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Home My WebLink AboutApplication and WC O��Y'9R � �.� ��` _ �� TOWN OF YARMOUTH Boazdof Health , � � �$ 1146 ROUTE 28, SOUTH YARMOUTH,MASSACHLJSETTS 02664-24451 � �. �, •�' Telephone(508)398-2231, ext. 1241 Health r`"`"�� Fa�c(508) 760-3472 Division To: Yarmouth Business Establishments NvNr��ZS GR�� Mo�_ From: Bruce G. Murphy, Director � �_—�_� _ __. Yarmouth Health Department� ^ uE� J..� Lui� Date: November 7, 2014 HEAL?'! ��?T. Subject: Increase in License/Permit Fees Please be aware that the Yazmouth Boazd of Health, under the direction of the Yannouth Boazd of Selechnen, has raised a number of license and permit fees issued through the Yannouth 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 compensation coverage information (certificate of insurance OR completed �davit) arior 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 80.o0 Public WhirlpooUVapor Baths $ 80.00 � �do:oD Tobacco Sales $ 95.00 Motels $ 55.00 � p Food Service 0-100 Seats $ 85.00 Food Service Over 100 Seats $1Sfl.00 Retail Food Service <25,000 sq. ft. $ 80.00 Retail Food Service>25,000 sq. 8. $225.00 Other fees owed but not listed above: $ 35.00 Con�nN. 8�'�ST Total fees owed for your establishment: 2.5 O,pO 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 DeCembeC 31, 2014. [Those establishments which open in the spring will be allowed to provide food andlor 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 BOARA,Q,�F HEALTI� .�� o �� APPLICATION FOR LICENSE/P��t1MIT -'ZQ�� z � � c� � : DEC U.�,�014 * Please complete form and attach all necessary do entsby ere ber IS 20 Failure to do so will result in the return of your applicahon p cke�EqLTH DEPT. ESTABLISHMENT NAME: P TA ID: LOCATION ADDRESS:.Jr.J U I' - Gil �7 �' Y out EL.#: 0 -��.5�5�1 MAILING ADDRESS: Q n'I S 0 ✓ � E-MAIL ADDRESS: ��l�O .� h u�tP vs (�� Mo�-e l. c�m OWNERNAME: �MriSY� Patel CORPORATION NAME (IF APPLICABLE): Sri Yl M /NC MANAGER'S NAME: ll 1 A 7 TEL.#: - 7 S-S�IO a �Lit�rG aDD�ss:�3 Ro� � 2�'/'r✓la �n sfi , � a�r rn n � rh,�l��_ 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. I'Zv,� v'�.4 r� �F1-T EL a. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cazdiopulmonary 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 prov�de new copies and maintain a Tile at your place of business. i. PRRTN ��tT�L z. A�rnR9 �y �� 'L 3. 01� n nV �P rn D _ 4. ��Ca n PY P�CD2ZGL 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. /�/��' 2. � /� PERSON IN CHARGE: Each food establishment must have at least one Person In Chazge (PIC) on site during hours of operation. �. n//�} 2. N/A� _ ALLERGEN CERTIFICATIONS: All food service establishments aze required to haue 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 Deparhnent will not use past years' records. You must provide new copies and maintain a file at your establishment. �. N'/t� 2. NI A- 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 Tle at your place of business. �. N'�A- 2. N/� 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&B $55 CABIN $55 I MOTEL $110 -03a INN $55 CAMP $55 �SWIMMINGPOOL$IlOea. ! LODGE $55 _TRAILERPARK $105 �WHIRLPOOL $110ea. , 2�'j FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# WCENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERM[T# 0-100 SEATS $125 �CONTINENTAL $35 lS��7 NON-PROFIT $30 � >100 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 $110 NAMECHANGE: $15 AMOUNTDUE _ $ 3�5.00 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM'""*** •—`�� v`Ov � (��`-� l2-'��l`( ADMINISTRATION » Undcr Chapter 152,Section 25C,Subsection 6,the T'own of Yazmouth 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 Cer[ificate of Worker's Compensation Insurance. THE ATTACHED STAT'E WOI2K�R'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPI,ETED AND SIGNED, OR CERT. dF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND f1TTACHED Toum of Yarmouth taxes and liens must be paid prior to renewal or issuance o£your permits. PLEASE CHECK APPKOPRIATELY IF PATD: ' /� XES y NO MOTELS ANA OTHER I.OLIGING ESTABLISHMENTS TRAIYSIENT OCCUPANCY: For parposes