI CO CODE: 12637
INSURED: PRODUCER:
POLAR EXPRESS LLC EDWARD F SDLLIVAN INS
10 HARVEST HOI.LOW DRIVE 507 HIGH ST �
HARWICH PORT MA 02696 DEDHAM MA 02026
Insured is A LIMITED LIABILITY COt�ANY
Other work places and identification numbers are shown in the schedule(s)attached.
2. The policy period is from 07-01-14 to 07-01-15 12:01 A.M. at the insured's mailing address.
3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers
Compensation Law of the state(s) listed here:
h1P,
B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed in
item 3.A. The limits of our liability under Part Two are:
Bodily Injury by Accident: $ 100000 Each Accident
Bodily Injury by Disease: $ 500000 policy Limit
Bodily Injury by Disease: $ 100000 Each Employee
C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here:
AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN RS ICY LA t�ID ME MI MN
1� MS MT NC NE Nfi NJ NM NV NY OR OR PA RI SC SD TN TX OT VA VT WI
WV
D. This policy includes these endorsements and schedules:
SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE
4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating
Plans. All required information is subject to verification and change by audit to be made ANNUALLY.
DATE OF ISSUE: OS-21-14 HC
OFFICE: HQDSON/BOSTON 126 DIRECT BILL
PRODUCER: EDWARD F SULI.IVAN INS CRF87
TRAYELERS� WORKERS CdMPENSATldN
or�e moweett s4vaRs AND
eax2soRn, cr osis3 EMpLOYERS LIABILITY POLICY
TYPE V INFOf2MATION PAGE WC 00 00 q1 ( A)
PpLICY NUMBER: (ISU9-1A37070-A-19)
CLASSlFIGATION SGHEDUIE:
PREMIUM BA$IS
ESTIMATED �TES ESTIMATED
TQTQL ANNUAI PER 5100 OF ANNUA�
CLASSIFICATIONS CODE NO REMUNERATION REMUNERATION pREMIUM
SEE EXTENSION OF INFORMATION PAGE - SCAEDOLE(5)
$IC-CODE: 5951 NAICS: 445299
-----------------------------------------------------------------------------------
STANDARD
TOTAI, ESTIMATED ANNtTAL STANDARD PREMIONI $ 212
LdS5 CONSTANT 20
PREMIOM DISCOTINT NONE
0940-20 EXFENSE CONSTANT 250
TERRORISM 6
TOTAI, ESTIMATED PREMIUM d88
TAXES AND SURCHARGES 7
DE�SZT Ab�i1NT DDE 49S
Minimum Premium: $ 219
DATE OF 1SSUE: 05-21-19 HC
OFFIGE: HUDSpN/BpSTpN 126
PRQD11GEft: EDWARD F S4LLIVAN INS CRF$7 CQONTERSIGNSD-A�a�NT