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Home My WebLink AboutApplication and WCr Og�Y`�R ` �� -�`_ �� TOWN OF YARMOUTH Boead�of 0 --:_. � "3 1146 ROUTE 28, SOUTH YARMOUTH,MASSACHUSETTS 02664-24451 - �. �,� E�° "-� Telephone(508)398-2231,ext. 1241 Health r"`"` Fa�c(508) 760-3472 Division G3C�C�C��MGD To: Yazmouth Business Establishments `/q2no�� 2Esoe,T � Utl; 'i 5 ZU14 From: Bruce G. Murphy, Director HEALTH DEPT. Yannouth Health Depar[ment� Date: November 7,2014 Subject: Increase in License/Permit Fees Please be awaze that the Yazmouth Boazd of Health, under the direction of the Yazmouth 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 Yazmouth Business License/Pernut 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 Yazmouth Health Department with a11 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 Swinuning Pools $ 80.00 (a� l b0. O PublicWhirlpooUVaporBaths $ 80.00 [,� $ S�.p� Tobacco Sa1es $ 95.00 Motels $ 55.00 � 55.00 Food Service 0-100 Seats $ 85.00 _ Fonsl�erxic�Qver__144 Seats _ $160.00 Retail Food Service Q5,000 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�5•� 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 provfde food and/or 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 BOARD OF HEALTH �t� "� 5 (O14 APPLICATION FOR LICENSE/P��Yt�14I�?�0��v * Please com plete form and attach all necess a t y doc ��ts y D�Yce 'b r 1 DEPT. Failure to do so will result in the retu�f yo�application p�cke . ESTABLISHMENT NAME:_ T'he Yarmouth Resort TAX ID: �-� LOCATION ADDRESS: 343 Main Street-Route 28 TEL.#: 50S '�'�5 . �/SS MAILING ADDRESS: West Yarmouth, MA 02673 � E-MAILADDRESS: f�� /()L()(L1pl. Gt�r�'1 OWNERNAME: �I.�itn Fk/ilv.orcl� . CORPORATION NAME (IF APPLICABLE):N l� MANAGER'S NAME: �S` I � C' - N — NCk�� TEL.#:!p/ � • lo MAILING ADDRESS: 4 � A rooLCExTiFicaTiorrs: t�Au- �-� w��- �P�✓t��D � D�e��NG- 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. �.`S'u,��;� �- M - Ma�rr-€� 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 a11 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 your place of business. 1. S lvi� C'- Mou►'�- a. /)e-l� �e �d fi �,'� s 3. �n� ��n 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 file at your establishment. 1. /v�A 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 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 590.009(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. 1. N�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 Department will not use past years' records. You must provide new copies and maintain a file at your p(ace of business. 1. N JA' 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# L CENSE REQUtRED FEE P RMIT# _B&B $55 CABIN $55 � MOTEL $110 J _03� _INN $55 CAMP $55 �.SWIMMING POOL$I l0ea.�IS-Q �p�5� _LODGE $55 _TRAILERPARK $105 �WHIRLPOOL $ll0ea.�-t,T�}-11? FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# [,ICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100SEATS $125 _CONTINENTAL $35 NON-PROFIT $30 >100 SEATS $200 _COMMON VIC. $60 WHOLESALE $80 RETAIL SERVICE: —RESID.KITCHEN $80 LICENSEq REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# =<z5,000sq.ft. $150 _FROZENq ESSERT$240 VENDING-FOOD $25 D $ TOBACCO $110 NnmE crinNCE: g�s AMOUNT DUE _ $ ��O-00 *****PLEASE TURN OVER AND COMPLETEQ�'H SIDE OF FORM***** /�C G �C.l �ZQ(S� �� eA T„ R¢e r .:.., w ��, ..�� Cli��n807 /��`� � ADMI1�iISTRATION , Undet�Ghapter l 52,Section 25C, Subsection 6,the Tawn af Yarmauth is now required ta hold issuanoe or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insuranee. TF{E ATTACHED STATE WOi2KER'S COMPENSATIQN INSU72ANCE AFFIDAVIT MUST BE COMPLETED AND SIGNEll, OR C�RT. dP 1NS[JRr�NCE ATTACHED ✓ OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACH�D Tawn of Yarxnouth taxes and liens rnust be paid prior to renewal or issuance of your perrnits. PLEASE CHECK APPROPRIATELY IF PAID: YES '`� NO�_ MOTELS ANA OTHER LODGING ESTABLISHMEIVTS TRANSIENP OCCUPANCY: Far purposes of the limitations ofMotel or Hotel use,TraMsiextoc+cupaa�cy