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Home My WebLink AboutApplication and WC, _ �oF�R,�o TOWN OF YARMOUTH Boazdof � - ' -- �, Health � :. K "'3 1146 ROUTE 28, SOUTH YARMOUTH,MASSACHtJSETTS 02664-24451 - - �. �'�tr�eME`yk � Telephone(508)398-2231,ext. 1241 Di s n Fa7c(508) 760-3472 L3C�GrC�O�IC�D To: YazmouthBusinessEstablishments KEI�p,�s BAr�-y � UE� 3.1 20t4 From: Bruce G. Murphy, Director HEALTH DEPT. Yarmouth Health Deparhnent� Date: November 7, 2014 Subject: Increase in License/Permit Fees Please be aware that the Yazmouth Boazd of Health, under the direction of the Yarmouth Boazd of Selechnen, 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/Pemut Application for 2015. You will note that the fees listed aze the fees effec6ve 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 certifications and worker's compensaUon coverage information (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 � 95.00 - - - - - --- Food Service Over 100 Seats �166.00 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: (00�,0 p ��N `�� Tota1 fees owed for your establishment: �l�kS-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 spring prior to opening" on the application.J BGM/maf � � � TOWN OF YARMOUTH BOARD OC� ��3#L�#I ,'! �' , � , APPLICATION FOR LICENSE/PERMI3'-2015 ' . DEC � � ZO14 " * Please complete form and attach all necessary documents by Decemb r IS 2014. Failure to do so will result in the return of your application pac DEPT. ESTABLISHMENT NAME: r TAX ID• ' LOCATIONADDRESS: `� a cS, l�A TEL.#: f o"2gb MAILING ADDRESS: LU 2/o� E-MAiL ADDRESS: r/ . P.a>"✓1 OWNER NAME: PJ� CORPORATION NAME (IF APPL CA�LE): MANAGER'S NAME: !' �-�PY� TEL.#: 2 2 c'7 MAILING ADDRESS: n 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. 1. 2• 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 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. T6e Health Department will not use past years'records. You must�rovi e ne�,w//co�p�� maintain a file at your est�blishment. � 1._�� I 1 cx� PERSON IN CHARGE: Each food es lishment m t have at least one Person In Charge (PIC) on site during hours of operation. 1.�'�� -�t 7�-C�' 2. - — _ ALLERGEN CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who has Allergen certification, as defined in the State Sanitary Code far Food Service Establishments, 105 CMR 590.009(G)(3)(a). Please attach copies of certification to this applicaUon. The Health Deparhnent will not use past years' records. You must prov� new p�e nd m intain a file at your establishment. l.l /'Ci�� .S�C � 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 # l 7 OFFICE USE ONLY -- - LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# L[CENSE REQUIRED FEE PERMIT# � B&B $55 CABIN $55 MOTEL $1(0 �� [NN $55 CAMP $55 SWIMMING POOL$110ea - LODGE $55 TRAILERPARK $105 _WHIRLPOOL . $110ea FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMTT# . �0-t00SEATS $125 �IS�I� CONTINENTAL $35 NON-PROFIT $30 >100 SEATS $200 �COMMON VTC. $60 �p _WHOLESALE $80 — —RESID.KITCHEN $80 � RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# UCENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# � <50 sq.ft. $50 >25,000 sq.8. $285 VENDING-FOOD $25 _QS,OOOsq.ft. $150 —FROZENDESSERT $40 _TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE _ $ I BS.O� *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** �� , ��`J`�4 ��t33 ►2�3�1�� ADMINISTRATION Under Chapter 152,Section 25C,Subsection 6,the Town of Yarmouth is naw 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 Worker's Compensation Insurance, TkIE ATTACHEll STATE W4RKER'S CQMPENSATIQN INSITI2ANCE AFFYDAVIT Mi1ST SE COMPLETED AND SIGNED, OR � CF,RT. QF ZNSURANCE ATTACHFD PR WORKER'S COMP. AFFIDAVIT SIGNED ANI7 ATTACHED Town of Yarmouth taxes and liens must be paid prior to cenewal ar issuance oFyour permits. PLEASE CHECK APPROPRIATELY IF PAID: / YES i/ NO MOTELS ANA OTHER LODGING ESTABLLSHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be limited to the temporary and shart term occupancy,ordinarily and oustornarily associated with motel and hotel use. Transient occupants must have and ba able to demonstrate that they maintain a principaI place of residence elsewhere. Trensient occupancy shall generally refer to continuaus accupancy of not rnore than thirly{30)days,and �n 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 transiant. Occupancy that is subject to the collection af Roam Occupancy Excise,as defined in M.G.L. c. 64G or 834 CMR 64G,as amended, shall generally be considered Transient. P40L5 P{3C}L 4PENING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Deparhnent prior to opening. Contact the Health Departrnent to schedule the inspection