HomeMy WebLinkAboutApplication and WC ��'°F��`�� TOWN OF YARMOUTH Boazdof
Health
� --• ` `�`3 1146 ROUTE 28, SOUTH YARMOUTH,MASSACHLTSETTS 02664-24451 '
�. �, ,W 'r Telephone(508)398-2231,ext. 1241 Health
'�"°"`£ Fax(508)760-3472 Division
�
To: Yazmouth Business Establishments -DEgs l��t c_ Ca G3[�S(�[�pb[�po
From: Bnxce G. Murphy, Director �t� �9 L�14 '
Yannouth Health Department
HEALTH DEPT.
Date: November 7, 2014
Subject: Increase in License/Pernut Fees
- - _
Please be awaze that the Yannouth Boazd of Health, under the direction of the Yazmouth Boazd
of Selectmen, has raised a number of license and permit fees issued through the Yarmouth
Health Department, effective January l, 2015.
Attached is the Yarmouth 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 Yannouth Health
Department with all required certifications and worker's compensation coverage information
(certificate of insurance OR completed affidavit) arior to December 31, 2014, you will be
allowed to pay the 2014 rates for the following licenses:
Current 2014 Fee
Public Swiminiug Pools $ 80.00 �2
Public WhirlpooUVapor Baths $ 80.00 � �,�
Tobacco Sales $ 95.00
Motels $ 55.00
Restaurants 0-100 Seats $ 85.00
_ �es�a�an�s Cver 2U(Y i�ats -y.�i�:0v -- -- _ _ __
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: �(l�p.�
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 springprior to opening" on the applfcation.J
BGM/maf
� d TOWN OF YARMOUTH BOARD OF HEt�L'�I� � ���'�� o
��� APPLICATION FOR LICEN'�E��VIo��:�(1,��� UEI; O J Z014
* Please complete form and attach all nec��s ocumeirts by�ece ber 1 S 2014.
Failure to do so will result in the return of your application p cke . EPT.
ESTABLISHMENT NAME: d t 6's N:// Co,�,ao .4sse� TAX ID•
LOCATION ADDRESS: .�'9 m,i-i,ah /J�^.��.�r mo:�+/� Po.t inA TEL.#: Sc 8- 3Ps- 9v99
MAILING ADDRESS: .S'n...N o ZG�5
E-MAIL ADDRESS:
OWNER NAME:
CORPORATION NAME (IF APPLICABLE):
MANAGER'SNAME: B,oae.r P/�apat� �'��nr.�m�nt TEL.#: ,5'v8- 385-9y�9
MAILING ADDRESS:
POOL CERTIFICATIONS: � c.U=// f ro✓i d e ,`n S'/JR%/+q jE ,
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 minimum of two employees currently certified in basic water safety, standard First Aid
and Communiry 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 provide new copies and maintain a Tile at your place of business.
L 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. 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.
1. 2.
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
provide new copies and maintain a file at your establishment.
L 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-choking procedures below and
attach copies of employee certifications to this form. The Health Deparhnent 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 PERMIT# LICENSE REQUIRED FEE PERMIT#
B&B $55 CABIN $55 MOTEL $110
INN $55 CAMP $55 �SWIMMING POOL$1IOea-��I�_
_LODGE $55 _TRAILERPARK $105 �WHIALPOOL $110ea. �{ �
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# L[CENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
0-100 SEATS $125 _CONTINENTAL $35 NON-PROFIT $30
>100 SEATS $200 COMMON VIC. $60 WHOLESALE $80
—RESID.KITCHEN $80
RETAIL SERVICE:
LICENSE REQUIRED FEE PERMIT# LICEN5E 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
NAME CHANGE: $15 AMOUNT DUE _ $ ZZ� :00
•"***PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** �C: �d I���O 6
e1lt�3o`l9 ►��t��`�
ADMINISTRATIQN
Under Chapter 152,Section 25C,Subsection 6,the Tawn of Yarmouth is naw required to hold issuance or renewal
nf any license or permit to operate a business if a person or company does not have a Certificate qf Workers
Compensation Insuranee. THE ATTACHEll S'I'ATE W012K�R'S CC?MPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNEll, OR
CGRT. 4F iNSURANCE ATTACHED �''
OR
WORKER'S COMP. APFIDAVIT SIGNED ANL3 ATTACH�,D
Tawn of Yannouth taxes and liens must be paid prior to renewal or issuanoe of your permits. PLEASE CHECK
APPItOPI2IATELY IF PAID:
YES Nd
MOTELS AND OTHER LODGING FSTABI,ISfIMENTS
TRANSIEPiT OCCUPANCY: Fot purposes ot the limitations ofMotel or HoYel use,Transient occupancy shaltbe
limited to the temporary and short term occupancy,ordinrarily and customarily associated with moYei and hotel use.
