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HomeMy WebLinkAboutApplication and WC i > .' OF_1'A� �� . � _ _�o TOWN OF YARMOUTH BHa�f fl -:.. :�- �1"3 1146 ROUTE 28, SOUTH YARMOUTH,MASSACHIJSETTS 02664-24451 - �. �+r E,'� :� Telephone(508)398-2231,ext. 1241 Health �A CME Fax(508) 760-3472 Division To: Yannouth Business Establishments CapE CoD Fi�n�i�y ��SoR,-r � From: Bruce G. Murphy, Director ��6����p Yarmouth Health Departrrtent Ut� i 1 [u14 Date: 'November 7, 2014 HEALTH DEPT. Subject: Increase in License/Permit Fees Please be aware that the Yarmouth Board of Health, under the direction of the Yarmouth Boazd of Selectmen, 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 January l, 2015. However, if you fully complete the applicarion, and submit it to the Yazmouth Health Department with a11 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 CZ-� I �00.00 PublicWhirlpooUVaporBaths $ 80.00 �i� � 80.00 Tobacco Sa1es $ 95.00 Motels $ 55.00 �'-�- , Restaurants 0-100 Seats $ 85.00 RestanrantsOver 100 Seats _ _ $16�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: Total fees owed for your establishment: �2 S-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 certifications prior to opening, however, you must note "Will provide in the springprior to opening" on the application.J BGM/maf `' � � TOWN OF YARMOUTH BOARD OF HEALTH � � o . ��� APPLICATION FOR LICENSE/P�RMIT -2015 :;, UE(; '1 � Y U 14 * Please complete form and attach a11 nece�a�d umerccs;by Dece ber IS 2014. Failure to do so will result in the ret4�r4i of�oiri�p`piicahon p ketHEALTH DEPT. ESTABLISHMENTNAME: CAPFC,dI)fh{mil� Q�yft,�' TAXID: �'7- �3G3'8/3 LOCATIONADDRESS:S�z /rta-irv &t. Lu�sTy�emou�'h � 4n�4oz��3TEL.#: So�- 7"71-v �ai MAILING ADDRESS: PO/5oX �l 8I GU, yazm�u�, /Y►� t�z[_ -�a E-MAILADDRESS: �'o�. maiYama. �afiai( [�m OWNERNAME: Josreh /17qie��amrt CORPORATION NAME (IF APPLICABLE): SANnbqa mRyaan >��' l �vC MANAGER'SNAME: Io�eph YYrA+e�w�� TEL.#: f�7�3'7S-S�lo� MAILINGADDRESS:�.j�¢�t�.g� LU.+-jAir:nr� l'ha- 0�-(�73 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. 1 �� '�`�'1rb�- ��@V� ������v►, 2. Pool operators must list a minimuxn 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 Tile at your place of business. 1. �/+�n.E fsEl+l.ke 2. ►�a�il✓v, Pe< l,Cv 3. r�.l� �aTui �d�2rf.c8 4. ffrLi s-fr�xr,� ��c,l�v 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 Sle at your establishment. 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-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 I MOTEL - $110 � .fS��2 INN $55 CAMP $55 �SWIMMINGPOOL$110ea SG G57 _[,ODGE $55 _TRAILERPARK $105 �WF{IRLPOOL $110ea.�� FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100SEATS $125 _CONTINENTAL $35 NON-PROFIT $30 >I00 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 _Q5,000 sq.ft. $150 =FROZEN DESSERT $40 TOBACCO $110 NAMECHANGE: $IS AMOUNTDUE _ $ ��O.00> *'***PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM•**'* �L�� � �r�Qv C��Z7�o 3 IZ.