The URL can be used to link to this page

Home My WebLink AboutApplication and WC oF'YAR ��' ��' _ `�� TOWN OF YARMOUTH Ha�f � � ` °3 1146 ROUTE 28, SOUTH YARMOUTH, MASSACHLJSETTS 02664-24451 � �. �,Tr�tM��,,�' 'r Telephone(508)398-2231, ext. 1241 Di s n� Fax(508)760-3472 To: Yazmouth Business Establishments Mg2K�Pt-p�cs A-r Pi�T�s Co�E From: Bruce G. Murphy, Director � ��pd�D Yannouth Health Department� ut� 't 5 2014 Date: November 7, 2014 HEALTH DEPT. Subject: Increase in License/Permit Fees Please be awaze that the Yarmouth Boazd of Health, under the direction of the Yazmouth Boazd of Selectrnen, has raised a number of license and pernut fees issued through the Yarmouth Health Department, effective 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 Januazy 1, 2015. However, if you fully complete the application, and submit it to the Yarmouth Health Department with all required certifications and worker's compensafion coverage information (certificate of insurance OR completed affidavit) orior 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 Sa1es $ 95.00 Motels $ 55.00 Food Service 0-100 Seats $ 85.00 .00 Food Service Over 100 Seats $t60.00 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: 150.00 �M�ti,°r�ss�; `� � GSOSQ.Ft.�. Total fees owed for your establishment: � 235.da NOTE: To be entitled to pay the current 2014 rates listed above, your business application, food and/or pool certitications, along with worker's compensation information must be received, or mailed (postmarked) on or prioT to DeCember 31, 2014. [Those establishments which open in the spring will be allowed to provide food and/or pool certifacations prior to opening, however, you must note "Will provide in the springprior to opening" on the application.J BGM/maf i _ � d � TOWN OF YARMOUTA BOARD OF HEALTH P«'�COJ APPLICATION FOR LICENSE/P��I,�T�� '� 5 1U14 � * Please complete form and attach all necessary cuments 6y D ` bAil '0S PT Failure to do so will result in the return of our a 'lication pac e . Y PP ESTABLISHMENTNAME:��k✓<\1,�z`I�UAe-� A-� (�lY�h�s ce�vE. TAXID• LOCATION ADDRESS: 7 `-1 Z i2ovT� �.& 5 `l�l�-V�.c.Y �419' TEL.#: 5UY- 3�GG�-( - S Z�52-- MAILINGADDRESS: �v-,-.��-- E-MAILADDRESS: vc. SU� a-o--Q� c-w�- OWNERNAME: a,a(ci�f'(Ca-� (, Lw{- ( I�L �S Letv�-Eh�� c CORPORATION NAME (IF APPLICABLE): (�i YLa-"rk� cx+�.. 5.4�r c�2-. MANAGER'S NAME: �( ,�„,� L L�-r TEL.#: S�g' y—5Z5 L MAILING ADDRESS: �4 7 {Q-�++/'� � S Y(�-(�tJL+`�' 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 minunum 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 file at your place of business. l. 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. C.�--v'r-C O� 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. ��`�L-✓t7 l �-ct'�� 2. ALLERGEN CERTIFICATIONS: All food service establishments 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. l� � �.v-v-e._ 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 file at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# a O 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 SWIMMINGPOOL$110ea '. _LODGE $55 =TRAILER PARK $105 _WHIRLPOOL $1IOea. '�, FOOD SERVICE: � LICENSE REQUIRED FEE PERM[T# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LO-IOOSEATS $125 1 - bg WNTINENTAL $35 NON-PROFIT $30 _>100 SEATS $200 �COMMON VIC. $60 � _WHOLESALE $80 � —RESID.KITCHEN $SO �� RETAIL SERVICE: '�, LICENSE REQUIRED FEE P RMIT# LICENSE REQUIRED FEE PERMIT# L[CENSE REQUIRED FEE PERMIT# �'� �<50 sy.ft. $50 � I -U � >25,000 sq ft. $285 VENDING-FOOD $25 - _<25,000 sq.ft. $150 � =FROZEN DESSERT $40 � =TOBACCO $ll0 '�, NAMECHANGE: $IS AMOUNTDUE _ $ 2"]5.00 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** ��'�� r a'� `�� '(�t"8�l ��b�� ; , , ADMINISTRATION