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Home My WebLink AboutApplication and WC C . I . 4,.yH ` �° -� ,�'�Q TOWN OF YARMOUTH Boazdof � � _ _ $ � Health I 0 —.,:. ` `j 1146 ROUTE 28, SOUTH YARMOUTH, MASSACHLJSETTS 02664-24451 - j �. ;, e"' 'r Telephone(508)398-2231,ext. 1241 Health 'i r�AtME£ Fax(508) 760-3472 Division I � To: Yazmouth Business Establishments B��H�ntA�Y lt�tJ p�� ! From: Bnxce G. Murphy, Director � '� 9 2��1 Yannouth Health Department Date: November 7, 2014 H�-TH DEP7; Subject Increase in License/Permit Fees ' F = ,J � �� — -__- _ __ _—— _- c... � . • _ -- - - - - --- Please be aware that the Yannouth Boazd of Health, under the direction of the Yannouth Boazd of Selectmen, has raised a number of license and pernut fees issued through the Yarmouth Health Department, effective January 1, 2015. i Attached is the Yarmouth Business License/Permit Applicadon 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 i Department with all required certifications and worker's compensation coverage information (certificate of insurance OR completed affidavit) orior to December 31, 2014, you will be allowed to pay the 2014 rates for the following licenses: j I Current 2014 Fee Public Swimming Pools $ 80.00 Public WhirlpooUVapor Baths $ 80.00 Tobacco Sales $ 95.00 Motels $ 55.00 55.�0 Restaurants 0-100 Seats $ 85.00 Restaurants �ver lOD Seats- _ $160.00-___- - -- - _ _ _ - Retail Food Service CL5,000 sq. ft. $ 80.00 Retail Food Service>25,000 sq. ft. $225.00 Other fees owed but not listed above: Total fees owed for your establishment: 55-O� NOTE: To be entitled to pay the current 2014 rates listed above, your business application, food and/or pool certifications, along with worker's compensation information must be received, or mailed (postmarked) on or prior to December 31� 2014. [Those establishments which open in the spring will be allowed to provide food and/or pool certifications prior to opening, however, you must note "Wild provide in the spring prior to opening" on the application.J BGM/maf � , gEwc,4twa`r INN a � TOWN OF YARMOUTH BOARD OF HEALTH APPLICATION FOR LICENSE/PERMIT -2015 * Please complete form and attach a11 necessary documents by December I S 2014. Failure to do so will result in the return of your application pac et. ESTABLISHMENT NAME: AX ID: � LocaTiorravD�ss� t�4 c�cai c eR-�,��nc+ 'rEL#• �ost R�� 1�6 MAILINGADDRESS: �R��iv� C�aecSr-�.'c'�t �1.VcRlrYY�c��. �M�A - o'�f,a3 E-MAII,ADDRESS: �cx 0�t,sna.a n c�uk �` Cq�y�_ OWNER NAME: c �-� • CORPORATION NAME (IF APPLICABLE): � 2rr • � MANAGER'SNAME• 'E�e�eN0. S�dlc�ho 1n TEL.#: �O�-5�$�R'g12 , MAILING ADDRESS: �a1R. "c6�o.:v� C�$ \.S �P a'eslrect\Eq xv�A c>7--�`�'� 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 certifica6on to this form. _ __ - — 1. -- N�'�- _ - - �.- - �� Pool operators must list a minimum of two employees currently certified in basic water safety, standazd 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 Aealth 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 Establishxnents, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department wi11 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 . -_ _ __ --- - �--- - _ ALLERGEN CERTIFICATIONS: All food service establishments aze required to haue at least one full-time employee who has Allergen certifica6on, 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. L 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-chokuig 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 !S—O`E(� —INN $55 CAMP $55 SWIMMINGPOOL$IlOea LODGE $55 TRAILER PARK $105 _WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE RE UIRED FEE PERMIT# 0-100 SEATS $125 —CONTINENTAL $35 NON-PRO�[T $30 >100 SEATS $200 COMMON VIC. $60 WHOLESALE $80 — - — —RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# WCENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq.R. $50 >25,000sq ft. $285 VENDING-FOOD $25 � =<25,000 sq.ft. $150 —FROZEN DESSERT $40 _TOBACCO $1 IO NAME CHANGE: $15 AMOUNT DUE _� $ I�O.00 \l, � *'"•"*pLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***'* � � � ..._..._.