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Home My WebLink AboutApplication and WC . : , ��°��;�[ TOWN OF YARMOUTH Boazdof �► Health � —.... ` � `� 1146 ROUTE 28, SOUTH YARMOUTH,MASSACHiJSETTS 02664-24451 �: �, ,� :r Telephone(508)398-2231, ext. 1241 Health )rA c HEE Division FaY(508) 760-3472 To: Yarmouth Business Establishments TrrE Bws�u�G OyST�i2 P�ED r g��* From: Bruce G. Mutphy,Director � Q��d�D Yazmouth Health Department� UtC 1 1 2014 Date: November 7, 2014 HEALTH DEPT. Subject: Increase in License/Permit Fees Please be aware that the Yarmouth Boazd of Health, under the direction of the Yannouth Board of Selectmen, has raised a number of license and permit fees issued through the Yazmouth Health Department, effective January 1, 2015. Attached is the Yarntouth Business License/Permit Applicafion for 2015. You will note that the fees listed aze the fees effecUve January l, 2015. These fees will be due if you complete and submit the application after January 1, 2015. However, if you fully complete the applicarion, and submit it to the Yarmouth Health Department with all required certifications and worker's compensation coverage information (certificate of insurance OR completed �davit) 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 .00 Food 5ervice Over 100 Seats $i60.00 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: I IS.� 0+6 �caMKON vtc . Tota1 fees owed for your establishment: � 200.00 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 certif cations prior to opening, however, you must note "Will provide in the spring prior to opening" on the application.J BGM/maf , a�� TOWN OF YARMOUTH BOARD OF HEALTH �' � APPLICATION FOR LICENS�/PE��„f ff1�`;"� Utl; 1 1 lU I� ''" * Please complete form and attach all necessas}fdociunent�by..De ber EPT. Failure to do so will result in the retut�of you�appHcatron pa . ESTABLISHMENTNAME: � �• t: z/ r� � •+ rzak .>s TAXID: ( LOCATION ADDRESS: o� v rr EL.#: SD�� - .��r - MAILINGADDRESS:/ �� n-�� f � i ��z ;�,� A��` /L�h��. 7's" E-MAILADDRESS:. f ''�r ft -7t • . OWNERNAME: % 1 � ✓ CORPORATION NAME IF APPLICABLE): ,iJ�,} MANAGER'S NAME: o l� S �v�� TEL.#:5^ - �i!- 5 • MAILINGADDRESS: //�_g :� �arvn��'Th : �- ✓1,:1 .�% �G2/, ��i" POOL CERTIFICATIONS: The pool supervisor must be certi�ed 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 - _ _- � i � _ _ _ 2 / Pool operators must list a minimum of two employees cunently 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 provide new copies and maintain a Tle at your place of business. 1. 2. 3. 4. 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 £le at your establishment. 1. �-IT LLy ��LV� 2• �-,-�—r PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. � 1. �'j'i c(.L �� fi/ �� 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 Deparhnent will not use past years' records. You must provide new copies and maintain a file at your establishment. 1. -F� 51 LV11 z• 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 Department will not use past years' records. You must provide new copies and maintain a file at your place of business. " ' ,� l. HTi 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE P RMIT# LICENSE REQUIRED FEE PERMTT# LICENSE REQUIRED FEE PERMIT# �B&B $55 �j-00� _CABIN $55 _MOTEL $110 INN $55 CAMP � $55 SWIMMING POOL$110ea. LODGE $55 TRAILERPARK $105 _WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE P��iMIT,j�, LICENSE REQUTAED FEE PERMIT# LICENSE AEQUIRED FEE PERMIT# 1 0-IOOSEATS $125 �,t�5�� CONTINENTAL $3S NON-PROFIT $30 _>700 SEATS $200 �COMMON VIC. $60 �=6� I _WHOLESALE $80 � —RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUTAED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 <25,OOOsq.ft. $150 —FROZENDESSERT $40 _TOBACCO $110 NAME CHANGE: $l5 AMOUNT DUE _ $ 2`ko .O O *•***PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM****• �C GC ��O• l�(,! �.