HomeMy WebLinkAboutApplication and WC OF_Y``�R
�� .�` _ _�`�o TOWN OF YARMOUTH Ha�f �
0 —... � `3 1146 ROUTE 28, SOUTH YARMOUTH, MASSACHLJSETTS 02664-24451 �
�. �.,� �.� 'r Telephone(508)398-2231, ext. 1241 Health
'10ME Fa�c(508) 760-3472 Division
To: YazmouthBusinessEstablishments y�ovrn MiNi M�eT �[;�[�OMGDD
From: Bruce G. Murphy, Director � UtC 0 3 2014
Yannouth Health Department�
HEALTH DEPT.
Date: November 7, 2014
Subject: Increase in License/Permit Fees
_ ___
Please be awaze that the Yarmouth Boazd of Health, under the direction of the Yannouth Board
of Selectrnen, has raised a number of license and permit fees issued through the Yarmouth
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 application, and submit it to the Yannouth Health
Department with all required certifications and worker's compensation 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 Swinmiing Pools $ 80.00
Public WhirlpooUVapor Baths $ 80.00
Tobacco Sales $ 95.00 q .p�5
Motels $ 55.00
Food Service 0-100 Seats $ 85.00
Food Service Oyer 100 Seats $160.00
Retail Food Service CL5,000 sq. ft. $ 80.00 $ 80.00
Retail Food Service>25,000 sq. ft. $225.00
Other fees owed but not listed above:
Total fees owed for your establishment: � I'1S c0
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
pCior to DeCembel' 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 sprtngprior to opening" on the application.J
BGM/maf
' ���
a TOWN OF YARMOUTH BOARD OF HEALTH o�
��� APPLICATION FOR LICE)VS��II� �° Ut� U 3 2014
�e c • ; ' � . 1
* Please complete form and attach all n�eess"a�do�uin@ ' yi �ce nbe ���pT
Failure to do so will result in the'returA o€ybnr�appliaafion p .
ESTABLISHMENT NAME: �+u.� Y�I T ID:
LOCATIONADDRESS: $�l5 RO�hF,`�� Uni-ie��r 5•4Q✓�YiO�M1+� Y1A�} 02G�64 TEL.#: 5�-a�'8 -�384
MAILING ADDRESS: � v�'��- AS A'� ,
E-MAILADDRESS: QU�tam_ ,9�� �d h3-{-�'h�il . ('9vti..
OWNER NAME: Puna n� G��4-a+v�
CORPORATION NAME(IF APPLICABLE): Sti'�e C�aheSti r-htSvtS �C
MANAGER'SNAME: S11'3�Ji4 (3�15ne� TEL.#: 5+3�36�-`�3 0
MAILING ADDRESS: 53 D�EI1 (z,�?�l�e �el �vk M� d7,6Yq
POOL CERTIFICATIONS:
The pool supervisor must be certiTied as a Pool Oper ,as required by State law. Please list the designated
Pool Operator(s) and attach a copy of the certificaf o this form.
. _ ---- -- -- _ _ _ _ _ _ _
1. 2.
Pool operators must list a minim of two employees currently certified in basic water safety, standard First Aid
and Community Cardiopulm Resuscitation (CPR), having one certified employee on premises at all times.
Please list the employees ow and attach copies of their certifications to this form. The Health Department will
not use past years' r ords. You must provide new copies and maintain a T►le at your place of business.
1. 2.
3. 4.
FOOD PROTECTION MANAGERS - CERTIFICATION .
All food service establishments are required to have east one full-time employee who is certified as a Food
Protection Manager, as defined in the State Sanit Code for Food Service Establishments, 105 CMR 590.000.
Please attach copies of certification to this app � tion. The Health Department will not use past years'records.
You must provide new copies and main n a file at your establishment.
1. �•
PERSON IN CHARGE:
Each food establishment ust have at least one Person In Charge (PIC) on site during hours of operation.
L _ �• _ __ _ _
ALLERGEN CERTIFICATIONS:
All food service establishments are required to ha at least one full-time employee who has Allergen certification,
as defined in the State Sanitary Code for Foo ervice Establishments, 105 CMR 590.009(G)(3)(a). Please attach
copies of certification to this applicaUon. he Health Department will not use past years' records. You must
provide new copies and maintain a e at your establishment.