`1'ransient occupants mast have and be able to demonstrate that they maintain a principal place af residence
elsewhere.Transient occupancy shall generally refer to continuous occupancy of not more than thiriy(30)days,and
an aggregate af not more than ninety(90)days within any six(6)month period. Use of a guest unit as a residence or
dwelling unit shalI not be oonsidered transient. Oecupaney that zs suhject to ihe eolleetion of Room Qeeupanoy
�xcise,as defined in M.G.L. c. 64G or 830 CMI2 64G, as amended, shall generally be considered Transient.
raoz�s
PQOL OPENING:All swimming,wading and whirlpools which hava beei�closed for the season must be inspected
by the Health Departrnent prior to opening. Contact the Health Department to schedule the inspection three(3)
days priar to opeaing, PLEASE NdT�: People are NQT al(owed ta si#in the pool area until the pool has been
inspected and opened.
PQOL WATER TESTING: The water must be tested far pseudamonas,total coliform and standard plate count
by a State certified Iab, and submitted to the Health Department three (3) days prior to opening, and quarterly
thareafter.
P40L CLOSING: Every outdoor in ground swimm3ng poal must be drained or covered within seven{7)days of
alosing.
_ _ FOOD SERVI�E
3EASONAL FOOD SERVICE QPENING:
All fopd service establishments must be inspected by the Health Department prior to openiug. Please contact the
Health Department to schedule the inspection three (3)days prior to opening.
CA�'ERING POLiC'S':
Anyone who caters within the Town of Yarmouth rnust notify the Yannouth HeaIth Department by filing the
required Temparary Foad Service Application form 72 hours prior to the catered event. These farms can be
obtained at the Health Department,or from the Town's website at www.yarmouth.ma.us under Health Departrnent,
Dawnloadable Forms.
FROZEN DF.SSERTS:
Frozen desserts must be tested by a State certified lab prior to opening and monthly thereafter,with sample results
submitted to the Health Departrnent. Failure to do so wiTl result in the suspension or revocation of your Frozen
I7essert PermiC until the above lerms have beec�met.
OUTSID� CAF�S;
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval frotn the Board of Health.
OUTDOOR COOHING:
Outdoor cooking,preparation,or display of any faod product by a retail or food service establishxnent is pre�hibited.
NOTICE: Permits run annually from January 1 tn December 31. IT I5 YOUR RESPONSIBILITY TO RETI.tRN
`I'HE CQMPLETED REN�WAL APPLICATIQN{S}AND REQLTIREI3 FEE(S}BY Z7ECEMBBR 15,2014.
ALL RENOVATIONS TO ANY FOOD LSTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT,ETC.}, MLTST BE REPQRTED'ZO AN A PROVED BY THE BC?ARD OF HEALTH PRIOR
TO COMMENCBMENT. RENOVATIONS MAY A SITE PLAN.
DA3'E: �Z -/-i`1 SIGNATtTRE: �,+a.
PRFNT NAME& TITLE: f�vf �i_ .4.e� Y"r-o��t �z-___.���n��r�c.