___._.._.. ._ .. i I ADMINISTRATION � Under Chapter 152,Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal � i 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 i AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR I CERT. OF INSURANCE ATTACHED ( OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taYes 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 ar Hotel use,Transient occupancy shall be i limited to the temporary and short term occupancy,ordinazily 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 ar 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 aze 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 OPEIVING: 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 Yannouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtamed at the Health Department,or from the Town's website at www.yarmouth.ma.us under Health Depariment, Downloadable Forms. FROZEN DESSERTS: i 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 CAFES: I Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. OUTDOOR COOHING: Outdoor cooking,prepazation,or display of any food product by a retail or food service establishment is prohibited. NOTICE:Permits run annually from January i to December 31. IT IS YOUR RESPONSIBILITY TO RET'[JRN 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 AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: SIGNATURE: i PRINT NAME & TITLE: Rev. l l/03/14 � � � The Commonwealth ofMassachuset[s Department oflndustrial Accidents • O�ce oflnvestigatdons ` 1 Congress Street, Suite I00 Boston, MA 02114-2017 www.mass.gov/dia l Workers' Compensation Insurance Affidavit: General Businesses , A licant Information Please Print Le 'bl �I Business/Organization Name: I Address: �� c�.�Y� S�e k �a$ �y�. .�{ , City/State/Zip: p, sU,` Phone #: �� - �� -�-l`7 (C '�, Are you an employer? Check the appropriate bos: Bnsiness Type(required): 1.❑ I am a employer with employees(full and/ 5. ❑ Retail or part-time).* 6. ❑ RestaurantBar/Eating Establishment Z.-�- amT a sT io-n'efor or artneishi and have no " — P P p P 7. ❑ Office and/or Sates (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 exemption per c. 152, §1(4),and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]* 4.❑ We aze a non-profit organization, stafFed by volunteers, I1.0 Health Caze f with no employees. [No workers' comp. insurance req.] 12.❑ Other ; •Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy infotmation. � **If the cotporate officers have exempted themselves,but ihe corporaUoa has other employees,a workers'compeusation policy is requind and such an �. organization should check box#1. ��. I am an employer that isproviding workers'com1pensation insurance for my emplayees. Below rs thepoGcy information. Insurance Company Name: ��\2Sa eA �1�lSU'Y, R'Y� C.� - �� - Insurer's Address: 3�{ . �c-,�� S��Q.�,� � City/State/Zip: � . �Q`�`n'�QU.