�lB� /�r`/'� < . . ADMINISTRATION Under Chapter 152,Section 25C,Subsection 6,the Town of Yannouth is naw required to hold issuance or renewal of any license or permit to operate a business if a person or company does not haue a Certificate of Worker's Compe:nsation Insurance. THE AT"1'ACHED STATE W012KEB'S COMPENSAI'ION INSUIZANCE AFFIDAVIT MUST BE COMPLF.TED AND SIGNEll, OIi CERT. QF 1NStIRANCE ATTACHZiD_� OR WORKER'S COMP. AFFIDAVIT SIGNED AND A`IT�I.CHED Torvn of Yannouth taYes and liens rnust be paid prior to renewal or issuance of your permits. PLEASE CH�CK APPROPTLIAI`ELY IF PAID: YES �l/ NO � MOTELS AND OTHF.R LODGING ESTABLISHMENTS TRANSIF.N1'OCCIJYANCY: For purposes oPthe limitations of MoteI or Hote1 use,Transient occupancy shail be limited to the temporary and short term occupancy,ordinariIy and custarnarily assocrated with motel and hotel use. TransSent occupants must have and be able to demonstrate that they maintain a principal place of residence elsewhere.Transient occupancy shall generally refer ta continuous accupancy of not rnore than thirty(34)days,and an aggregate of not more tl�an ninety(90)days within any six(6)month periad. Use of a guest unit as a residence or dweiling unit shall not be considered transient. Occupancy that is subject ta the coIlectian af Raom Oceupancy I;xcise, as defined in M.G.L. c. 64G ar 830 CMlt 64G,as amended, shall generally be considered Transient. POi?I,S P(?OL O PENING:All swimming,wading axtd whirlpools�vhich have been closed far the season must be inspected by the Health Department prior to opening. Contact the Health Departrnetat to achedule the inspection three(3) days prior to apening. PLEASE NdTE: Peaple are NQT allowad to sit in the pool area until the poal has been inspected and opened. PQOL WATER TESTING: The water must be tested for pseudomonas,total coli£orm and standard plate count by a State certified lab, and submitted to the Health Department Uuee (3) days prior to opening, and quarterly thereafter. P40L CLOSING: fivery outdoor in ground swimming paoi rnust be drained or covered within seven(7)days of closing. FOOD SERVICE SEASONAL FOOD SERVICE OPEIVING: All food service establishments must be inspected by the I3ealth Department priar to opening. Please contaet the F3ealth Department to schedule the inspection three (3)days prior to opening. CATERING P4l:ICY: Anyone who caters within the Town of Yarmouth rnust notify the Yarmouth Health Department by filing the required Temporary Pood Service Application form 72 hours priar ta the catered event. These f'orms can be obtained at the Health Department,ar from the Town's website at www.yarmouth.ma.us under Haalth Deparin�ent, Downloadable Forzns. FROZEPi DESSERTS: Frozen desserts must be tested by a State certified lab prior to opening and monthly thereafter,with sample results submitted to the Health Department, Failure to do sp will result in the suspension or revoeation of your Frozen Dessart Permit unti3 the above terrns have been met. CfUTSIDE CAF�S: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior apptpval frorn the Board of Health. OUTDOOR COOHIIVG: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prahibited. NOTICE: Permits run annually from January 1 to December 3 L IT IS YOUR RESPONSIBILITY TO RBT'tTRN THE COMPLETED RENEWt3L APPLICATIdN(S}AND REQUIRED F�E{S}BY DECEMBER 15, 2014. ALL RENOVATIONS T4 ANY FOOD ESTABLiSHMENT, MdTEL OR FOOL (i.e,, PAINTINti, NEW EQI3IPMENT,ETC.},MU3T BE REPClRT�D TO AND APPRCI VED BY THE BOAIZ.I}C7F HEALTH PRiQR TQ COMMENCEMENT. RENOVATIONS MAI,' I�EQCJIRF�'�ITE PLAN. � . � DATB� ��1,f!Y SIGNATURE;rr�'},�-Lt. �t PRINTNAME& TITLE:��i�t; . 1LV� S'.;L�: PRC?�l�(�7"C Rev. 11f03174 ` \ ' ' ' � The Commonwealth ofMassachusetts Department of Industrial Accidents Offace 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/Organization Name: Address: City/State/Zip: Phone#: Are you an employer? Check the appropriate box: Business Type(required): 1.❑ I am a employer with employees(full and/ 5. ❑ Retail or�art-rime�.*_ 6. ❑ RestaurantlBaz/Eating Establishment _ - -- - -- 2.� I am a sole proprietor or partnership and have no 7, � p�{'ice 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.❑ Manufacturing no employees. [No workers' comp. insurance required]* 11.� Health Caze 4.