Rev. 11t63114
� � � The Commonwealth ofMassachusetts
Department oflndustrialAccidents
Office oflnvestigations
' I Congress Street, Suite I00
Boston, MA 02I14-20U
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
A�alicant Information Please Print Legibiv
Business/Organization Name: �J e b's N-// C'�v oom � ,.n Assoc�..�on
Address: :a?y �n ,�,-,a � Q�
City/State/Zip: y,4�,„a�-�h Po�f, �n� Phone #: _S�os - _385- 95i9'�
Are you an employer? Check the appropriate bos: Business Type(required):
1.❑ I am a employer with employees(full and/ 5. ❑ Retail
or part-time).* 6. ❑ RestaurantBaz/Eating Establishment
2.Q I am a sole proprietor or parfnership 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] 8• ❑ 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]* 11.0 Health Care
4.Q We are a non-profit organization,staffed by volunteers,
with no employees. [No workers' comp. insurance req.] 12.[�Other /�6q
*My applicant that checks box#1 mus[also 5ll out the section below showing their workexs'compensatiw policy information.
**If the coiporete officets have exemp[ed themselves,but the corporation has other employees,a workus'wmpeasation policy is requ'ved and such an
orgauization should check box#1.
I am an employer that is providing workers'compensation insur¢nce for my emp[oyees. Be[ow is the po[icy inforneation.
InsuranceCompanyName: �'NA /nSu�P.4Nte L'n.
Insurer's Address: P � . BoX 5�9�5
City/StaYe/Zip: O�¢/a,y,pof FL 3z 6oZ - y 9 c.5
Policy#or Self-ins. Lic. # y 7 y7 Pi g -y -i y Expiration Date: '7-i3—/S
Attach a copy of the workers' compensation policy declaration page(showing the policy number and ezpiration date).
Failure to secure coverage as required under Section 25A of DIGL c_i_52 can lead to the imposition 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$250.0 da against the violator. Be advised that a copy of this statement may be forwazded to the Office of
Investigations f e IA for insurance coverage verification.
I do hereby c r the pains and penalties ofperjury that the information provided above is true and correct.
Si ature: �^ Date: i i
Phone#: J'ou -,�g5-9�1
O�cinl use only. Do not write in this area,fo be completed by city or town o�ciaL
City or Town: Permit/License#
Issuing Authorily(circle one):
1.Board of Health 2. Building Department 3. City/Town Clerk 4.Licensing Board 5. Selectmen's O�ce
6.Other
Contact Person: Phone#:
www.mass.gov/dia
--� ��51a.�
___---.
NOTICE � � NOTICE
TO u TO
� a
�
EMPLOYEES a QT EMPLOYEES
7 `W
� v
O,9M 5�8
The Commonwealth of Massachusetts
DEPARTMENT OF INDUSTRIAL ACCIDENTS
600 Washington Street, Boston, Massachusetts 02111
617-727-4900 — http://www•mass.gov/dia
As required by Massachusetts General Law, Chapter 152, Sections 21, 22&3Q this will give you notice that
I (we) have provided for payment to our injured employees under the above mentioned chapter by
msuring with:
CNA INSURANCE COMPANIES
NAME OF INSURANCE COMPANY
P.O. BOX 1450
MIDDLEBORO MA 02344-1450
ADDRESS OF INSURANCE COMPANY
(6S59U6-4747P19-4-14) � 0?-13-14 TO 07-13-15
POLICY NUMBER EFFECTIVE DATES
= ROGERS & GRAY INS AGCY I 434 �RTE 134 �
��
�� SOUTH DENNIS MA 02660
- NAME OF INSURANCE AGENT ADDRESS PHONE #
� DEBS HILL CONDOMINIUM 29 MIRIAH DRIVE
= ASSOCIATION
�� VARMOUTH PORT
'� MA 02675
= - _ - - _
= EMPLOYER ADDRESS
- . _ _
��
-.= EMPLOYER'S WORKERS COMPENSATION OFFICER(IF ANY) DATE
� MEDICAL TREATMENT
^= The above named insurer is required in cases of personal injuries arising out of and in the course of
�= employment to furnish adequate and reasonable hospital and medical services in accordance with the
°— provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the
'— injured employee. The employee may select his or her own physician. The reasonable cost of the services
� provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably
� connected to the work related injury. In cases requiring hospital attention, employees are hereby nodfied
that the insurer has arranged for such attention at the
NAME OF HOSPITAL ADDRESS
oaz,az W20P1G02 TO BE POSTED BY EMPLOYER
��'�. .I��s ��c.s.
