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Home My WebLink AboutApplication and WC O��Y'�R ��' �` a �� TOWN OF YARMOUTH Hathf � �. "` `j 1146 ROUTE 28, SOUTH YARMOUTH, MASSACHUSETTS 02664-24451 - �. �., �o° $ Telephone(508)398-2231,ext. 1241 Health '�`"E Fax(508) 760-3472 Division To: Yannouth Business Establishments �-t-�c K-�TcH� -l��c 1�-o�AGt �• From: Bruce G. Murphy, Director � �_----- J � Yazmouth Health Department� � ;�i��'�,„ <;,� k Date: November 7, 2014 H�qLTp; ;;;�� Subject: Increase in License/Permit Fees Please be awaze that the Yazmouth Boazd of Health, under the direction of the Yarmouth Board of Selechnen, has raised a number of license and permit fees issued through the Yannouth Health Department, effective January 1, 2015. Attached is the Yarmouth Business License/Pernut Application for 2015. You will note that the fees listed aze the fees effective 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 application, and submit it to the Yarmouth Health Department with all required certifications and worker's compensation coverage information (certificate of insurance OR completed affidavit) nrior 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 Sa1es $ 95.00 Motels $ 55.00 Food Service 0-100 Seats $ 85.00 $ 35.� Food Service O-ver IDO Seats $I bt�:00 Retail Food Service C15,000 sq. ft. $ 80.00 � ,q�,pp Retail Food Service>25,000 sq. ft. $225.00 Other fees owed but not listed above: � c�O.00 cpr.r.oN vic . Tota1 fees owed for your establishment: �22 S,o0 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 certifcations prior to opening, however, you must note "Will provide in the spring prior to opening" on the application.J BGM/maf ( (�, � ��11(J��PV ' a TOWN OF YAI2MOUTH BOARD OF HEALTF� v�` °^ � �� APPLICATIONFORLICENSE/PERMI'��2Q,15�. I�� `+p� �� '' * Please complete form and attach all necessary doc�,nient�,by-Derem�i�"' 29�LTH DEPT. Failure to do so will result in the return of your application packet. ESTABLISHMENT NAME: K C. l � C. � ID: -� - �} LOCATION ADDRESS: R=- I�3 J TEL.#: S b ' 7(- 3 � MAILING ADDRESS: � c � E-MAILADDRESS: G S - OWNERNAME: �/��1t(� �(=YvtPSE`( CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: 1L ='�-t S'�` TEL.#: 0 " " a �L�rrGaDDxEss:Joa �r��,� rza� s �,� eyv�o�� tf r�.� ��G6�( 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 _ Z \_ _ Pool oper ors must list a minimum of two employees currently certified in basie water safety, standard First Aid and Commum diopulmonary Resuscitation (CPR),,kaving one certified emptoyee on premises at all times. Please list the emplo below and attach copies of theii certifications to this form.T►ic- ealth Department will not use past years' records: �qu must prov�d�-i�ew copies and maintain a fil�'at you ace 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 Establishxnents, 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. ��\?i,tJ ��1'�,� �� _ _ . . _ 2. fJf�� C� L�I N ALLERGEN C�{ZTIFICATION�C� All food service establishments are required to have at least one full-time employee who has Allergen certificaUon, 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 �le at your establishment. �. D�1�� or�r�P �� z. a�__�,�2e,� O��PS E`( 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 file at your place of business. i. O�V�O r�r�tPSF`-( z. `�'RUt,� gP-�N 3�M�fl�I f ul,�Sr�N 4. ZA t—�i��, T�'f dF N V 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 $I10 I1V1V $55 CAMP $55 SWIMMINGPOOL$110ea. LODGE $55 TRAILER PARK $105 _WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE P RMI # LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �0-100SEATS $125 �i5-�I`�S CONTINENTA[, $35 NON-PROFIT $30 _>100 SEATS $200 TCOMMON 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,OOOsq.ft. $150 �r�fp —FROZENDESSERT $40 _TOBACCO $ll0 NAME CHANGE: $15 AMOUNT DUE _ $ 3 3 S.00 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM**•** T ^ ADMINISTRATION Under Chapter 152,SecTion 25C,Snbsection 6,the Town of Yarmouth is naw 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 Compensation Insurance. TFIE ATTACFIED STATE Wdi2KER'S COMPENSATION Ii�iSITitANCE AFFYDAVIT MUST SE COMPLETED AND SIGNED, OR CERT. 4F iNSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED t/ Town of Xannouth taxes and liens rnust be paid prior to renewal ar issuanae of your permits. PLEASE CHECK APPROPI2IATELY IF PAID: YES `�"� NO MOTELS ANA OTHER LODGING ESTABLISHMENTS `I'RA,NSIENT OCCUPANCY: For