❑ We aze a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.❑ Other *Any applicant thffi checks box#1 must aLso fill out the section below showing the'v workecs'compensation policy information. **If the co�porate officers have exempted themselves,but the corporarion has other employees,a workers'compeusation policy is required and such an organization should check box#1. � I am an employer that is providing workers'compensarion insurance for my employees. Be[ow is the policy information. Inswance 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 policy number and eapiration date). Failure to secure coverage as required under Secuon 25A of MGL c. 152 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$250.00 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 do hereby ceRify,under the pains and penalties ofperjury that the information provided above is true and correc�t. Siz�ature• Date: Phone#: Offacial use only. Do not write in this area,to be comp[eted by city or town offuia4 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 Persou: Phone#: www.mass.gov/dia ACO� CERTIFICATE OF LIABILITY INSURANCE oA��M�,wo�� - iziosizo�a THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO R16HT3 UPON THE CERTIFICATE HOLDER THIS CERTIFICATE DOES NOT AFFIRMATNELY OR NEGATIVELY AMEND, EXTEND OR ALTER TME COVERAGE AFFORDED 8Y TME POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTRUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATNE OR PRODUCER,AND THE CERTIFICATE HOLDER IMPORTANT: If the certfipte holder Is an ADDITIONAL INSURED,the policy(les) must De antlorsed. If SUBROGATION IS WAIVED, subJecf M the terms and wnditions of the poliey,eertain polieies may require an endorsemenl.A atatement on this eaRifieaU does not confer rights to!he certificate holder in Ileu of such endorsement�s). iROWCER CONTACT AUTOMATIC DATA PROCESSING INSURANCE AGCY INC Px�N,� : a sn-oase Fa�c no: e» enouo 1 ADP BLVD MS 325 E-wu� ROSEUIND,NJ 07068 °° cb1"tl ' '�"`�C0"' (B77�B77-0428 INSURER(S�AFFORDINGCOVEMGE NpICR ClSURER A:TXE TRAVELERS INDENMfY COYPANT OF CONNECTICVf INSURED N18URER B: SILVA,HOLLY THE BLUSHING OYSTER BED&BREAKFAST �NSIIRERC: 166 RT BA insunert o: YARMOUTH PORT,MA 02675 INSURERE: IN&URER F: COVERAGES CERTIFICATE NUMBER: 643729155521343 REVISION NUMBER: THIS IS TO CERTIFY THAT 7HE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY RE�UIREMENT, TERM OR CAN�ITION OF ANV CONTRACT OR O1NER DOCUMENT WITH RESPECT TO WHICH THIS . _ .. � - CERTIFICATE MAV BE 133UED OR-MAV PERFAIN, THEINSURlWCE itFFORDEb BY THE POLIGES DESCRIBED HEREIN IS SU&IECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BV PAID CLAIMS. INSR ADD SUBR POLICY EFF PoLICY W �7p TYPEOFINBURRNCE �Ngp yyyp POl1CYNUM6ER MW M� LIMITS COMNERC111LGENERALW�BILRY EACHOCCURRENCE $ N CWMS�MADE �OCCUR nce $ MED IXP qre $ PERSONALSADVINJURY S GEN'LAGGREGATELIMRAPPLIESPER: GENERALAGGREGATE $ PRO ��Y JECT �� PRODUCTS-COMP AGG $ OTHER: $ A�Q�B��, COMBINEDSINGLELIMIT $ (Fa aaMenq ANYAUTO BODILYINJURV(Perpnaon) $ ALLOWNED SCHEDULE� AUTQS AVf03 BODILVINJURV(Pe�ecckent) $ MIREDAUTOS NON-0WNE� AUTOS ��GE $ $ UN6RELlA WB OCCUR EACH OCCURRENCE $ FXCE&4W8 CLAIMS-MADE FGGREG4TE $ DED REfEM10N$ $ /{ M'awcEps�°wExsnnoN nin UB3D114470-14 O6/OB/20'14 O6/O6/2015 X srnn� e°rsTM MlDENPLOYERS'W1BIllTY YM ANYPROPRIETOWPARTNEWIXECUTNE❑ E.LEACHACCIDENf S�OO,OOO �ICEWMEMBER IXCUIDEDT �aeoq in Nx) _ ._ ____. ._.__ e�.oisEnse-[n�rnr�oree S 100.000 _. __ __ . _—_ . .. rcyes.aes�ceunaer .. - . . . . . _ . . -. OESCRIPTION OF OPERATIONS Oebx E.L.DISEASE-POLICY LIMR S SOO,OOO DESCRIYTON OF OPERAl10N3I LOCI1110NS1 VEMICIES(ACOflD fY1.AtltlMonsl RemsA�Schtluk,may be etbeMA M mwe�pxa k nqWntl) FOR INFORMATION ONLY CERTIFICATE HOLDER CANCELLATION SILVA,HOLLY THE BLUSHING SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE OYSTER BED 8 BREAKFAST TXE EXPIRATION DATE iHEREOF, NOTICE WILL BE UELNEREO IN 168 RT 6A ACCOFtDANCE WRH THE POLICY PROVISION3. YARMOUTH PORT,MA 02675 RU1110RIZEOREPRESEN1Al1VE � � - ��, �7988-2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014l01) The ACORD name and logo are registered marks of ACORD