1. Z•
HEIMLICH CERTIFIC IONS:
All food service estab 'shments with 25 seats ar more must have at least one employee trained in the Heimlich
Maneuver on the p ises 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. 2.
3. 4.
RESTAURANT SEATING: TOTAL #
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERM[T# LICENSE REQUIRED FEE PERMIT#
B&B $55 CABIN $55 MOTEL $110
INN $55 CAMP $55 SWIMMINGPOOL$ll0ea
LODGE $55 TRAILERPARK $105 _WHIRLPOOL $110ea.
FOOD SERVICE:
LICENSE REQNRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
0-IOOSEATS $125 _CONTINENTAL $35 NON-PROFIT $30
>]00 SEATS $200 COMMON VIC. $60 WHOLESALE $80
—RESID.KITCHEN $80
RETAIL SERVICE:
LICENSE REQIDRED FEE PERMIT# LICENSE REQUIRED FEE PERM[T# LICENSE REQUIRED FEE PERMIT#
<50 sq.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25
Z<25,000 sq.ft. $150 �� _FROZEN DESSERT $40 �TOBACCO $1l0 �ZZ
rrwmEcxnrvce: S�s AMOUNTDUE _ $ 2�o• ob
��I I �7�
'****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*"*** �"���— r/ �7S w
� � I S?o% /Z�d 3/��
ADMINISTRATION
Under Chapter 152, Section 25C, Subsection 6,the Town af Yazmauth is naw required to hold issuance or renewal
of any license or permit to operate a business if a person or company does not have a Certiftcate af Worker's
Compensation Insurance. T1iE ATTACHED STATE WOI2K�R'S COMPENSATION INSUl2ANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR
CER1'. 4F INSURANCE ATTACH�D i�
OR
WORKER'S COMP. AFFIt3AVIT SIGNED ANI3 ATTACHBD
'Town of Yatmouth taxes and liens must be paid prior to renewal or issuance of your petmits. PLEASE CHECR
APPROPRtATELY IF PAID:
YES � NO
MOTELS AND OTH�R LODGING F.STABLISHMENTS
TRANSTENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient accupancy shall be
Izmited to the temparary and shart term occupancy,ordinarily etnd custornarily associated with motel and hotel use.
Transient occupants must have and be able ta dernonstrate that they maintain a principal piace of residence
elsewhere.Transient occupancy sha11 generally refer to continuous occupancy of not more than flvrty(30)days,and
an aggregate af not more than ninety(90)days wilhin any six(6)manth period. Use of a guest unit as a residence or
dwelling unit sha11 not be considered transient. Occupancy that is subject to the collectian of Itoam Occupancy
�xcise, as detined in M.G.I,. c. 64G or 830 CMR 64G, as amended, sha11 generally be considered Transient.
YQOLS
P40L OPENING:All swimming,wading and whirlpaols which have been ciased for the season znust be inspected
by the Health lleparhnent prior to opening. Contact the Health Department to schedule the inspection three(3)
days priar to opening. PLEASE N4TE: People are NdT allowed to sit in the pooi area uz�til the paal has been
inspected and opened.
1'OOL WATER TESTING: The water must be tested far pseudomonas,total coliform and standard plate count
by a State certified lab, and submitted to the Health Department three (3} days pzior to opening, and quarterly
thereafter.
PO4L CLOSING:Bvery autdoar in ground swimming pooi must be drained or covered within seven(7}days of
closing.
FO011 SERVICE
SEASONAL FOOD SERVICE OPENING:
All food service estabIishments rnust be inspected by the I�ealth Department prior to opening. Please contact the
Health Department to schedule the inspection tl�ree (3)days prior to apening.
