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Home My WebLink AboutApplication and WC . OF Y`�R �� -�"_'�`,�� TOWN OF YARMOUTH Ha�f � -� � � y 1146 ROUTE 28, SOUTH YARMOUTH, MASSACHUSETTS 02664-24451 - H �., �,e% � Telephone(508)398-2231, ext. 1241 Health �r �A C NE Fa�c(508)760-3472 DivisiQ' G3C�C�,�u's�L� To: Yazmouth Business Establishments T,t� OcaaN C�.v(3 Utl: U� LU i4 From: Bruce G. Murphy, Director � HEALTH DEPT. Yarmouth Health Department� Date: November 7, 2014 Subject: Increase in License/Pernut Fees Please be awaze that the Yannouth Boazd of Health, under the direcrion of the Yarmouth Board of Selechnen, has raised a number of license and permit fees issued tluough the Yazmouth Health Department, effective January 1, 2015. ' Attached is the Yannouth 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 applicadon, and submit it to the Yarmouth Health Deparnnent with a11 required certificaUons and worker's compensarion 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 i Public Swimming Pools $ 80.00 � 8o�ob Public WhirlpooUVapor Baths $ 80.00 gp. Tobacco Sales $ 95.00 Motels $ 55.00 ,� Sg,pp Food Service 0-100 Seats $ 85.00 Foed Service OveF ��eatg = — - �}5e.D3 _ —.---- --._ --._ _ ___ -'I 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: �3S.oo c�nN.m-Fr,r.c�r � Total fees owed for your establishment: $2Saon NOTE: To be entitled to pay the current 2014 rates listed above, your business application, food and/or pool certificallons, along with worker's compensation information must be received, or mailed (post�arked) on or �' prior to DeCembeP 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 I � I � ocEr.tiCwB � � TOWN OF YARMOUTH BOARD OF HEALTH ��6��MC�DD � � APPLICATION FOR LICENSE/PE�,TT�-"��'0�� tz' ,, QE� Q 2 ZQ�4 * Please complete form and attach all necessary d ume�� eCem r IS 2014. Failure to do so will result in the return of yow'applicatton pac t. HEALTH DEPT. ' ESTABLISHMENT NAME: c TAX ID: — ^ LOCATIONADDRESS: 3��f S- 2 �YtV� TEL.#: MAILING ADDRESS: E-MAII.ADDRESS: ��S�('(1 b�'(I C��,��SCaV'—I�S, � GYYI OWNER NAME: CORPORATION NAME (IF APPLICABLE : ' MANAGER'S NAME: L j YI(',I G �C� C C��P�U TEL.#: -0 S 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. i. - �a'�-1�`�LL�=�v� ��" a. �� S C c�� 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. ; I �. : �� ,o rn0.�s � 3. .,�� v► � 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 Deparhnent will not use past years'records. You must provide new copies and maintain a file at your establishment. i. h/��' 2. N��- PERSON IN CHARGE: ' Each food establishment must have at least one Person In Chazge (PICj on site during hours of operation. �. �✓/A 2. ni/A _ � 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 pravide-vew copees and-maintain s-�ile at-your establishment. i. rV�A' a. N��" HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must haue at least one employee trained in the Heimlich I Maneuver on the premises at a11 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. N��" 2. �/� , 3. 4. RESTAURANT SEATING: TOTAL # OFFICE USE ONLY j LODGING: ' LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE P RMIT# �. —B&B $55 —CABIN $SS MOTEL $110 -�� INN $55 CAMP $55 �SWtMMINGPOOL$IlOea �' LODGE $55 TRAILERPARK $105 I WHIRLPOOL $110ea Z i I FOOD SERVICE: � I LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE P RMIT# L[CENSE REQUIRED FEE PERMIT# '� 0-]00 SEATS $125 _j_.CONTINENTAL $35 ,i–17 G� NON-PROFIT $30 ' >I00 SEATS �$200 _COMMON VIC. $60 WHOLESALE $80 i —RESID.KITCHEN $80 RETAIL SERVICE: '��, LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �'�. <50 sq.ft. $50 >25,000sq ft. $285 VENDING-FOOD $25 '� —<z5,000 sq.ft. $150 —FROZEN DESSERT $40 _TOBACCO $110 i NAME CHANGE: $IS AMOUNT DUE _ $ 3 65 •O O I '****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*"*•* �� f � ��7� ��t�� _ __ . __._ . .: ; a ADMINISTRATION � Under Chapter 152,Section 25C,Subsection 6,the Town of Yarmouth is naw required to hold issuance or renewal �, of any lic�nsa or permit to operata a business if a person or cornpany does not have a Certificate of Worker's Compensation Insurance. THE A7"TACHED 5TA1'E W012KER'S COMPElYSA7"IQtv INSIJI2ANGE AFFIDAVIT MUST BE COlVIPLETED AND SIGNED, OR CERT. 4F INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarrnouth taxes and liens must be paid prior to renewal oz issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER I.ODGING ESTABLISHMENTS � i TRANSTEI�IT OCCUPANCY: For purposes of tne limitations of Motel ar Hotel use,Transient accupancy shall be ! limited to the temporary and shart term occupancy,ordinarily and customarily associated with matel and hotel use. Transient occupants must have and be able to demonstrate that they maintain a principal place of residence eisewhere.Transient occupancy shall generally refer to continuous accupancy of`not more than thiriy(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 Raom t}ecupancy ; Excise,as defined in M.G.L. c. 64G ar 834 CMI2 64G, as amended,shall generally be considered Transient. POQLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspeeted by the Health Department prior to opening. Contact the T-Tealth Departrnent to schedule 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. i P4UL WATER TE3TING: The water must be tested for pseudomonas,total coliform and standard plate aaunt by a State certified lab, and submitted to the Health DapartrnenC three (3) days prior to opening, and quarterly thereafter. E POQL CLOSING: Every outdoar in ground swimming pool must be drained ar covered within seven{7}days of � closing. i FOOD SF:RVICE ' SEASONAL FOOD SERVICE dPENING: All food service establishments must be inspected by the Health Department prior to opening. Please contact the � Heaith Department to schedule the inspection three(3)days prior to opening. CATERING POLICY: � Anyone who caters within the Town af Yarmaixth must notify the Yarmouth Health Departrnent by filing the ` ; requtred Temporary Food Service Agplieation farm 72 1�ours prior to tfie ca�ered eve3zt�� Y'hese fnrms can be �� obtained at the Health Deparhnent,or from the Tawn's website at www.xarmouth.rna.us under Health Aepartrnent, Downloadable Forms. FRdZEN DESSERTS: Frozen desserts must be tested by a State certified lab prior to opening and rnonthly thereafter,with sample results submitted to the T-Tealth Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Parmit until the above 2ern�.s have been met, OUTSIDE CATES; ' Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval frorn the Boazd of Health. , OUTDQOR COOHING: � Outdoor 000king,preparation,ar display of any faod product by a retail or food service esiablishment is prohibited. ' _ ___ _ _. _— _ _- _ _ _ j _ __-- _ _ � 1VOTICE:Parmits run annually fram January 1 ta December 31. IT IS YOiTR 12ESPONSIBILITY T'O RE"P[tRN 1'HE COMPLETET3 RENEWAL APPLICA't`ION{S}ANI}REQUIRI3I}PEE(S}BY DECEMBER 15, 2014. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR FQOL (i.e., PAINTING, NEW EQUIFMENT, ETC.}, MUST BE TZEPC7RTED TO fiND APPROVED BY TI iE B4t1RD{7F HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PI�AN. � DATE: SIGNATURE: PRINT NAME&TITLE: Rev.11103A4 I � The Commonwealth ofMassachusetls • Department of Industrial Accidents Office oflnvestigations ' I Cangress Street, Suite 100 Boston,MA 02114-20U www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Anaficant Information Please Print Le¢iblv Business/Organization Name: � �e. (�C-e�.n C,I�,(� Address: � � S- ��(�{�i �� City/State/Zip: • �ll(��Ou Phone#: � �) �� {o�J��J Are you an employer? Check the appropriate box: Business Type(required): l.�am a employer with��L employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ RestauranUBaz/Eating Establishment 2.