\� ��`� - d �6 '� 3 . Policy#or Self-ins. Lic. # `O�Q�C`�OG�� k3. Expiration Date: � - `,�� -�O\S • AttacL a copy of the workers' compensation policy declaration page(showing the poticy nnmber and espiration date). Failure to secure coverage as required under Secfion 25A of MGL c. 152 can lead to the imposirion of criminal penalries of a , — -------- --- ---- -- ---- — — - - — _ _ fine up to $1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP V✓ORK ORDBR and a fine i of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of InvesrigaUons of the DIA for insurance coverage verifica6on. I do hereby certi unde he pain d penalties of perjury that the tnformation provided above is true and correct. Si ature: �-� � - Date: �('�'a'1 � � \� ` Phone#: �Z� �' �� d� Offacial use on[y. Do not write in this area,to be completed by city or town offtciaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Healt6 2. Building Department 3.City/Town Clerk 4.Licensing Board 5. Selectmen's Office 6.Other Contact Person: Phone#: www.mass.gov/dia � � � i �' � '� . �..__ � _;�, _�. _ _ _ _ � iti ��. .v_ .,.. . : -4� ��. . .:. �- . � , .-.,,. . ...: � - __ _ _ ' ,, , . " __ _ .i. — �..�. =_u � - •� _ _ - z_ i - , _- ; � v:—. I4 • _ .,a - �.u i .� ' ' . ' r Ai. rt -'.:T v - _ ,•,r'r -iTicT'' ' 7� �vo� M�� .o-ra �� .r^ I. .� � � :N"�Y:["i •C'_�.M' •�• � : � • Y t_ 1J 1� - :.�J... /_:1..:�'�'Y: .�I_ f -. n • - '�� : ;��.�..�_.�i. r .� ,. . � _ . ':!'I_ '�i .- — _ �_ • _ • — _ �l�' :�ti= ..1.-• — - - .. , a M� a ' [� F�" � � "- _ _ ,.^ . I_ .ru •' "'�.- _ "- i e,> `�'�' _ - ' � w •., , - r = 'i�-_ �u� �� • ��r�. - _._r� _ • . ' ' " .�. - �.��-r '�., �i�, r-rr ..r _ a n � e.- w ' �,�� a � i_� n�i .n r � ��P=,7G1�7 � - �L�'-'1aW1 � .-...^ �� ,...:- �� ■■ � ■ � ��, ■ .,_-., d.rwii �� ■ =� ■ .,-c�■ . _ ..'■ • �I �� ■ �� ■ ��I ■ -�� .,� , .�. .,. '�� ^`"�� . ., " � ;�� .. a .. . � �IS} •...�I'ti ��;.� ,_ ='�-z?�� '. ::.>._n �- � 11 1 � 1 �. ■ :. �.. ..�, .i �_ � � 11 � W� 1 � � 1 � .,', . . ,... . ..:_.. ' . �� _....._ ._.__. ._ . .. �—��. � I .___. _ _ ._ . q:il Y1.:.�i lr�- • . y • •.. � t '_:.- .. .. . - ._ L I � , � > r '� r �. � 1 fr 7.I :Y I S . i'l' }T' � _�A��II�� I _' ___.-. ._..__ ___.. I� . .—. __.. .:L:,=- �� ._�-- _.^—} :�}'v.�l . � .. � _ :Y J- .i:l�1.'. . - - '- . � , NOTICE � � NOTICE TO � TO � � :� 0 EMPLOYEES e� EMPLOYEES y `W / y\ 0,9M 5�6 The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston, Massachusetts 02111 617-727�900 — http://www.mass.gov/dia As uired by Massachusetts Generat Law,Chapter 152,Sections 21,22&30,this will give you notice that I�we) have provided for payment to our in�jured employees under the above men6oned chapter by msuring with: � THE TRAVELERS INSURANCE COhPANIES NAME OF INSURANCE COMPANY P.O. BOX 1450 MIDDLEBORO. MA 02344-1450 ADDRESS OF INSURANCE COMPANY (7PJU6-6600245-0-14) 05-22-14 TO 05-22-15 � POLICY NUMBER EFFECTIVE DATES m� SCHLEGEL & SCHLEI�L INS 34 MAIN STREET � U�ST YARMOUTH MA 02673 ^� NAME OF INSURANCE AGENT �DR� PHONE# � � BRIDGE OVER CORPORATION 1 SIDDHARTH LAi� o� a� HOLBROOK �� MA 02343 � EMPLOYER p,DDRFSs .� s -= EMPLOYER'S WORKERS COMPENSATION OFFICER(IF ANY) DATE _� � MEDICAL TREATMENT � = The above named insurer is required in cases of peisonal injuries arising out of and in the course of s empioyment to fumish adequate and reasonable hospital and medical services in accordance with the '= provisions of the Workers' Compensation Act A copy of the First Report of Injury must be given to the '� injured empioyee. The employee may select his or her own physician. The reasonable cost of the services � ' � provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably I = connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the iasurer has arranged for such attention at the ' i NAME OF HOSPTTAL ADDRESS � „�, w�oP��o2 TO BE POSTED BY EMPLOI'ER (