` � ;�`� � � TOWN OF YARMOUTH BOARD OF HEALTH
' � � APPLICATION FOR LICENSE/PERMIT -2015
`'' * Please complete form and attach all necessary documents by December I S, 2014.
Failure to do so will result in the return of your application packet.
�._�_�
ESTABLISHMENT NAME: ���,d�'s N• �I C r:�.�c� Asso� TAX ID:
LOCATION ADDRESS: ;�?�� �-r� ��:�h ,D r^ �/��,,,,�,-}-�-h f'�rl; �nATEL.#: So,�- 3��- yy��
MAILING ADDRESS: �,,,, s c'��-75
E-MAIL ADDRESS:
OWNER NAME:
CORPORATION NAME (IF APPLICABLE):
MANAGER'SNAME: �4pR�„� Pr�;A�',^T �r,a��.« �t��- TEL.#: 5v�r- 38sryy��9
MAILING ADDRESS:
��OL CERTIFICATIONS: � L����� ���✓%�� �`n �-����'''^� � ,
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. 1�i�o Lc�- ��sac. 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 ypur place of business.
1. ���3 2.
3. 4.
FOOD PROTECTION MANAGERS -CERTIFICATIONS:
All food service establishments are required to have at least one fu11-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 1N CHARGE:
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
l. 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 for Food Service Establishments, 105 CMR 590.0(39(G)(3)(a}. 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 e�tablishment.
1. 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-chokulg procedures below and
attach copies of employee certificatians to this form. The Health Department will not use past years' records.
You must provide new copies and maintain a file at your piace of business.
l. 2•
3. 4.
T T l�T A T TT A 1 TT L�I T A TTh T!�. Tl1T A T �IL .
�
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a
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i
� � The Commonwealth ofMassachusetts
Department of Industrial Accidents
; I Congress Street,Suite 100
Boston,MA 02114-2017
www mass.gov/dia
Workers'Compensation Insurance Affidavit:General Businesses.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Apnlicant Information Please Print Legiblv
I /
i Business/Organization Name: �e 6 's �1// ��,,,�drn;n,°r��, �9s so c .
{
� Address: �9 �,ili;v di �r'•
i
City/State/Zip: y�9'rmoU�'h /Od��' Phone#: 508 • a'85- `�y 9 9
Are you an employer?Check the appropriate boa: Business Type(required):
1.❑ I am a employer with_ employees(full and/ 5. ❑Retail
or part-time).* 6. �Restaurant/Baz/Eating Establishment
2.❑ I am a sole proprietor or partnership and have no �. �Office and/or Sales(incl.real estate,auto,etc.)
� employees working for me in any capacity.
I [No workers'comp.insurance required] g• ❑Non-profit
� 3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment
their right of exemption per c. 152,§1(4),and we have 10.Q Manufacturing
no employees. [No workers'comp.insurance required]*
4.[�We are a non-profit organization,staffed by volunteers, 11.0 Health Care
� with no employees. [No workers'comp.insurance req.] 12.[�Other /��
j *Any applicant that checks box#1 must aLso fill out�e section below showing their workecs'compensation policy information.
� **Ifthe coipoiate officecs have exempted themselves,but the coxpoiation has other employees,a workeis'compensation policy is required and such an
iorgani�ation should check box#1.
� I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information.
Insurance CompanyName: �y�,g i N 5��,¢wNf G
Insurer's Address: /� D• B�C S/9G5
� City/State/Zip: O ie/a.-�rc�0 ��- �Z b��2 - S�9'�S
Policy#or Self-ins.Lic.# �S/�] c/� /� ��} ' �/��`/ Expiration Date: � ���/�(o
Attach a copy of the workers'compen as tion policy declaration page(showing the policy number and eapiratt'on date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year 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 xiolator. Be advised that a capy of this statement may be fonvarded to the Office of -
IInvestigations f e for insurance coverage verification.
I do hereby c er the pains and penalties of perjury that the information provided above is irue and correcG
Si ature: � ` Date: G-9��
Phone#: o - �1 9
Official use only. Do not write in this area,to be compdeted by city or town officiaL
City or Town: PermitlLicense#
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 _