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Home My WebLink AboutApplication and WC �-�,.._ ��°��\`�� TOWN OF YARMOUTH Boazdof Health a —.:. _ ~�`j 1146 ROUTE 28, SOUTH YARMOUTH,MASSACHLJSETTS 02664-24451 - �. �,r �s�'�$ Telephone(508)398-2231, ext. 1241 Health �A C ME Faz(5 0 8)7 6 0-34 7 2 Division � 3 G3GGcGOMC�D To: Yazmouth Business Establishments T�tE Cov� /s,T y�¢,n�o��R�t D�` � � Z014 From: Bruce G. Murphy, Director � Yazmouth Health Department� H E A L T H DEPT. Date: November 7, 2014 Subject Increase in License/Permit Fees --- _--_ Please be awaze that the Yazmouth Boazd of Health, under the direction of the Yannouth Boazd ___ _ of_Selecimen, �as.raised_a_numher--of-lic�xis�and-pemut fees issued through the Yazmouth Health Department, effective January l, 2015. Attached is the Yannouth 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 1, 2015. However, if you fully complete the application, and submit it to the Yannouth 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 �3> 2�40 .00 Public WhirlpooUVapor Baths $ 80.00 �i � � �}0.p� Tobacco Sales $ 95.00 Motels $ 55.00 � S s.� Food Service 0-100 Seats $ 85.00 Food Service Over 100 Seafs $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: Total fees owed for your establishment: �375•C�D 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 �� "rrYE coJE � TOWN OF YARMOUTH BOARD OF HEALTH G3LGrC��'1C�DD k�� APPLICATION FOR LICENSE/PE,,IiNIIT-.230�5j �� , p�� ZO14 " * Please complete form and attach all necessary��e�is by_Dece $er 15 2014. Failure to do so will result in the retum of yoiir application p ckewEALTH DEPT. ESTABLISHMENT NAME: - T ID: i n�aTmN annuFa�• /p3 (ylA-M/ �- • Y�4,e�i�� o2r.'�3TEL.#:S�R -��/-3r.G� MAILING ADDRESS: E-MAILADDRESS: �:dux�.� ItCF�I'Gc�"Harw�o�h. CaY+'� OWNER NAME: CORPORATION NAME (IF APPLICABLE): MANAGER'SNAME: ��G1}A�F,L. F-�W14�c1,13 TEL.#:5�-Zldl-40R� MAILING ADDRESS:��c !�1 P..D� Ln� y� '� � 6VlA� a26� POOL CERTIFICATIONS: The pool supervisor must be certi�ed as a Pool Operator,as required by State law. Please list the designated Pool O erator(s) and attach a copy of the certification to this form. -----= 1 j� �-- --- -- �� , _ ��LI�� .� -- - , i: 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.—s,�� CLb��..c� �.57 z. 3, 4. 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 wiil not use past years'records. You must provide new copies and maintain a file at your establishment. 1. 2• PERSON IN CHARGE: Each food establishxnent 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 file at your establishment. 1. 2• HEIMLICH CERTIFICATIONS: All food service establishxnents 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. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE P IT# B&B $55 CABIN $55 I MOTEL $110 �635� I1V1V $55 CAMP $55 �SWIMMINGPOOL$ll0ea�0/a/�2 _LODGE $55 _TRAILER PARK $105 �WHIRLPOOL $110ea. � �FOOD SERVICE: LICENSE REQUIRED FEE PERM[T# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100SEATS $125 _CONTINENTAL $35 NON-PROFIT $30 >100 SEATS $200 COMMON VIC. $60 WHOLESALE $80 —RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERM[T# 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: $15 AMOUNT DUE _ $ .00 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** ��- � J7S OQ c��397 f�ll�� _ ._. ..