� I am a sole proprietor or parmership and have no 7. � Office and/or Sates(incl.real estate,auto, etc.) employees working for me in any capaciTy. [No workers' comp.insurance required] 8• ❑Non-profit 3.❑ We aze a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §l(4), and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]* 11.❑ Health Caze 4.❑ We aze a non-profit organizarion,staffed by volunteers, T�,.hGShQ(��- with no employees. [No workers' comp. insurance req.] 12.❑ Other 'Any applicant that checks box#1 must also fill out the section below showuig their workecs'compensation policy information. � *•If the cocpornte officers have exempted themselves,but ihe cotporation has other employees,a workers'compensation policy is required and such a¢ organi�ation should check box#1. � I am an employer that isprovidinng workers'compensation insurance for my employees. Be[ow is ihepalicy inforntation. Insurance Company Name: F-� � {� Insurer's Address: �{ � , �Qx —1 � � � City/State/Zip: ��N � � ^ U Policy#or Self-ins.Lic.# �,I��Z"'� �W �� hl — VI �� Expiration Date: � � Attach a copy of the workers' compensation policy declaration page(showing the po6cy number an eapiration date). ' Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposi6on of criminal penal6es of a - I 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 Invesrigations of the DIA for insurance coverage verification. I I do hereby e ' ,under the ins and penalties of p rjury that the information provided above is true and correct. ! w� /� ' Si ature: Date: �� L � � Phone#: Official use on[y. Do sot write in this area,to be comp[eted by city or town officiaL � City or Town: Permit/License# i Issuing Authority(circle one): I 1.Board of Health 2. Building Department 3.City/Town Clerk 4. Liceasing Board 5. Selectmen's Office 6.Other j Contact Person: Phone#• � www.mass.gov/dia , • .M. 1 T 1�L�a' A.I.M Mutual Insurance Company � `_ Massachusetts Employers Insurance Company New Hampshire Employers Insurance Company � INSURANCE COMPANIES Associated Employers Insurance Company BILLING STATEMENT �� 7hia statemeM represerM.s additlonal charges andlor,credits to your accouM. � Page: 1 of 1 � SPM Resorts InC Policy Number: WMZ-800-8003831-2014A(1) I 329 South Shore Drive Policy Term: 4/1/2014-4/1/2015! South Yatmouth, MA 02664 Statement Date: 9/2/2014 Statement Number: 808197 • Due Date: 10/1/2014 Amount Due: $1,126:00 i i ---..� � �-�---' - - ----- - ` _ — ---�._T,_� _ — � `-612i20'�� a an�as ofTast staTme� $960.00 ! 6/20/2014 Payment-Check 15631 -$960.00 � 9/2/2014 Instaliment#2 of 3 Premium $1,090.00 Instaliment#2 of 3 DIA Assessment $36.00 � I Date � Amt. � r��___— AIC# ac� __ . _ _ _ _ � . � � , �,provedsy: �� _ _ �`- ' � i Broker: 1005- 1 HUB IMemational New England LLC Phone: (800)370-0642 If a prior balance appears on your statement,a portion ot the Current Balance may be due earlier than the Due Date shown. Premium amounts shown may also be subjed to audit. For billing inquiries, please call(800)876-2765 54 ThiM Avenue• P.O. Box 4070 •vBurlington, MA 01803-0970 • Tel: 781.221.1600/ 800.876.2765 • Fax: 781.272.5� 847 BRIDGEWATER• BURLINGTON•CONCORD, NH•HOLYOKE• MARLBOROUGH spvnsored by Assodated Industries of Massachusetts ---- - --- -- - - - - - - - -- -- - - -- - - -- - -- -- - - - --- - - Return Payment Stub Insured: SPM R2SOrtslnc - Polic Number: WMZ-800-8003831-2014A(1) j Instructions: Polic Term: 4/1/2014-4/1/2015 1. Make checks Statement Date: �9 0 41 . payacie ro n;i.M.Mumai msurence company. Statement Number. 808197 2. Include your Policy Number on me cneck. � Due Date' �� 10/1/2014 3. Remwe sWC at peRora6ons and return wtth payment in enGosed envelope. AmOUOt DUE: $1,126.00 ��:' A.I.M. Mutual Insurance Company ' P.O. Box4131 Pol Premium Policy Id Pol Unit Insured No �Woburn, MA 01888�131 $3,990 1535105 1 8003831 Product: Guaranteed Cost AIM 02 000808197 001535105 001 00000112600 9 800 i