Under'Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORK�R'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED � OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yannouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES \� NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes ofthe limitations ofMotel or Hotel use,Transient occupancy shall be limited to the temporary and short term oceupancy,ordinarily and customarily associated with motel and hotel use. Transient occupants must have and be able to demonstrate that they maintain a principal place of residence elsewhere.Transient occupancy shall generally refer to continuous occupancy of not more 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. 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, sha11 generally be considered Transient. POOL5 POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. Contact the Health Department to schedule the inspection three(3) days prior to opening. PLEASE NOTE: People are NOT allowed to sit in the pool azea until the pool has been inspected and opened. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standazd plate count by a State certified lab, and submitted to the Health Department three (3) days prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained ar covered within seven(7)days of closing. FOOD SERVICE SEASONAL FOOD 5ERVICE OPENING: All food service establishments must be inspected by the Health Department prior to opening. Please contact the Health Department to schedule the inspection three (3) days prior to opening. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Heaith Department,or from the Town's website at www.varmouthma.us under Health Departrnent, Downloadable Forms. FROZEN DESSERTS: Frozen desserts must be tested by a State certified lab prior to opening and,monthly thereafter,with sample results submitted to the Health Department. Failure to do so will result in the suspension or revocation 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 COOHING: _____ QuYdoQr cooking,pr�aration,or display of any food product by a retail or food service establishment is prohibited. ' NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RE'I'URN THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 15, 2014. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MiJST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: �LI!I7,cr �N SIGNATURE: � �Y�--� PRINT NAME& TITLE:_ ��-RQ Z �v`�c. C�u-lYi�� Rev.11/03/14 . , . . � f � � � The Commonwealth ofMassachusetts Department of Industrial Accidents Office oflnvestigations ' 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legiblv Business/Organization Name: rV1t�R.((S�(� �� 09-� (�i (�S CCSIT`�-� Address: � y Z �u � � v �� City/State/Zip: �ou��- �(V}-i2,✓VWifil� V1�'Phone#: ,��' �� { — S �- $ Z- Ar,�e y,�o an employer?Check the appropriate bos: Business e(required): 1.L� I am a employer with � employees(full and/ 5. etail or part-time).* S��-5 u M�gZ 6. ❑ RestaurantBaz/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] 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 10.❑ Manufacturing no employees. [No workers' comp. insurance required]* 4.❑ We aze a non-profit organization,staffed by volunteers, 1 I.� Health Caze with no employees. [No workers' comp. insurance req.] 12.� Other 'Any applicant that checks box#1 must also 51l out the section below showing their workers'compensation policy infolmation � **If the cotporate officexs have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#L �. I am an employer that isproviding workers'compensation insurance for my employees. Below is the policy information. ', Insurance Company Name: L�.(,t,-T2r1GS (Af SUlC.�JIiG� G YZ21UlP Insurer's Address: `�� K � W/V� F�nJ/� S 7-' 1�-4 • � � � 55 � City/State/Zip: (`�1 l f�LAn(�'J � 1�/V� '-�e6 �o `�C� Policy#or Self-ins.Lic. # �l-�C � Z�J� � � Expiration Date: O I I�I� !