�-. ADMINISTRATION iJnder Chapter 152,Section 25C, Subsection 6,the Town of Yarmouth is now required ta hold issuance or renewal of any license or permit to operate a business if a person or cornpany does not have a Certificafe of Worker's Compensation Insurance. THE ATTACIIED STAT'E WORKF:R'S COMY'ENSATIQN INSURANCE AFFIDAVIT MUST BE COMPLETED AND 5IGNED, UR CERT. OF INSURANCE ATTACH�D � OR WOR.t�ER'S COMP. AFFII7AVIT SIGNED ANT3 ATTACHED 1'own of Xarmouth taxes and liens must be paid priox to renewal ar issuance of your permits. PLEASE CHECK APPROPRIATELY IF�PAID: YES � RIO MOTELS AND OTHER LODGING F.STABLISHMENTS TRANSIEN.T OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be limited to the temporary and shart term occupancy,ordinaxily and customarily associated with motel and hatel use. Transzent occupants must have and be ahle to demanstrate that they maintain a principal place of residenca elsewhere.Transient occupancy shall generally rc:fer to continuous occupancy of not more than thiriy(30)clays,and an aggregate of not more than ninety(90)days within any six(6)month period. Use of a guest wilt as a residenoe or dwelling unit shall not be considered transient. Occupancy that is subject#o Yhe collectzon of IZaom Occupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended,shall generally be considered Transient POdLS POt1L CiPENING:All swimming,wading and whiripools which have been ciosed for the seasan must be inspected by the Health Departrnent prior to opening. Contact the Health Departrnent to schedule the inspection three(3) days prior to opening. PLEASE NOTE: People are NOT allowed to sit in#he pool area until the poal has been inspected and opened. POQL WATER TESTING: The water must be tested for pseudomonas,tota!coliform and standard plate count by a State certified lab, and submitted to the Health Department three (3) days prior to opening, and quarierly tlzereafter. POOL CLQSING: Every outdaar in graund swirnming poai must be drained or caverefl within seven{7}days of olosuig. _ . _ EO011 S�RVICE —..__ __ . _. _ SEASONAL FOCID SERVICE QPENING: All food service establishments must be inspected by the Health Department prior to openiug. Pleas�confact the F3ealth Dcpartrnent to schedule the inspeciion three(3) days prior to apening. CATERING PQLICl': Anyone who caters witkin Yhe Town of Yatmouth rnust notify the Yarmouth Health Depaztment by filing the required Temparary Foad Servica Applicatzon form 72 haurs prior ta the catered event. These forms can be obtained at the Health Department,az from the Town's website at www. armouthma.us under Healtl�Deparhnent, Dawnloadahle Fazms. FROZEN DES3ERTS: Frozen desserts must be tested by a State certified lab prior to opening and rnonthly thereafter,with sample results submitted to the Health Departrnent. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the abvve terms have been met. QUTSIDE CAFES: Outside cafes(i.e.,outdoor seatrng with waiter/waitress service),must have prior approval frorn tha Board of Health. OUTDOOR COOHING: Outdoor cooking,prepazatian,or display of any faod product by a n:tail or fapd service establishment is prohibited. NOTICE;Permits run annually from January I to December 31. IT IS YOUR REBPONSIBILITY Td RETURN THE COMPLETED RENEWAL APPLIGATION{S}AND REQUiRE�,I? FEE{S}BY DECEMBER 1 S, 2014. ALL RENOVATTONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.}, MUST BE REPORTED"I'O AND APPROVED BY THE BOtiR.I}OF HEAI,TH PRIQR TO COMMENC M NT. RENOVATIONS AY RE UIRE A SITE P N. DAT�.: !o� o�ll/ SIGNATU . PR1NT IVAME & TITLE: � .