HomeMy WebLinkAboutApplication and WC, �
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� ��°���`�o TOWN � F YARMOUTH Heaof
�—.._ �� 1146 ROIJTE 28, SOUTH YARMOUTH, MASSACHUSETTS 02664-24451 Heal�
II . �,, Ee° • Telephone(508)398-2231, ext. 1241
�A L Nf Fas(508) 760-3472 Division
To: Yazmouth Business Establishments SUBulray �k 1231 Z—
From: Bruce G. Murphy, Director
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Yarmouth Healttt Department� Utl: Z 2 2�14
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 permit fees issued through the Yazmouth
Health Deparhment, effecrive January 1, 2015.
Attached is the Yarmouth Business License/Permit Application for 2015. You will note that the
fees listed aze the fees effecfive 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 Yazmouth Health
Department with all required certificarions and worker's compensation 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 Sales $ 95.00
Motels $ 55.00 '
Food Service 0-100 Seats $ 85.00 BS-pp '
Food Service Over 100 Seats $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: 85,U 0
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 '
prioP to DeCembeT 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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d TOWN OF YARMOUTH BOARD OF HEALTH G3C�C5C�OMC�DD
tf�� APPLICATION FOR LICENS�f�R�IT -��IS �°: l ) /
`� * Please complete form and attach all necessaryd����y .e mber IS ZOI�14
Failure to do so will result in the r�urn �+��pplicahon ac • �TH DEP7.
ESTABLISHMENT NAME: <Sa,c3 v ino�✓s LLC ,bgA w id ID: �'
LOCATION ADDRESS: /d N/f/�TL-''s ,frs/ +YS��p�nodr/,; /711f od�(�L TEL.#: Sok-.�¢-9�d
MAILING ADDRESS: �f� P.rE .Gfi« K EAsr -�r,e�c=rv<u�e,�� / D�/�t`
E-MAII.ADDRESS: /t7G@eoxnef
OWNERNAME: �i�-m�s%zi
CORPORATION NAME (IF APPLICABLE):
MANAGER'SNAME: - In�i ( iv2v ✓1U}.fe 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.
-- --_ ___ _ __ _
L _ . 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 file at your place of business.
1. 2•
3. q.
FOOD PROTECTION MANAGERS - CERTIFICATIONS: ,
All food service establishments aze required to have at least one full-time employee who is certified as a Food I
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. a�i SY,eT zA 2. I,
PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
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1. ;02� �`1�fh-� 2. - — ;
ALLERGEN CERTIFICATIONS:
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 Deparhnent will not use past years' records. You must �
provide new copies and maintain a file at your establishment.
1. �NRrs n�PH�a �Fi iC' 2.
HEIMLICH CERTIFICATIONS:
All food service establishxnents 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 Tle at your place of business. �
1. 2. �,
3. 4. �I
RESTAURANT SEATING: TOTAL# v j
_ i
OFFICE USE ONLY
LODGING: 'I
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_B&B $55 CABIN $55 MOTEL $110 i
INN $55 CAMP $55 SWIMMINGPOOL$IlOea
LODGE $55 TRAILERPARK $105 WHIRLPOO[, $tl0ea
FOOD SERVICE: '',
LICENSE REQUIRED FEE P RMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# ���.
�0-100SEATS $125 �(�� _CONTINENTAL $35 NON-PROFIT $30 I.
>I00 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
=<25,000 sq.ft. $150 _FROZEN DESSERT $40 _TOBACCO $1l0
NAME CHANGE: $15 AMOUNT DUE _ $ I 2S.O O '�,
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*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** �
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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 ta operate a business if a person or company does not have a Certificate of Worleer's �
Compensation Insurance. TIiE ATTACHED STA'I'E WOItKER'S COMPENSATIQN INSUItANCE �
AFFIDA"YIT MIJST BE COMPLETED AND SIGNEL),OR ;
CERT. OF INSUR.�INCE ATTACHED ✓
OR
WORifER'S COMP. AFFIDAVIT SIGNED ANll A'I'TACHED
Toum of Yarttaoutla taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROP1tiATELY IF PAID:
YES s/ NO
MOTELS AND OTH.ER LODGING ESTABI.,ISHMENTS I
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TRA�NSIENT OCCUPANCI': For purposes of the limitatioixs of Motel or Hotei use,Transient occupancy shall be
limited to the temporary and short term occupancy,ordinarily and oustomarily associated with motel and hotel use.