shall be limited to the temporary and short tarm occupancy,ordinarily and customarily assocrated with motel and hotel use. Transient occupants must have and be able to demanstrate that they maintain a principal glace of residence elsewhere.Transient occupancy shall generally refer ta continuous occupancy of not more thati thirty(30)days,and an aggregate o£not more than ninety(90)days within any six(6)month period. Use ofa guest unit as a residence or dwel2ing unit shall nat be considered transient. Occupancy tlaat is subject to the collection af Ttaom 4ecupancy Excise,as defined in M.G.L, a 64G or$34 CMR 64G, as amended,shall �enerally be considered Transient. YOOLS PQQL OPEIVING:All swimming,wading and whirlpaols which have been c2osed for the season must be inspected by the Health Department prior to opening. Contact the Tiealth DepartmeY�t to schedule the inspection three(3) days priar to openiug. PLEASE NOTE: People are NOT allowed to sit in the poal area until the pool has been inspected and opened. POOL 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 three (3} days prior to opening, and quarterly thereafter. PtJOL CLOSfNG: Every outdoar in ground swimming poai rnust be drained oz covered within seven{7)days of closing. __ _ FO011 SERVICE SEASONAL FOCID SERVICE OPENING: t�ll food service establishtnents must be inspected by the Health Department prior to opening. Please contact the Health Department to schedule the inspection three(3) days prior to opening. CATERiNG POLICX: Anyone who caters within the Town of Yarmouth rnust notify the Yarmouth Health Department by filing the xequired Temporary Food Service Applicatian form 72 hours prior to the catered event. These forms can be obtained aY the Health Department,or frorn the Tawn's website at www.vazrnouth.ma.us under Health Depru�hnent, Downloadable Forms. FROZEN DESSERTS: Frozen desserts must be tested by a State certifieti lab prior to apening and rnonthly thereafter,with sample results submitted to the Health Department. Failure to do so will result in the suspension or revocation of your Frazen Dessert Permit unYil the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval frorn the Board ofHealth. OUTDOOR CO()HING: Qutdoor cooking,preparation,�r dispIay ofany food product by a retail or food service establishment is prohibited. NOTTCE:Permits run annually from January 1 to December 31. IT IS'YOUR RESPONSIBILITY TO I�'PIJRN THE COMPLETED RENEWAL APPLICATIflN(S}AND REQUIREI}FEE{S}BY DECEMBFR 15,2014. ALL RENOVATIONS TO ANY FOOD ESTABLISHMEIvT, MOTEL OR PdOL (i.e., PAINTING, NEW EQUIPMI;NT, ETC.}, MUST BE REPt}RTEF}TO AND APPROVBD BY TI-IE Bt}:lI2.D C}F HEALTH FRICIR TO CQMMENCEMEIYT. RENOVATIONS MAY RE UI ' A SIT}:PLAN. r�aT�: /� ./�� /'-� st�NATUr�: PRINT I�tAIviE & TITLE; ��t�f � .1�P�� Rev. i if03114 t� . The Commonwealth ofMassachusetts � Department of Industrial Accidents Office oflnvestigations I Congress Street, Suite I00 Boston, MA 02II4-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Aunlicant Informarion T'he Yarmouth Resort Please Print Legiblv 343 Main Street-Route 28 Business/Organization Name:_West Yarmouth, MA 02673 Address: www.yannouthresort.com City/State/Zip: Phone #: �U� •�� 'S15�7 Are yo an employer? Check the appropriate bos: Business Type(required): 1.[�I am a employer with��-� employees (full and/ 5. ❑ Retail or part-rime).* 6. ❑ RestauranUBaz/Earing Establishment - - - - _ _ 2.Q 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] 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 I 0.Q Manufacturing no employees. [No workers' comp. insurance required]* 11.❑ Health Caze 4.❑ We aze a non-profit organization, staffed by volunteers, �p with no employees. [No workers' comp. insurance req.] 12.�Other /Yl�GC *Any applicant that checks box#1 must also fill out the section below showing the'u workers'compensalion policy information. '•If the co:porate officeis have exempted themselves,but the co:poration I�s other employees,a workers'compensation policy is requ'ved aud such an organization should check box#I. I am an empinyer that is providing workers'compensation insurance for my employees. Be[ow is the policy information. Inswance Company Name: �,Q O �}�T.l.