ofthe limitations of MoCel or Hotel use,Transient occupancy shali be limited to the temporary and short term occupancy,ordin�trily and custamarily assooiated with motel and hotel use. 1'rans3ent occupants must have and be able fo demanstrate that they maintain a principal place af residence elsewhere.Transient occupancy shall generally refer ta continuous occupancy af not more than thirky(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 ar dwelling unit sha21 not be considered transient. Occupancy that is subject to the collectian of Room Occupancy Excise,as defined in M.G.L. c. 54G or 834 CMR 64Ci,as amended, sha11 generally be considered Transrent. POOLS POC3L OPENING:All swimming,tvading and whirlpaols which have been closed f`ar the season must be iizspected by the Health DeparUnent prior to opening. Contact the Fiealth Department to schedule the inspection three(3) days prior to opening. PLBASE NOTB: Peaple are NOT allowed to sit in the pool area unfil the pool has heen inspected and opened. PQOL V1'ATER'TESTING: The water must be tested 1or pseudomonas,total coliform and standazd plate caunt by a State certified lab, and submitted to the Health Deparkrnent three (3} days prior to opening, and quarterly thereafter. POOL CLOSING:Every outdaor in graund swsmming pool must be drained or cavered within seven{7}days af closing. F�OD SERVICLT SEASONAL FOOD SERVICE UPENING: All food service establishments must be inspectad by the Health Department prior to openiug. Please contact the Health Departmenk to schedule the inspection three{3) days priar to apening. CATERING POLIC'Y: Anyone who caters within the Town pf Yatmouth rnust noCify the Yarmouth Health Department by filing the required Tempa Foad Service Applicatio� form 72 haurs priar ta the catered event. These fornls can be obtained at the H�th Department,or frpm the Town's website at��wv.yartnouth.naa.us under Health Department, Doumloadable Forms. FROZEN DF.SSEBTS: Fzozen desserts must be tested by a State certified lab prior to opening and rnonthly thereafter,with sample results submitted to the Health Department. Failure to do so will result in the suspension or revocatipn oFyour Frozen Dessert Permit untii the above terms have been met. OUTSIDk; CA�'ES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. OUTDOOR COOHING: Outdoor cooking,preparatian,or display of any food product by a retail or food service establishment is prohibited. NOTICE:Permits run annualIy from January 1 to December 31. IT IS XOiJR ItESPONSIBILITY TO RETi.JRN THE COMPLETED RENI;WAL APPLICATION(S}AND REQtJIREI}PEE(S}BY DECEMBER I5, 2014. ALL RENOVATIONS TO ANY FOOD �STABLISHMENT, M01"EL OR POOL (i.e:, PAINTING, NEW EQUIPMENT, ETC.},MUST IiE REPORT�D T4 AND APPROVED BY THE BOARI�OF HEAL`FH PI2IOR 'I"0 COMMENCBMENT. REIVOVATIONS MAY 12E IRE A SITE PLAN. DATE; 12 /Ot l2p I�l SI�N�TUxE: ' PRIN'F NAME&TITLE: YI.S � Nl��j� ��f� - ftev. i t103ti4 �� ' ' r� The Commonwealth ofMassachusetts Department oflndustrial Accidents _ O�ce oflnvestigations ' 1 Congress Street, Suite I00 Boston, MA 02114-2017 � www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Le2iblv Business/OrganizationName: SR�M /NC ��g H ��-Pv� G�_� Mo �-e,Q Address: ✓�.53 /�1 a�n �r �,�v r� a8 � City/State/Zip: lN� Ya rrn o� �h� ��'� �6�Phone#: ,�7 �O � 7 7�- J�z/�a Are you an employer? Check the appropriate box: Business Type(required): 1� I am a employer with � � employees(full and/ 5. ❑ Retail or part-time).* 6. ❑ RestaurantlBaz/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] g• ❑ Non-profit 3.❑ We are a corporarion and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4), and we have 10.� Manufacriuing no employees. [No workers' comp. insurance requiredj* 4.❑ We aze a non-profit organizarion,staffed by volunteers, 11.❑ Health Caze with no employees.[No workers' comp. insurance req.] 12.� Other M0�� q �1 �� 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy infoimation. '*If the corporate officecs have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organi�ation should check box#1. � I am an emplayer that is proviyd�ing w�por�ke�r�s'compensation insurance for my emp[oyees. Below is the policy informaf P Y ldr�"rr—��1� ��I�c�f'`��A-Tt� 1i3�� 1�R�. Insurance Com an Name: �''�'s ' Insurer's Address:�4�' ��/YC�`iZ�[�` � CiTy/State/Zip: ~ • R.