CATERING POLIC'Y:
Anyane who caters within the Town of Yatmouth must notify the Yarmouth Heatth Department by filing the
reqmred Tempo ry Faod Service Applicatian form 72 hours prior to the catered avent. These farms can be
obtained at the He�lth Depariment,ar from the Tawn's website at�mww.yarmouch.ma.us under Health T7epartment,
Dowriloadable Forms,
k'120ZEN DF.SSF.RTS:
Frozen desserts must be tested by a Staie certified lab prior to apening and monthly khereafter,with sampla results
submitted to the Health Department. Failure to do so will resulf in the suspension or revocation of your Frazen
Dassert Permit until the above tarms have been met
t7UTSIDE CAFE3:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval frorn tha Boazd af Health.
OUTDOCIR COOHING:
Outdaor cooking,preparatian,or dispIay of any food product by a retail or faod serviee establishment is prohibtted.
NOTICE;Permits run annuatly from January I to December 31. IT IS YOUR I2E9PONSIBILITY TO RETt.IIZN
THE COMPLETEI}REAIEWAL APPLICATION{S}AND REQIJIRFD FEE(S}BY DECEMBER 15, 2414.
ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POdL (i.e., PAINTING, NEW
EQUIPMENT,ETC.},MUST BE REPORTED T'O AND APPRQVEI3 BY THE BOARD QF HBALTH PRI4R
TO COMMENCEMENT. RENOVATIONS MAY ILEQUIRE A SITE PLAN.
DAT�: La-�l�( SIGNATIJRE: �l y��—
r�vT NaM�� �riz��.�: ��n /�ts� (\+�a�.�-)
Rev. 31t43ti4 �
� The Commonwealth ofMassachusetts
Department of Industrial Accidents
Office of Investigations
I Congress Street, Suite 100
Boston, MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legiblv
Business/OrganizationName: Yf}2�+n"`f�-1 I�lli�nl�� fl�1q�2T�
Address: gUs RcM�k a`� r Uhl'{e � �9
City/State/Zip: �� YQ��''�� ►Ytt} Ut�6y Phone #: �- a`�5'� ' ��
Are you an employer? Check the appropriate boa: Busines�Type(required):
1.❑ I am a employer with employees (full and/ 5. `�Retail
or part-time).* 6. ❑ RestauranUBaz/Eating Establishment
__ — -- _ __ _ _
2. I am a so e pmpnetor or partnership andhave 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. ❑ Entertainment
their right of exemption per c. 152, §1(4),and we have 10.❑ Manufacturing
no employees. [No workers' comp. insurance required]* 1 I.❑ Health Caze
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#I must also fill out the section below showing their workers'compensation policy infoimation.
*'If the corporate officets have exempted tt�emselves,but the corporation has o[her employees,a workers'compensation policy is required md such an
organization should check box#1.
I am an employer that is providing workers'compensation insurance for my emp(oyees. Below is the policy information.
Insurance Company Name:
Insurer's Address:
City/State/Zip:
Policy#or Self-ins.Lic. # Expiration Date:
Attach a copy of the workers' compensation policy declaration page(showing the poticy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penakies 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Of#ice of
Investiga6ons of the DIA for insurance coverage verificafion.
I do hereby cenify,under the pains and penalties ofperjury that the information provided above is true and correct.
Si ature: � � Date: �a'3 ,�N
Phone#:
Official use on[y. Do not write in this area,to be completed by city or town offaciaL
City ar Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2. Building Department 3. City/Towu Clerk 4.Liceasing Board 5. Selectmen's Office
6.Other
Contact Person: Phone#:
www.mass.gov/dia
A�'— — Z.g OATB(MM/OpM'Y1�
�K�" GERTlFICATE OF LIABILITY INSURANCE zatatzai�
THIS CERTIFICA7E IS ISSUED AS A MA77ER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFlCATP DOEB tiOT AFFIRMATIYEIY OR NEGATIYELY AMENp, EXTEND OR At7ER THE C6VERAGE AFFORDED BY THE POLiCiE3
BELOW. THIS CERTIFICATE OF INSURANCE D41ES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER�S), AUTHOR2E0
ftEPRESENTATiVf OR PRODUCER,AND Tt1E GERTIFiCATE HOLOER.