� }�Qj - a � Rcw. II143t14 � ,4co� CERTIFICATE OF LIABILITY INSURANCE °"�,""�°°"y""' `� a/2s/zoia THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELV OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THI$ CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.� � IMPORTANT: If the ceRificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. H SUBROGATION IS WAIVED,subject to the terms.and condittons of the polity,eeRain policies may requfre an endorsemeM. A statement on this certificate does not coMer rights to the certiflcate holder in lieu of such endorsement(s). - PROOUCER � A T D18I16 CaLIDd1II � NAME: The Armstrong Company Insurance Consultant� PxoNE , (310)530-0099 F^X e,�310)530-0098 2780 Skypark Dr, 3te 440 . E'�� .dcarmain@axmatronginsco.com � INSURERS AFFORDINGCOVERAGE NAIC• Torrance CA 90505 insuxEnaAmerican 3tates Inaurance Co INSURED- INSURERB:P00IIS288 Insurance Com an Cove at Yarmouth Resort Hotel Ownera ixsursenc:3t. Paul Fire and Marine 183 Main Street INSURERDACE W@StCY1B9CEL' Insurance - INSURER E: West Yarmouth MA 02673-4653 INSURERF: COVERAGES CERTIFICATE NUMBER:Ci.1442500922 REVISION NUMBER: THIS IS TO CERTIFY THAT hiE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE MSURED NAMED ABOVE FOR THE POLICY PERIOD � iNDICAT€D. NOl1MTN5TANDING RNY REQUIREtNENT, TERM OR CONDITION DF ANY CON7fiRCT OR OTHER �OCUMENT VNTH RESPECT TO WHfCH THIS CERTIFICATE MAY BE ISSUED OR MAV 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 BV PAID CLAIMS. INSR POIACY EFF POIJCY IXP � �7R � 1YPE OF INSURANCE POIICY NUMBER MM/DO MMIDDIYY9Y UNITS GENERAL IJABIIJTY . EACH OCCURRENCE $ S�OOO�OOO X COMMERCWL GENERAL LIABILITY P MIS S Ee o¢urrance 5 1�000�000 A CLAIMS-hWDE �OCCUR 10638480980 /1/2014 /1/2015 MEDEXP( onaperson) 3 10�000 . PERSONAL 8 ADV INJURY 5 I�OOO�OOC GENERALAGGREGATE $ 2�OOO�OOO GEN'LAGGREGATEUMRAPPLIESPER: PRODUCTS-COMP/OPAGG $ 2�00O�OOC POLICY PR� X LOC E AUTOMOBILELIABILJTY Eaacu enl � 1 000 000 B ANY AUTO BODILY INJURV(Per petson) $ /LLLOVMIED x SCHEDULED 8756G92 /1/2014 /1/2015 BODILYINJURV Peracatlenl $ AUTOS A1J�05 -� � X HIREDAUTOS X qON SWNED � PROPERiNDMANGE s Uninwretlmororiatc«nbi�red $ 1 000 OOC X UMBRELLA LIAB OCCUR EqCH OCCURRENCE $ ZS�OOO�OOC C' EX�E$$Upe CLAIMS-MADE AGGREGATE S 2S�OOO�OOC �E� RETENTION$ ING /3/201C /1/201$ $ j� WORKERSCOMPENSATON WCSTATU- OTH- ANDEMPIAYERS'llA&LITY ,.�N ANY PROPRIETORIPARTNERiEXECUTIVE E.L EACH ACCIDENT $ 1 OOO OOC OFFICERIMEMBEREXCLUDEO? � N�A (MantlatoryinNH� lYfC37589930 /1/2014 /1/2015 E.L.DISEASE-EAEMPLOVE $ 1 00� OOC Ifyes,deacribe uMer �ESCRIPTION OF OPERATIONS Oelow E.l DISEASE-POLICV LIMIT $ S OOO OOC D PiOpBity : - � 3T606107-002. /1/2016 /1/2015 BlenkMLimH-Primay $10�000�00C . � -- oeduciiMe $10�00( DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Atta<h ACORD 101,Ntltlition�l Remaiica ScMtlule,H more apaea la nqWntl) The Certi£icate Holdar is hereby named Additional Insured with respects to the property and general liability located at: 183 Main Street, Route 28, Weat Yarmouth, MA 02673-4653 but only as their interest - may appear. **10 day Notice oP Cancellation for non-payment o£ premium. � - CERT�FICATEHOLDER� CANCELLATION " � SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN � Town of Yarmouth ACCORDANCE WI7H THE POLICY PROVISIONS. Route 28 South Yarmouth, MA 02666 AUTNORI2EDREPRESENTATIVE � /�_� � ACORD 25(2010/O5) . �7988-2010 ACORD CORPORATION. All righls reserved. INS025�zoioos�.oi The ACORD name and logo are registered marks of ACORD