��1 C'� � 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 espiration date). Failure to secure coverage as required under Sec6on 25A of MGL c. 152 can lead to the imposition of criminal penalries 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 fne of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwazded to the Office of Invesrigations of the DIA for insurance coverage verificarion. I do hereby certify,under the pains and pena[ties ofperjury that the information provided above is true and correct. Simahue: ��{) � � -�'� Date: D P � � �i �d/Y Phone#: Official use only. Do not write in this area,to be completed by city or town offtciaL City or Town: Permit/License# Issuing Aut6ority(circle one): i.Board of Health 2. Building Department 3. City/Town Clerk 4.Licensing Board 5. Selectmeds Office 6. Other Contact Person: Phone#: www.mass.gov/dia . AGORi�' � � SLH DA�<eeMmwvYYq �--- �CERTIFiCATE OF LiABILITY 1NSURANCE R054 �2is�aoi4 TMt3 CEKitFIGATEt3!$SUEO AS A tdATtER+�ltiF�itAZiUN OlN.Y AND t�ffERS NO RItiHTS UPai TNE CERi1FICA7E HOLOER TNlS CERTiFICATE DGES NqT AFflRMATNELY OR NE4ATNELY AMEN4,EXTEND OR AI.TER THE COVERAGE AFFdRDED BY THE POLICIES $EIOW. THt3 GERT3�ATE OF ttiStIRANCE QOE$FKYf CIXiS7TNTE A CQNFRACT BETWEEi+I THE i3SUi1�MISURER{S},AUSNORIZED REPRESENTATIVE OR PR4DUCER.ANDTHE CER71FlCA7E HOLDER. IIV4PQRTAMT:Htt�e cardHcate haNMr�att AdDliTONAL ilt5tlRE6,tlre PdkY{ka)must be eadorsad tf SUBROC�SA7701�3 WNVED.suhleet to ttre terms and candftlans M the policy,certmin pollelas may requfre an endo�semeM. A sltatemeM on this certifioate doss not coMer rights to the certfficaEe holder in Iteu cf such sndafssrtwrt{sj. ncr F SMITFi INSURA.NCE INCJPAC wc,«o.�m: ��f� 025471 P: F: �ss: PO BpX 33015 "��"""pN4�E '"�' SAN ANTQNIO TX 7$265 asii�rsn: aaztfoxd easualty sns co 294z9 sisw+m mau�uxe: s�c: YARMOUTH RESORT CONDOMINIUM TRUST ��o 343 ROUTE 28 �+�""ERE' WEST YARMOUTH MA d2fi73 �f' CpYERAGES CERTIFlCATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLJCIES OF �NSURANCE LISTm BELAW NAVE 6EEN �SSUED T6 TNE MSURED NAMED ABOVE FOR THE PpI.�CY pERIOD INDICATED. NO7WITHSTAND�NC+ J�NY REQUIREMENT, "fER1d OR COND1710N OF ANY CdNTRAC:'T aR OiHER DOCUMENT WITH RESPEC7' TO WHICH THIS {',FR7IF�ATE MA.Y � Icw^UED OR M0.Y PERTAIN, TF� INSURRNCE AFFQRDED 6Y Tt� POLIGES bESCRiBED IiERNN 1S SU&IEGT TO RtI. THE TERMS,EXCLUSIONS AND CONDffIOM3 OF R'.rl1CN POLICIES.LIMI7S SHOWN MAY HAVE BEEN REDUCEO BV PPJD pAIMS. � TPP&OFIASUR.iNCE AD➢L SUBR p�,q�J,y�gSg DOLtCPEFP X1LfCPECP u,y�S RACH UCCURfkENCE COMMPRCW.OENERPL 11ABILiTY onna�mr�� CIAIM&AWDE❑Of:CUR PREp1136 � A�E#i{MymaPersafJ PEit90NN 8MV IWUiCY {3@i6�AA.AGGRCCdTE GEN'L AGGRE6A7E LIMR P3'Pl1ES PER: POLICV �a LQC f+RODUCfS-C4MPIOPAGG a�� on+Ert c:OnB�e�F.o swCi.��utuT AVtONO&1HlW0fttFY axiikYMi .. ..... ANYAUTO BO�IIVINAIRV1�Pewwp At10WNEO SCHEIXiI-ED BODp_YINNRYIPeraaident) AUTOS AUTOS l�AOPERtt DAMAGE HMiE4hU7 �� (Pxar.N�7 UMBRELLALIAtl OGIiUR EACH IX7CURR@10E EXCES8LIA8 CtAiMSMADE FrGGRE¢4TE pE NETENrwxE A08SAFtDMlE+�SATtW�' Y+ 3TAlUiE 9F MD F.MPGOYf,FS'GGB/!f!1 uuavvaae�vwerorwnmr+ew�c� rrti ei-�aa+n�o�r+r 100,000 °�Q�'"�F"a`�0' � "'" 02 V7EG LJ7666 iz/zii2oia iziziizozs E.L.DISEASEFAFM1BLOVEE 100, OOp A (n��ry in NM re�s.a�we� ean�sens�-eaacrunrcr 5500.�00 6E$(�RIPfItlN OF CMsERATIX�13 Eebx DEStX�flON OF q�6RAil4N5JLOC.iTNJNS/9HLCtEB�0.COAD 401.AdNNmY M�wb 8d�le.vaY N�M scn apan ie rtpW�Pr Those usual to the Insured's Operations. Ocaupancy License CERTIFICATE HOLDER GANCELLATro►r StI4UtD ANY OF THE ABOVE DESCPoBE6 POLICIES SE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE Town Of Yermoath 1NACCORDANCEWiTH'f3�POL1 PROVFSIONS. Building Inspector "N��"'"� . 3146 RdUTE 28 �GG-�„ �a.U[j,rt,y✓ S YARMOUTA, MA �2564 m 198&2014 ACORD CQRPORATION.All rights reserved. AC4RD 25(201M41) The ACORD name and Iogo are registered marks of ACORD