�����- � .. . . .. . f � ADMINISTRATION � Undex Chapter 152,Section 25C, Subsection 6,the Tqwn of Yarmauth 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 Certificate of Worker's Compensatiorz Insuratzce. TXiE ATTACEiED STATE WQI2KER'S COMPENSATION INSUI2ANCE AFFTDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHEI? OR � WORKER'S COMP. AFFIDAVIT SIGNED AND A`ITACHEI3 V Tawn of Yannouth taxes and liens rnusY be paid prior to renewal or issuance of your permits. PLEASE CHECK APPI2OPIZIATELY IF PAID: YES v NQ MOTELS AND OTHER LODGING FSTABLISI3MENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel usa,Transient occupancy shall be limited to the temporary and short term occupancy,ordinarily and customarily associated with motel and hotel use. Transient occupants must have and be able to demonstrate that they maintain a principai place of Xesidence elsewhere.Transient occupancy shall generally refer to continuous occupancy of not more than thirty(30)days,and an aggregate af not more than ninety(90)days within any six(6}month period. Use of a guest unit as aresidenoe or dwelling unit shall not be eonsidered transient. Occupancy that is suhject to the colleetion of Raom Qccupancy I:xcise,as defined in M.G.L. c. 64G or 830 CMR 64C"i, as amended, shall genexally be considered Transient. P4ClLS PdOL OPENING:All swimming,wading and whirlpools�uhich have been ciosed far the season must be inspected by the Health Departrnent prior to opening. Contact the F3ealth Department to schedule the inspection three(3) days priar to apening. PLEASE NOT`E: People are NOT allawefl to sit zn the poal area until the paol has been inspected and opened. POOL WATER TESTING: The water must bc tested for pseudomonas,total coli£onrt and standard plate caunt by a State certified lab, and submitted to the Health Departrnent tfiree (3} days prior to opening, and quarterly thereafter. POOL CL4SING; Every autdaar in ground swimming paal rnust be drained or covered within seven{7)days af closing. FOOU SERVICE SEASONAL FOOD SERVICE dPENING: All food service establishments must be ins�ected by the Health Department prior ta opening. Please contact the Health Departrnent to schedule the inspection three (3)days prior to opening. CATERiNG POI,ICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temparary Food Service Application forrn 72 hours prior to the catered event: These forms can be abtained at the Health Department,or fram the Town's website at www.yarmouth.ma.us undar Health Departrnent, I7ownloadable Forms. FROZEN DESSERTS: Frozen desserts must be tested by a State certified lab priar to opening and monthly thereafter,with sarnple results submitted to the T-Tealth Department. FaiIure to do sa will result in the suspension or revooation of your Frozen Dessert Permit untii the above terms have heen met. QUTSIDE CA��,`Sc Outside cafes(i.e,outdoor seating with waiter/waitress service),must have prior approval frorn the Board of Health. OUTDOOR C04KING: _ _ Outdoor cooking,preparationso.r display of apy_foodpr_oduct by a_retail or food service establishmept is pr�hibited. NOTICE:Permits run annually from 7anuary 1 to December 31. IT IS YOUR 12ESPONSIBILITY TO RETLIRN THE COMPLETED RENEWAL APPLICATION{S}ANI3 REQUIRED FEE(S}BY DECEMBER 15, 2014. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., FAINTING, NEW EQUIPMENT,ETC.}, MUST BE REPORTED'CO AND APPROVEI7 BI' THE Bt}ARD OF HEALTH PR[OR TO COMMENCEMENT. RENOVATIONS MAY I2EQUIRE A SITE PLAN. DATE: SIGNATURE: PRINT NAME& TITLE: ' Rev. I1tP3114 . � t� The Commonwealth ofMassachusetts ' Department of Industrial Accidents Office of Investigatiores 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance AfSdavit: General Businesses Applicant Information Please Print LeEiblv Business/Organization Name: Su,r�o��� ��m,�t,;�1 nL �BA�� �D F9ma� Address: �'1 z V)�,'yu S� ��� City/State/Zip: lli. l.1��� l�9. G 2..