three(3) days prior to apening. PLEASE NOTl:: Peaple are NC3T allawed to sit in the pool area until the pool has been inspected and opened. POOL WATER T"ESTING: The water must be tested for pseudomonas,total coliforn7 and standard plate count by a State certified lab, and submitted to the Health Department three (3) days prior to opening, and qnarterly thereaRer. POOL CI�OSING: Every outdaor in ground swirnming paoi must be drained oz covered within seven(7)days of closing. FQOD SF.RVICE SEASONAL FOOD SERVICE OPENING: All food service establishxnents must be rnspected by the Health Departrnent prior to opening. Please contact the Health Departrnent to schedule the inspectian three (3)days prior to opening, CATERiNG PQLICl': Anyone who caters within the Town of Yarmouth rnust notify the Yazmouth Health Department by filing the requzred Temparary Foad Service Application farm 72 hours prior to the catered event. These forms can be obtained at the Health Deparhnent,or frorn the Town's website at www.yazmouth.ma.us under Health Department, Dawnlaadable Forms. FI20ZEN DESSERTS: Frozen desserts must be tested by a State certified lab prior to opening mnd tnonthly thereafter,with sarnple results submitted to the Health Department. Failure to do sa wiil resalt in the suspension or revoeation of your Frozen Dassert Permit until the above terms have been met. dUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. OTTTDOOR COOHING: . Outdoor cooki�reparatian,or display ofany faod product by a retail ar food service establishment is prohibited. NOTICE:Permits run annually from January 1 to December 31. IT IS YOLTR RESPONSIBILITY Tt3 R�Tt3RN THE CQMPLETED RENEWAL APPLICATION{S)AND REQLTIRED FEE(S}BY DECEMBER 15, 24i4. t1LL RENOVATIdNS TO ANY FOOD ESTABLISHMENT, MOTEL OR PO4L (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTBD T4 AND APPROVED BY THE BC}AR.D OR HEALTH PRIC?R TO COMMENCEMENT. RENOVATIONS MAY RE UIRE S E PLAN. DAT�: �2 3� „�JIT SIGNATURE: PRINT NAME&TITLE:.��"'S � �l�L,a'1�/.� ftev. !l103t14 � /�� Date Prepared: 03!20 l i a DIRECT BILL WORKERS' COMPENSATION AND EMPLOYER'S LIABILITY INSURANCE POLICY MERGiANTS MUTUAL INSIkiANCE CaMPANY BUFFALO, NY 14202 NCCI COMPANY NUMBER: 15652 INFORMATION PAGE POLICY NUMBER: M�CA9097799 TRANSACTION TYPE: RENEWAL AGENCY/BROKER: �TM�TERN INSURANCE A(iCY RENEWAL OF NUMBER: NICA9097799 AGENT CODE: 66614/NER06/033 BUSINESS TYPE: INDIVIDUAL 1. THE KE ITH KESTEN INTERSTATE/INTRASTATE RISK ID: INSURED DBA KEILAR'S BAKERY BOARD FILE NUMBER: MAILING 1 CYqJET ROAD ADDRESS w YARMOUTH, MA 02673-3609 DE T FlCATION NUMBER: 285496129 OTHER WORKPLACES NOT SHOWN ABOVE: (ADDRESS,CiTY, STATE,ZIP CODE) 2. POLICY PERIOD is from 04/75/14 to 04/15/15 12:01 AM standard time at the insured's mailing address. 3. A. Workers' Compensation Insurance: Part One of the policy applies to the Workers' Compensation Law of the states listed here: MA 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 $1 �000,000 each accident Bodily Injury by Disease $1 ,000,000 policy limit Bodily Injury by Disease $1 ,000,000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: D. This policy includes ihese endorsements and schedules: MS IU 05 11 99 MU O6 3J 04 07 N� 00 00 00 B N[C 00 00 01 A WC 00 01 14 NIC 00 04 21 C YIC 00 04 22 A WC 20 03 01 WC 20 03 02 A WC 20 03 03 D WC 20 04 O1 WC 20 04 04 WC 20 O6 01 A 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Code Premium Basis Rates Per Estimated Annual Classifications No. Total Estimated Annual $100 of Premium Remuneration Remuneration SEE EXTENSION OF INFORMATION PAGE MINIMUM PREMIUM $ 2�6 DEPOSIT PREMIUM $ 1 .630 TOTAI ESTIMATED ANNUAL PREMIUM $ 1 ,630 Interim adjustments of premiums shall be made: ANNUAL /� Countersignetl by: , ,� ,h�,j��/ � f �,�� q�) uthorized r�presentative Date COPYR�GHT 1987 NATIONAL COUNCIL ON COMPENSATION INSURANCE WC 00 00 01 A I�ED COPY � MERCHANTS MUTUAL INSURANCE COMPANY � ��//�I� WORKERS' COMPENSATION EXTENSION OF INFORMATION PAGE POLICY NUMBER: VYCA9097799 THE KEITH KESTEN INSURED DBA KEILAR'S BAKERY MAILtNG 1 CYqJET ROAD ADDRESS W Y��' � 02673-3609 Premium Basis Total Estimated Rates Per Estimated Classifications Code Annual $100 of Annual No. Remuneration Remuneration Premium LOCATION 001 1 CYtlVET ROAD W YARMOUTH, MA 02673-3609 BAKERY & DRIVERS, ROUTE SUPERVISORS 2003 35,000 3.3300 1 ,166 INCREASED LIMITS EMPLOYERS' LIABILITY 9812 2.0000 % 75 TOTAL ESTIMATED STANOARD PREMIUM 1 ,241 MASS DIA 8999 1 ,166 .0340 40 EXPENSE CONSTlUVT 0900 338 TERRORISM RISK INSURANCE ACT • MA 8740 .0300 11 TOTAL ESTIMATED ANNUAL PREMIl�4 1 ,630 M I N I MI�A PREM I UM 276 DEPOS I T PREM I lsrl 1 ,630 COPYRIGHT 1987 NATIONAL COUNCIL ON COMPENSATION INSURANCE WC 00 00 01 A