purposes of the limitarions of Motel or Hotel use,Transient occupancy shall be limited to the temporary and short term occupancy,ordinarily and customarily associated with motel and hotel use. Transient occupants rnust have and be able to demonstrate that fhey maintain a grincipal place of residence elsewhere.Transient occupancy shall generally refer to continuous occupancy ofnot more than thiriy(34)days,and an aggregate of not more than ninety(90)days within any six(6)month peripd. Use of a guest unit as a residence or dweIling unit shall not be conszdered transient. Occupancy that is subject to the collection of Raom Oaeupancy I;xcise, as defined in M.G.I.. c. 64G ar 834 CMR 64G, as amended, shall generally be considered Transient. POOLS POOL OPENING:All swimming,wadittg and whirlpools which have been closed for the season musf be inspected by the Health Department prior to opening. Contact khe Health Departrnent to schedule the inspectian three(3) days prior to opening. PLBASE NOTE: People are NQT allowed ta sit in the pool area until the pool has been inspected and opened. POOL WATER TESTING. The water must be tesied for pseudomonas,total coliform and standard plate count by a State certified lab, and submitted to the Health Department three (3) days prior to opening, and quarterly thereafter. F'OQL CLOSING: Every autdoar in graund swinunin�pool must be drained ar cavered within seven{7)days af closing. FC►OD 9ER�%ICE SEASONAL FOOD SERVICE OPENING: All food service establishments must be inspected by the Health Department prior to opening. PIease contact the Heaith DeparCment to schedule tke inspectian three(3)days priar to opening. CATERIiVG POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the zeqnired Temparary Foad Service Applicatian form 72 hours priar to the catered event. These farms can be obtained at the Health I7epartment,or from the Town's website at www.�arrnouth.ma.us under Health Deparhnent, Do�vnioadable Forms. FROZEN DESSERTS: Frozen desserts must be tested by a State certified lab prior to opening and rnontl�ly thereafter,with sample results submitted to the Health Department. Failure to do so will result rn the suspension or revocation of your Frazen Dessert Permit until the above terms have been met. dUTSIDE CAF'ES: Outside cafes(i.e.,autdoor seating with waiter/waitress service),must have prior apprpval from the Board of Health. OUTDOC/R COOHING: Q�t�poc 4:ooking�reparation�or display of an�faod product by a rctail or food service establishment is proLibited. NOTICE: Permits run annually from January 1 to December 31. IT IS YOT.TK I2ESPONSIBILTTY TO RETURN THE CdRAPLETEi7 RENEWAL APPLTCATI4N{S)AIVD REQUIRED FEE(S}BY DECEMBER 15, 2014. ALL RENOVATIONS TO ANY POOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NBW EQUIPM�NT, ETC.}, MUST BE REPC?RTEI}TO AND APPROVEI7 BY THE BdARD C1P HEALTH PRTC}R TQ COMMENCEMENT. RENOVATIONS MAY QUIRE A SIT., AN. DATE:��S��C��_SIGNATURE: PR1NT NANFE& TITLE:_�j�11�__� �'G� Rev. l3f03174 I r.l� a . . .,,-. � �,i i . i �� .. _� � The Commonwealth ofMassachusetts Department of Industrial Accidents Offace oflnvestigations ' I Congress Street, Suite 100 Boston, MA 02II4-20U www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses A licant Information Please Print Le 'bl Business/Organization Name: � � Address: � City/State/Zip: W Z U� Phone #: �� ^ ! � � � �,>7 Ar,e�yo�u an employer? Check the propriate box: Busines Type(required): 1.L�' 1 am a employer with�employees (full and/ 5. [a'�etail orpart-time�.*___ 6. �RestauranUBaz/EatingEstablishment - - -- - - 2.❑ I am a sole proprietor or parmership 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 aze a corporarion and its o�cers 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 are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.� Other "My applicant that checks box#I must aLso fill out the section below showing their worken'compensation policy informatioa. •*If tLe co=porate officets have exempted themselves,but the cocpora[ion has other employees,a workers'compensation policy is Iequired and such an organization should check box#I. I am an employer that is providing workers'compensation insurance for my mp[oyees. Be[ow is the policy information. Insurance Company Name: f��' Q��t L R5 S 0�.��/`t Insurer's Address: �C V I,�(.