IMPORTAN7: If the certificate holder is an ApDI710NAL INSURED,the policy(ies)must be entlorsetl. tt SUBROOATION IS WAIVED,sudject to
the terms aiW¢uMttiws af fhe pWicy,certain policks may req�re an aiMotaemeM. A statement an Nris tertiticafe does(wt corrfer rights to ths
certiflcate Fwldmr in Iieu ot such endorsemen s).
Pf200410ER � NAME: `
MCSHEA IN3URANCE AGENCY INC PHONE Ez �SOS/4.ZO–�OLS. a��_(508)420-9010
1550 Falmouth Rd Ste #2
Centerville, MA 02632 .�ooaEss:
� IN311HEq15) AtfOflDiN4 LOVEflRGE NAK{
iruuaeaa:NATIONAL GRANGE IN3
INSVftED S$ree GaneBh Stare Ine. �NsuReRs�TRAVSLBRS INS CO
dba Yarmouth Mini Mart INSURERC:
845-852 Route 28, Onit 5 ir�suaeRo:
53 Deer Ridge Rd Maahpee MA 02649 �NSURERE:
3auth Yarmouth� �a 02664 INSUftERF:
COVERAGES CERTIFICATE NUMBER: � REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTNITHSTANDING ANY REQUIREMENT,TERM OR COND4TION OF ANY CONTRACT OR OTHER D�Ck1MENi WITM RESPEGT Tq WHICH THIS
CERiiFlCA7E MAY BE iSSUED pR MAY PERTA7N, THE INSURANCE AFFqRDEb eY THE POLiqES 6ESCR�BED HEREM IS SUBJECT TO ALL THE TERMS,
EXCWSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BV PAID Cl.A1MS.
�rq TYPE OF iNSUFtANCE POLICV NUMBER MM@D/YYVY MMIDD YYYY LiMiTS
GENEftAL LIA@ILITY EqCH OCCURftENCE $ S OOO OOO
� COMMEftCIAL GENERAL LIABIUTV PftEMI$ES Ea UccurzOnGe $ 5�q ���
cum+sa.+noe �occuR m�o�a�a,Y«��rson) s 10�404 �
A BPT01238 6��.��146��-3�1SPERSONALBADVINJURV $ 1, 000,000
_ —..—..
�Y C�ENERAL AGGREGATE $ 2�d�d a O O O
GEN'L AGGREGATE LIMR APPLIE$PER: PRODUCTS-COMP/OP AGG $ 2 i O O O i O O O
PC7LVCY �� LOC $
AUTOMOBILE LIABILITY �a�q�t $
ANVAUTQ BODILYINJURVIPerpBreon) $ .
ALIOWNE� SCHEdULE� gpDiLYiNJURY{Pereccitlent} �$
AUTOS NONLWNED OP DA E ...—.......
Ppraccident a
HIRED AUTOS AUTO$ ,_..._....__
$
UMBRELIA LIAB pCCUR EACH OCCURRENCE S
E%CESS LIAB CLAIMS-MADE AGGREGATE $
DEO RETENTIONE �
WORKERS COMPENSATION WC TATU- OTH-
AND EMPLOVERS'LIABILITY TO I ER
m,v raoPR�row���r,•,e Y'�Y" w�� U83A1b7974 6j16f146j16j1 E.�.Encwaccioerrr s 100,6Q0
B OFFICEWMEF@ER EXCLUDEO'1
(MaM�lury In NM� E.L.DISEASE-EA EMPL�YE�& 1 O O r O O O
Myes describeuMer
OESCRIPTION OF OPERATIQNS beiaw E.L�ISEASE-POLICV 41MIT S 5 0 0 i 0 Q�
OESCRIPTION OF OPERATIpNS/LpCATIONS/VEHICLES (Attach ACARD 101,AEEitional Remarks SUetlula,if mae space is required)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABpVE DESCRIBED PqUCIES BE CANCELLED BEFORE
TOWSl Of Y3riROtt��i 7HE EXPIRATION DATE THEREQF, N07{�E WIIL BE DEIiVERED IN
BqARD OF HEALTH ACCORDANCE WITH THE PQLICY PROVISIONS.
AUTH4RIZED ftEPRESENTATIVE
}��.e�..._
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