Transient occupants must haue and be able ta demonstrate that they maintain a principal place of residenca �
elsewhere.Transient occupancy shall general ly refer Yo continuous occupanoy of not rnore than thirty(30)days,and '.
an aggregate af not moxe than ninety(90)days within any six(6)month period. TJse of a guest unit as a residence or
dwelling unit shall not be cons3dered transient. Occupancy that is subject to the collet;tian af Room Occupancy
Excise,as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considerefl Transient.
POOLS
P(}OL OPENING:All swimming,wading and whirlpools which have been clased far t2�e season must be inspected ;
by the Health Department prior to opening. Contact the Health Departrnent to schedule the inspection three(3) '
days prior to opening. FLEASE NOTF: People are NOT allowed to sit in the poo] area until the pool has treen '
inspected and apened.
POOL WATER TESTING: The water must be tested for pseudqmonas,total coli£orm and standard plate count
by a State certified lab, and submitted to the Health Department three (3) days prior to opening, and quarteriy
thereafter.
P40L CL4SING: Every outdoor in ground swimming paol must be drained ar covered within seven{7)days af ;
olosing. I
FOOD SERVICE
SEASONAL FOOD SERVICE OPEIVING:
AII food service establishments must be inspected by the I�ealth Deparrinent prior to opening. Please contact the
Health Departrnent to schedule the inspection tltree (3)days prior to apening. �
CATERiNG POLICY: �
Anyone who caters within the Town of Yarmouth rnust notiFy the Yannouth Health Department by filing the
requiretl Temparary Foad Service Application form 72 haurs priar to the catered event. These forms can be j
obtained at the Health Department,or from the Town's website at www.yazrnouth.ma.us under Haalth Department,
Downioadable Forms.
FROZEN DESSERTS:
Frozen desserts must be tested by a State certified lab prior to apening and monthly thereafter,with sample results
submitted to the Health Departrnent. FaiIure to do so will result in the suspension or revocation of your Frazen
Dessert Permit untii the above terms have been met.
OUTSIDE CAFL+`S:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval frorn the Board of Health.
OUTAOOR COUHING:
Outdoor cooking,prepazation,or display of any€ood product by a retait or faod serviee estabtishment is prohibited.
NOTICE:Permits run annually frorn January I to December 31. I'1'IS 1'OITR I2ESPONSIBILITY TO RETtTRN '
THE COMPLETED RENEWAL APPLICATION(S}AND REQUIREI}FEE(S}BY DECEMBEl2 I5,2014. �
' ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEI. OR POOL (i.e., PAAVT'ING, NEW
� EQUIPMENT,ET"C.},MUST BE REPORTEI3'I'O ANI7 APPROVEI7 BY THE BOARD OF HEALTH PRTOR
I
TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
� DATGc !� a��- STGNATURE: „�- -
PRINT NAME& TITLE: /� -�c'' �
Rev. llf43t34
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� � The Commonwea[th ofMassachusetts
Department of Industrial Accidents
Offzce of Investigations
' 1 Congress Street, Suite Z00
Boston, MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
A�plicant Information Please Print Legiblv
Business/Organization Name: ���3�c qvrs�Tro.✓ LL[' Ji a.9 QS�gu�.9y ia3ia
Address: /02, Wifi�,'s ff�T-sY ��
City/State/Zip: S � ��d� Oa Phone#: SO� �3i�—%Sou
Are you an employer? Check the appropriate box: Business Type(required): ,
L� I am a employer with�_employees(full and/ 5. ❑ Retail ',
or part-time).* 6. �RestaurantBaz/Eating Establishment
— --- -- -
2. yI am a s�proprietor or paz[nership andTiave no � 0 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 corporarion and iu officers have exercised 9. ❑ EnteRainment
their right of exemprion per c. 152, §l(4), and we have 10.0 Manufacturing
no employees. [No workers' comp. insurance required]*
4.❑ We aze a non-profit organization, staffed by volunteers, �1.❑ Health Care
with no employees. [No workers' comp. insurance req.] 12.❑ Other ',
*Any applicant t6at checks box#1 must also fill out the section below showing theu workers'compensation policy infocmation. �'�
**If the corporete officexs have exempted themsehes,but the corporation has other employees,a workers'compensation policy is required and such an �
organization should check box#1. i
I am an emp[oyet that isproviding workers'compensation insurance for my employees. Be[ow is thepolicy dnformation. I
Inswance Company Name: �o�i�En/�c �NSd.eN�✓�/�m.�6I-n/L/
Insurer's Address:
City/State/Zip:
Policy#or Self-ins.Lic. # '��1�23�/%7� Expirafion Date: >� a�/ �
Attach a copy of the workers' compensation policy declaration page(showing the policy nnmber and expiration date). '
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposirion of criminal penalties of a I
__ - - - —_
fine up to $1,500.00 and%or one-yeaz imprisonment,as well as civil penal4ies in the form of a STOP WORK ORDER and a tine
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
InvesugaYions of the DIA for insurance covenge verification.