�S�LAy] , � � cs7o6� Policy#or Self-ins. Lic. # C��S E ��9 7 5� � � Expiration Date: �' I`='S 1°t� �S Attach a copy of the workers' compensation policy declara6on page(showing the policy number and eapira6on date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposi6on of criminal penalties 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwazded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify,under thepains andpenalties ofperjury that the information provided abave is true and correct. 4;o„ature• ��G�iC Date• �`Z �O/ �aC7/ ZJ Phone#• 2� �� 8� / '' �O � � Official use only. Do not write in this area,to be completed by city or town officiaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2. Building Department 3. City/Town Clerk 4.Licensing Board 5. Selectmen's Office 6. Other Contact Person• Phone#: � www.mass.gov/dia ��"1 SHRIINC-01 BLRO � '`��„�„�'R�' CERTIFIC�4TE t}F LtABILtTY tNSURANCE �Z;z,zo�a THIS CERTIF7GATE I5 IS$tlED AS A MATTER OF tNFORA9ATiON ONtY AND CONFERS NO RIGHTS UP4N THE C£RTIFICATE HOIDER THIS CERTIFICATE dOES NOT AFFIRMATIVELY OR NEGATIVEI.Y AMEND, EXTEND OR AI.TER THE GOVERAGE AFFORDED BY TH8 POLICIES � 6ELQW. 7HIS GERTIPfCA7E 4P INSURANCE DQES N4T CONSTITUTE A CONTRACT BETWEEN THE 1SSUING lNSURER(S), AUTHORiZED REpRESENTATIVE OR PRODUCER,AND THE CEftTIFICATE HOLDER. IMPORTANT: it the certiflcate twider�an ADOITI6NRi.INSURED,the pallcy(ies}must 6e entlorsed. !f SUBROGATION IS WAIYED, nubject W the Certns and cpndltions of the pollcy,certafn policles may require an endorsement A skatement on this certiflcate does not confer rights W the eeRtficate holder in lieu of such entlorsemenys). pRODUCER NAM@: Automatic Data Processi�g lnsurence Agency,Inc rxoN� Fnz�� t ADP Boulevard „ o E p. ...____.. atC No� E Ml1 �— Roselsntl,NJ 07068 ADDRESS: ,,,`_ INSVREWS)AiFORDINGCOVERAGE NAICp iNsuRerta:Travelers PropertY Casualty Company of Am 25682 .—. ...._...—. .. �xsursEo Sfirtm,Inc.DBA Hunters Gree�Mptel �NsuRerss: ,,,,, 553 Main Street Route 28 INSURERC: Sauth Yarmouth,MA 02673- iNsuaeao: ' INSURER E: INSUftER F: ' COYERAGES GEF2TIFICATE NUMBER: REVISlQN NtltABER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELpW HAVE BEEN ISSUED TO THE INSURED NAMEp ABOVE FQR THE POLICY PERIOD INDICA7E0. N01WI7HSTANDING ANY REQUIREMENT,7ERM OR CONDITION OP ANY CONTRAGT�R RTHER DOCUMEN7 WITH RESPECT TO NMIGH THIS CERTIFICATE MAY 8E ISSUED OR MAY PERTAIN, THE INSURANCE APFORpED BY THE POtiCIES DESCRIBED HEREIN IS SUBJECT TO ALL?HE TERMS, EXCLUSIONS AND CONpITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN ftEDUCED BY PAId CL41MS. �� TYPEOFINSURANCE A POL�CYNUMBEft MM1l YE MM�� T� GENERALIIABILITY EACHOCCURRENCE $ COMMERqALGENERALLIADI4TV Pft MISE Eeo rrence ; CtAIM$-MAOE �OCGVR MEDEXP(Myonepason) $ PERSONAL8ACIVINJURV b GENERAIAGfiREGATE . S ..—.. OEN'LAGGREGATELIMITAPPLIESPER: PROWCTS-COMP/OPAGG E POIIGY PRO. l� g AUTOMOBILE LIABIUTY MBIN SINGL LIMI Ea acdtlent E ANY AUTO I BODIIY INJURY(Parperson) E ALLOWNED SCyEOULED B�OILYINJIJRY(P6raccitlenlJ S AlJT05 �pyyNEO P PER 6AMA2'iE �� E HIREDAUTOS AVTOS PeYaccltlent $ UMBRELLAUFB (KCUR EACMOCCURRENCE 8 EXCE33 LIRB ��$.p�ADE AGGREGATE S DED RETENTION$ $ WQRKERB COIdAENSA710N WC 9TATU- ANDEMPI.OYERSUA&G�TY X TORYLIMITS R A ANYPROFRIEfORIPARTNERIEXECUTIVE Y�N UBSE7OE767'I4 412BI2O14 MRS/2O'IS E.I.EACHACCID M $ A�O.00O OFfICERrMEMBEREXQUOEDT • � NiA (MUMatoryinNM E.L.DISEASE-EAEMPLOYE S 'IOO,OO It yes aeScnEeuntler OESCRIPTIONOFOPERATIONSbalow E.lQ15E0.SE-POtiGYUMIT $ SOO� dESCRIP'TON OF�PEMTIONS I LOCATMNS t VENICI.ES{Rttech ACpRD t0/,AEMItonN Ranatla Sci�Mui4,Grtrore apsce is reqWred} CERTIFICATE HOLDER CANCELtATiON SHOUID ANY Of THE ABOUE DESCRISEQ POLICIES BE CANCELLED eEFORE iHE EXPIRATIUN DATE THEREOF, N0710E� WILL BE DELNERED IN Proof of Insurance ACCORDANCE WITH THE POLICY PROVISIONS. pUTNORIZED REPRE$ENTq7NE � Q 7988-2070 ACpRD CORPORATION. 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