� (%l,I� IJ��b, � City/State/Zip: �. � (A� ' Policy#or Self-ins.Lic. # Expiration Date: Attach a copy of the workers' compeasation policy declaration page(showing the policy nnmber and espir tion date). Failure to secure coverage as required under S�cYiQn25t1nfMGL c.152�can lead to thP imnosition_ofcriminal p�nalties_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 covemge verificarion. I do hereby ify,under t e pains d penalties ofperjury that the information provide abo e is true and correct r-- Si ature: Date: Phone#: Official use only. Do not write in this area,to 6e comp[eted by city or town officiaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2. Building Department 3.City/Towa Clerk 4.Licensing Board 5. Selectmeds Office 6.Other Contact Person: Phone#: www.mass.gov/dia To: Board of Health Page 'I o`3 20'IS-01-'152Q94:52 (GMn �-509-463-2322 Rom�. David Scho!ield SCHOFIELD INSURANCE SERVICES, INC. 1102 Main Street MILLIS, MA 02054 PHONE (508) 376-5464 FAX (508) 376-5468 Date: 2015-01-15 20:15:22 GMT ph�e: 508-376-5464 �: Keltic Kitchen p�: 15084632322 Comments: Enclosed please find the worker's compensation certificate for the Keltic Kitchen. ww.w.EFax.com 70: Board of Health Page 2 of 3 2015-0�-15 2Q94:52 (GMT) 'I-SOB-463-2322 Rom�. David Schoiield CERTIFICATE OF LIABILITY INSURANCE °"TE,"'"°°"""", o�ns�za�s vRcoucen THIS CERTIFICATE IS ISSUEO AS A MATTER OF INFORMHTION Schotield knsurance Services ONLY AND CONFERS NO RIGHTS UPON TME CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 1102 Main S(reel ALTER THE COVEftAGE AFFORDED BY THE POLICIES BELOW. Millis, MA 0205d � INSURERS AFFORDING COVERAGE NAIC# MsuaEo KelticHilchen iusuaeaF 47 5 Main Street iNsuaea e. INSURER G�. West Yarmouth MA 02673 iNsuaeR o�. MA Retail Merchants WC Group I INSUFER E- COVERAGES THE POLICIES OF INSURANCE LISTED BELOWHAVE BEEN ISSUED TO THE INSURED NAMEDABOVE FOR THE POLICY PERIOD INDICATE�.NOPNITHSTAN�ING ANY REQUIREMENT, TERM OR CONDITION OF ANY COMRACT OR OTHER �OCl1MENT WITH RESPECT TO WNICH THIS CERTIFICATE PAAV BE ISSUEO OR MAV PERTAIN,THE WSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EAC�USIONS AND CONOITIONS OF SUCH PO�ICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CWIMS. MSR OD'L � pp�ICYNUTABER POLICVEFFECTIVE FOLICVE%PIfWTION LIMITS OENERALLIA&LITV EACHOCCURRENCE 8 CONM'_R�InL6ENERnLLwBILitt � DFMAGETpRENTEG � C AIMSNADE �QCG_R MEGE%�F An O�e�5rcoc F PERSONkL 6 nDV NJIJRY I� � 6ENEUALAGr.REFH'E A GEM_A66RE6ATELIMITAFPLEiPER�. PRGDJC-�-COMFIOPAGB $ POJCi P�} LOC AUTOMOBILE LIABILITV COMBWEG 31NGLE LIMIi � qN� q�J7� (Ee e.r.ltlenp ALLO✓NVEO4UTp5 6�AILV IIJJLf'! >CHEDDLEDaUi05 (PerD�«�n) ^ HM1:ED AU�pS . gOC11LV IIJJ�RY � N00.rVrNED ALrt05 IPe�a<aaeni; � PROPFGTYpA�VABE � (Pf!BCC�danl; GARAGEIIPeILITY AUTOON v.EnnCODENT A NM' 4Ui0 pHEG iHAN EAA!'(_ $ NUTOONLY. AGG $ EXCESSIIIMBRE�IALIA9ILITY � EPGHOCCURREN�E $ 'u��UG � i�lFIMSMADE qp,�R=(ATE F } DEDU:Ti��E � FETENiIpN $ g WORNERSCOMPENSATIO�' � X Wi�STqTI� pTF- ANO EMPl0YER5'UABILITV D nNra�oveieroama�'rNeeie�aecuriv� 0140050306083415 1/1/2015 111R016 e�.eacHaruoenrt 4160,000 FFiee�ru-meeuezr_woEo° n (MandatorylnNN) EL DIJEASE-EAEMG�pYEE E ��O,OOO I�Ye=.Aec�ribF unrer '�ECu_F30v6i5N5Delow EL.DISEnSE-FOI.ICtCrt9T g $�D,OOD OiH ER I DESC WPTION OF OPERATIONS I LOCATIONS I VEHICLE51 E%CLUSIONS ADDEO 6V ENOORSEMENT I SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOUL�ANY OF THE ABOVE DESCftIBEO POLICIES BE CANCELLE�BEPORE TME EMPIRATION 7own of YarmoatA MA DAIE TMEREOF,THE ISSUING INSURER WILL ENOEAVOR TO MAIL 30 OAVS WRIREN NOTICE TO THE CERTIFICATE HOLDER NAMEO TO THE LEFT,BUT FAIIURE TO 00 50 SHALL IMPOSE NO OBLIGATION OR LIABILIT'OF ANY HINO UPON TME INSURER,ITS AGENTS OR REPRESENTqTIVES. ql1THORIiEO REPRESENTATIVE <MS> I' I ACORD 25 (2009101) O 1988-2009 AC RD R RATION. All rights reservetl. The ACORD name and logo are registered marks ot ACORD To: Board of Health Page 3 of 3 20'I 5-0�-15 20:'14:52(GMT) �-SOB-463-2322 Rom�. David Schofield IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be entlorsetl. A statement on this certificate does not confer rights to the certificate holder in Iieu of such endorsemenqs). If SUBROGATION IS WAIVEO, subject to the terms and conditions of the policy, certain policies may require an endorsement A statement on this certificate does not confer rights to ?he certificate holder in lieu af such endorsement(s). DISCLAIMER This Certificate of Insu2nce does not constitute a contract beriveen the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it atfirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25 (2009101)