� Attach a copy of the workers' compensation policy declaration page(showing the policy nnmber and ezpiration date). Failure to_Secure coverage as required_under Section 25A of MGL a 152 can lead to the imposition 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 WOh�C 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 Invesrigations of the DIA for insurance coverage verificarion. I do hereby cendfy,under thepains andpenalries ofperjury that the informarion provided above is true and correM. ' Si¢nature: ( .�� Date• �./.GL�-✓v�-Gu-✓ / a'[1 �y Phone#: � 8 - ��y- s�S }� Official use only. Do not write in this area,to be completed 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 Office ' 6. Other Contact Person• Phone#: ' www.mass.gov/dia '�. �-�� PCMAN-2 OP 10•KM ACORv- CERTIFICATE OF LIABILITY INSURANCE °"'�'"�°°"""" `–� 11@5l2014 THIS CER7IFICAiE IS ISSUED AS A MATTER OF IPIFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERI7PICATE HOIOER.TH4S . CERTiFICATE DOES N6T AFFlRMATNELY OR NEGATIVELY AINEN�, EXTEND OR ALTER THE COVERAGE AFFOROm BY THE POUGES BELOtlY. THIS CERTIFICATE OF tNSURANCE OOES NOT CONSTITUTE A CONTFtACT BETWEEN THE ISSUING INSURER(5), AUTHORIZED REPRESENTATNE OR PROOUCER,AND THE CER7IFICATE HOIDER IMPORTANT: IF fhe cartlfieate holder�an ADDITIONAL SNSURED,the poliey{fes) must be endorsed. If SUBROGATION IS WANED,subject to the tertns antl condtNons of the polky.cettain policioc may raquire an endorsement A statement on M�eertifleale does not confar rlgt�ffi!o the certiflcate holder in Iku oi such e�dorsement s rnoouer� E T Kart T.leuter lauter Irourance 6muP �e 989-835-6707 �9-835-2884 414 Townsend St P.O.Box 552 s� AAldland,MI48640 EM^� Karl T.leuter � ` W9URERSAFFORDWGCOYBKGE NAIc! a+au�nn:T.H.E Irisunnce Co ixsueeo P.C.Management n�suaeee: BradGreft ipauxa�e: — 2323 US 31 North - -- Treverse City,MI 49666 ��os INSIIR�I E: NlSYIRRF: COVERAGES CERTIFICATENUMBER: REVISIONNUMBER: TM6 IS TO CER7IFY THAT TF�POLIGES OF INSURANCE IISTED BELOW HAVE BEEN ISSUFD TO THE INSUREO NAMED ABOVE FOR TliE POLICY PERIOD . INDICA7ED. NOTWfiHSTANDINfi ANV RECIUIREMENT,TERM OR CONDITION OF ANY CONTAAGT OR OTH92�UMEM YNTH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUm OR MAY PERTAIN, THE INSUHANCE AFF�ROED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TD ALL THE TERMS, DIC WSIONS ANO CONUITIONS OF SUGH POUCIES LIMITS SFIOWN MAY HAVE 9EEN REIXICED BY PAIO CLNlAS. L1R 7YPEOFN8IMIANCE POLIGVNI7M6ER � 1tlN �.. WMY9iCWLGBiHiILLIM&LffY EACHOCCIN�ENCE 8 � GtAM78-MaOE ��WR PIiE1�p,5E81Eavmr�renre B MEDE%P wsP�� S ' PHiSOlUL6AWINJURY 5 GENLAGGflEfL1TELMrAPPLIESPER: GEIBiM.M�l1EGPTE E PO�ICY❑J�ECT ❑LOC PNanIILTS-CaA�qPAGG S OfFfER $ AUTOMWILEW18RfiY NeN$ S ANYRIRD BOOILYRIURYI�Vm�1 S ALLOWNEO SCHEIXILEO BOOILYWJURY1PormiMM) f AIJr06 AUTOS �onuras wN0f1ros� 8 s ��-u� pCGM E�CH OCClM1ikT1(� S FxCE88 W1B tl.AY3#INOE AGGNEGPiE S UEO flETBfiWNE S YYplKER9 CONPB1511i1ON PER 11HD E1IPLOYEfl9'tl�.ftY A ,wr�oanerowrnRruer�curnE r�N C123897 01(O7/2076 D1/6f12076 E��xncc�o�r s 1.000, ��e�nanucem �NIA (�1'M�flM) E4015EA�-EAENPLO E �.�� Yyea,tleevpevitlu OES �OPERA710NSbNow ELUISFASE-Pd.ICYLH9f S 1�000�00 oEBCRIPlIONOFOP6�N'MNS/LOCA710N3/VEMCLES(�ORO7Ut.AtldllomlRamvMSSchMtlIS�aSLGetletl�cERmomsWwMrepuhatl) rkare' Compenaation coveraga iacludae Pirate's Cova Baet and Pirate's Cwn katplace loaationa. CERTIPICATE HOLDER CANCELLATION TWNYA-1 SNOULD ANY OF THE ABOYE DESCRIBED POLIC�6E ceurc�i cD BEFORE TOWIfOfYarrtlOutll T� ��T�� DATE 7HERE�, NOTlCE 1MLL BE �EWEREO IN ACCOROANCE WI7H 7HE POLICV PROVISIONS 7743 Rte 26 South Yarmoutl�,MA 02664 ,��q�� , � Ka�1 T.leuter m 198&2074 ACORD CORPORATION. All rfghts reserved, ACORD 25(201M01) Tlre ACORU name and logo era registered marks of ACORD