Loading...
HomeMy WebLinkAboutApplication and WC i. • 10= . -..Q TOWN OF YARMOUTH Health = ' y '© y 1146 ROUTE 28, SOUTH YARMOUTH, MASSACHUSETTS 02664-24451 - :,rT�a�� 4,4, ' Telephone (508)398-2231, ext. 1241 th fir Division n (508)760-3472 To: Yarmouth Business Establishments y Be3as g Is- From: Bruce G. Murphy, Director MagL OSI'GD Yarmouth Health Department SEC 1 g 2014 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 Board of Selectmen, has raised a number of license and permit fees issued through the Yarmouth Health Department, effective January 1, 2015. Attached is the Yarmouth Business License/Permit Application for 2015. You will note that the fees listed are 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 Yarmouth Health Department with all 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 Swimming Pools $ 80.00 Public Whirlpool/Vapor Baths $ 80.00 Tobacco Sales $ 95.00 —Motels --- $ 55.00 Restaurants 0-100 Seats $ 85.00 Restaurants Over 100 Seats $160.00 4 160-00 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: 4 (00.00 c'0141,0►4vtc. Total fees owed for your establishment: $220.00 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 spring prior to opening" on the application.] BGM/maf r - U Ronc Eic-reG co r TOWN OF YARMOUTH BOARD OF HEAL ( D CA (�GrC� D�MC APPLICATION FOR LICEl SL E I ' 2 1 " DEC 19 2u14 � S ��..3 * Please complete form and attach all ne essary 6 it by December 15, 2014. Failure to do so will result in the return bf your application pac144EALTH DEPT. ESTABLISHMENT NAME: 11 6'AS bio TAX ID: LOCATION ADDRESS: Jf ,ems ,9g IL). /42mA-f ti TEL.#:�G`77I`07 99 MAILING ADDRESS: /b. are Lg /,U- y4i2/YlciAti //114 O2( 13 E-MAIL ADDRESS: Jcvlu&heyaha.i (`cs) 7 OWNER NAME: CORPORATION NAME (IF APPLICABLE): )I,/,Yl1 ,t.ieI MANAGER'S NAME: MAI 61.1..-u eci' TEL.#: 77 if-19V-15 3 S-) MAILING ADDRESS: //5'5 i2T- • gg N- *16144.4%l pr lip 67-4 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. 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 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 file at your establishment. OLLLtee/ 1 (2y 2 -i 1. 1)(1t, 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. � 1. LCA 61 e�7 2. �YI 6/Voce I 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. >�J iy ,5 2. / aCe. j/kect-4 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. 31. . �. IY) L 24. 7),�> ) Jo An SQ 4 RESTAURANT SEATING: TOTAL# Ng 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$110ea. LODGE $55 TRAILER PARK $105 WHIRLPOOL $I l0ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 CONTINENTAL $35 NON-PROFIT $30 j>100 SEATS $200 I 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 <25,000 sq.ft. $150 —FROZEN DESSERT $40 TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE = $ 2‘0 no *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** dC 2 ,406 ck 8Oz-8 iz/t4/I'! ADMINISTRATION Under Chapter 152,Section 25C, Subsection 6,the Town of Yarmouth 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 Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED /07 OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations 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 must have and be able to demonstrate that they maintain a principal place of residence elsewhere.Transient occupancy shall generally refer to continuous occupancy of not more than thirty(30)days,and an aggregate of not more than ninety(90)days within any six(6)month period. Use of a guest unit as a residence or dwelling unit shall not be considered transient. Occupancy that is subject to the collection of Room Occupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient. POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. Contact the Health Department to schedule the inspection three(3) days prior to opening. PLEASE NOTE: People are NOT allowed to sit in the pool area until the pool has been inspected and opened. POOL WATER TESTING: The water must be tested 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. POOL CLOSING:Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE SEASONAL FOOD SERVICE OPENING: All food service establishments 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 POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health Department,or from the Town's website at www.yarmouth.ma.us under Health Department, Downloadable Forms. FROZEN 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 so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFÉS: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 15, 2014. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO A aA PPR•VED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MA ' QWidj / E PLAN. DATE: ivy//1///4/ SIGNATURE: of �� /f PRINT NAME&TITLE: void '/I ( / U5, i1 i Rev. 11/03/14 1L/24/ZUL4 MON IL: U3 FAX 7Ul:599Z.$730 soutneasterri 1A IQ.JUOL/UUL ACERTIFICATE OF LIABILITY INSURANCE DATE(MMICIDrYYYY) Sta......."--- 11/24/2014 THIS CERTIFICATE IS ISSUED AS A MATTER. OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED, 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 the certificate holder in lieu of such endorsement(s). PRODUCER "INTRCT Lora FitzGerald Southeastern Insurance Agency .PHONE (508)997-6061 FAX (A/C,Na,Ext): (AIC,No):(508}990-2731 439 State Rd. AE-DDRESS:MAIL lfitz@sout.heaster*ins_clout P.O. Box 79398 I NSURER(S)AFFORDING COVERAGE NAIC# North Dartmouth MA 02747 INsusERA Arbella Protection Insurance 41360 INSURED INSURER B:General Star Indemnity Co. Yeahma Inc, DBA: 4 Bros. Bistro INSURER : C/O Cove Resort INSURER : 183 Main Street INSURER : W Yarmouth MA 02673 INSURER F: COVERAGES CERTIFICATE NUMBER:2014 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADI SUER POLICY EFF POLICY EXP LTR INSR WVD, POLICY NUMBER ,(MMIDDIYYYY) (MM/DDIYYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence) $ CLAIMS-MADE OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ _ GENE AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ —1 POLICY T LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ — ANY AUTO BODILY INJURY(Per person) $ ALL OWNED T SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ T NON-OWNED PROMERTY DAMAGE HIRED AUTOS _ AUTOS (Per acctdent) $ $ UMBRELLA LIAR OCCUR — EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ A AND EMMRS PLOYERS'LLIABILITY Y 1 N SATION X OR�NITS ETRE ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1 OFFICER/MEMBER FFICENEXCLUDED? N/A 9117390414 4/1/2014 4/1/2015 ,000,000 E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 B Liquor Liability TMA.699074 12/26/201312/26/2014 Limit of Liability 1,000 000 DESCRIPTION OF OPERATIONS/LOCATIONS 1 VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space is required) CERTIFICATE HOLDER CANCELLATION (508)398 0836 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 • S Yarmouth, L+lA 02664 AUTHORIZEDREPRESENTATIVE Lora FitzGerald/LHL ACORD 25(2010/05) 0 1988-2Q'I0 ACORD CORPORATION. All rights reserved.