I do hereby cen�,under thepains andpenalties ofperjury that the information provided above is due and correct. i
Sienature: tr��/�i,I�• Date• /�. /�o`ZD/'� il
Phone#: %O/ - f'd�/- �Q�it
Official use only. Do not write in this area,to be completed by city or town offtciaL I
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Healt6 2. Building Department 3.City/Town Clerk 4.Licensing Board 5. Selectmen's Office I
6. Other ,
Contact Persou: Phone#:
, www.mese.gov/dia i
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A«� CERTIFICATE OF LIABILITY INSURANCE °"����4"'
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THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
� CERTIFICATE�� DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES �
BELOW.-THIS CERTIFICATE OF INSURANCE DOES NOT CONSTRUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORRED �
REPRESENTATIVE OR PRODUCER AND THE CERTIFlCATE HOLDER.
IMPORTANT:If the certificate hoider is an ADDITIONAL INSURED,the policy(ies)must be e�iorsed.tt SUBROGATION IS WAIVED,subJect W `
the terms and condkions of the policy,certain poticies may require an endorsement A statement on this certificate does not confer rights to
the certMicate holder in lieu of such endorsemen s: �
IPRODUCEH CONTACT
NAME:
I CS&SBROWN&BROWN OF CT�INC. �NE � F�
.No Ea: INC.Nol:
I PO BOX 946580 E�i�
ADDRESS:
;Maitland,FL 32794-6580 INSURERS AFFORDING COVERAGE NAIC t
�1-866-883-7159 �NsuRER A: Continental Casuaity Company 20443
�INSUflED INSURER B:
�SUB ACQUISITION LLC DBA SUBWAY INSURERC
I 45 PINE HILL DRIVE INSURER D:
EAST GREEN W ICH, RI 02818 �NSURER E:
INSURER F:
COVERAGES CERTIFlCATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO 7HE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDINGANY RE�UIREMENT, TERM OR CANDRION OF ANY CANTRACT OR OTHEF DOCUMENT WITH RESPECT TO WHICH THIS
� CERTIFlCATE MAV 9E �SSUED OR, MAV PERTAIN, THE INSURANCE AFFORDED BY iHE POLIGES DESCRIBED HEREIN IS SUBJECT TO ALL lHE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.IJMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
iHSp q POLICY EFF POLICY E%P
��p iYPE OF INSUNANCE POl1CY NUMBEN ��.y �yp LMM73
A GENEfl/LLLIABILRV Y ��'j'�]97(�`� ����Q 11/25M5 �HOCCURRENCE '1�0�
COMMERCIALGENEflALLIABILITV PNEm3ES�aanwce) 300000
II CLAIMSMADE �OCCUR MED EXP(My arie peBM) �O OOO
I PERSONAL&ADVIWURY ZOOOOOO
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POLICY JECT X LOC �
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iA AUTOMOBILELIABILRY 4012379760 71/25/14 11/25/15 ��e�p 1,000,000
I BODILYINJURY(PerpBreon) $
ANY AUTO
ALIOWNED SCHEDULED BODILVIWURV(P9reccXiBn1) $
� AIROs �TO"' PROPEHTYDAMAGE
NON-0WNED
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O'fXEfl TORYLIMIT$ ER
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E.L DI3EASE-EA EMPLOYEE
E.L OISEASE-POLJCY LIMIT
D RIPTION OF PEIiA71ON6/IACATIONS/VEHICLES(Atlath ACad 101. Rmurka Schedub.il mOR epeCe is req�irBU)
Certiflcate Holder fs named as Independant Operators
Location#1 12 WHITES PATH,SUITE 5,SOUTH YARMOUTH,MA,02664,Store#12312
�CERTIFlCATE H04DER CANCELLATION �
I D'IXO��BriaMuN,�IRI SHOULD ANY OF TNE ABOVE DEBCRI�DPOUCIES BE CANCELLED BEFORE
THE EXPIRATION DATE -THEREOF, NOi10E WILL BE DEWERED IN�
ACCORDANCE WRH THE POLICY PROVI810N5.
C/O CONRI DEVELOPMENT GROUP INC.
930 WATERMAN AVE.
PROVIDENCE,RI 02914 ���,,.��
� a 1988-2070 ACORD CORPORATION.All rights reserved. �
n rnon oq iomnmcl Thn ACORD name and IoqO 3fe registered m0Ac8 of ACORD �