��-3 Phone #: �J'7f�'-375 -54�oz 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. ❑ RestauranUBaz/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. [No workers' comp.insurance required] 8• ❑Non-profit 3.❑ We are a corporarion and its officers have exercised 9. ❑ Entertainment their right of exemprion 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 //o� ;��`r� •Any applicant that checks box#1 must also filt out the sectioa below showiag the'v workecs'compensation policy information. **If the co:porate officers have exempted themselves,but the cotporation has other employees,a workecs'compensation policy is requ'ved and such an organizatian should check box#l. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: �ac�e!�n-S.u�t_�„vr1 Insurer's Address: /P G /'�-yL 6 Z �7 9 CiTy/State/Zip: /�yi--�-.r•L�c ��, G�--� Policy#or Self-ins.Lic. # .s�l(/ C � � 8�� � Expiration Date: ���/�/S Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure tnsecure cnverage as requir�ci under Section 25A Qf MCrI�c.��2,can lead.to ih�imoosili'on of c�r'minal penalti�s 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 Inves6gations ofthe DIA forinsurance coverage verificarion. I do hereby certify, er the pai and alties of perjury that the information provided above is true and correct. Si ahve: Date: ������ Phone#� g7fl- 37S-S�G�z- 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 '�R� GEi�TiFiCATE OF LiABiLITY tNSURANCE °"�`""'°°"�'�'"` 12 35 19 TtiS CERTIFICAtE� iBSt�D AS MQT7ER OF M�6RMATN}N 4NLY AND CONFERS ttb f2i6MS F�QN THE CFRfIFlGA7E FtBtDER TF$5 � G^ERIIFICAIE DOES N4T AFFIPoN TVELY OR NEGATIVELY AMBt�, EXTEND OR ILL1ER THE COVERAGE AFF4RUED BY THE POLIpEB BEI�N. TtqS CERtiFiGATB OF URANCE DOES NDT GONSTi'TU7@ A CON7RACT BE7WEEN T#� tSSUlNG IPL4URER{S), AlSTF10i�ZED REPRE8EMAlIV6 OR PRODUCE AND 7FIE CERfIFlCATE HOLDER. l : #fhe ce ta fid ie�ADDI ED,Yw polic e)must be en . K S BROGA N N 6,aubkN� the bmis and em�tialB of the p41 y,certain poGcies m6y requlre an endonement A 5140ement on thi s eert�ate ddeo nal eonbr ri�d Eb 11�0 CeNflCate hplQer inlieu of such e araamen '� °a��� n : Hria A lain Choioe Insuranoe Ag�ney� Inc. E B4� fi 9- 3 � �"'� : ��?g} 3as-laov 3,76 Summlr 6treet ��� +�w� ��—"""—` E'itoriburg, MA 01920 � e,�,�ballaialchoice-insurance.com ._+�!S�SL+�EfORarN3CaV E , tu.tcx � irdunean:Gua=d Insuranae Co M�EiN2E0 .. .•. � _••.-.--_._•_ .__ Ipd1NfRB: Y � Sandbar Managem t Ina � R c: �� Cspe Cod Znglat ie &ark i R o: � , P.O. Box QB1 E, � ifest Xarnouth, 02673 UR IIF: COYERAGE$ C RT�ICATENUMBER: REVt8t6NNUM�R: THIS IS TO CERTIFV THAT 7HE POLI �S QF INSURANCE USTEO 6ELOW NAVE BEEN ISSVED TQ 7HE INSURED NAMm ABOVE FOR TME POLICY PERI00 INDICATm. N07VWTHSTANDING AN 1REQIJ�REMENT.TERM OR CONDITlOtJ qF ANY CONTRAC7'�R O7HER OOCUMEM WRH RESPECT 70 WHICH THLS GERT�ICAiE iu�Y eE�SSUED OR M#Y PERTA7N,iwE iNSNtANCE AFFp�ED 8v YFE POLIGIES DESO�I�D HEREM IS SUBJECT'TO ALL THE TERMS, EXGLUSIONS ANO CONpTION5 OF SUI'?I P4l1C�ES.L W9TS SHUWN MAV NAVE BEEN REDUCED BV PACI CUlIMS. 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N0T7CE WILL BE OFUYERE4 MI TOMn of Yarmou� ACCQpOANCE W17N 7116 POLICV PROVISpNS. ROate� 2$ Yazsaveh, DGA 02�6d nu'mawzeortevwFstr�Tarne �� 9rian P. Allain �14II8-2614 ACORO CORPORATiON. AIi right5 reserved. ACQRD 26(3M0106) ' The ACORD name and loga ere registarcdmarks o(pCORp ➢lsont: FlUI: E-Mait: �, � ..._ .. ...__ —... . �