HomeMy WebLinkAboutApplication and WC OF��'q�R
�� -_ `�c TOWN OF YARMOUTH B�oard�of
a � "j 1146 ROUTE 28, SOUT'H YARMOUTH, MASSACH[JSETTS 02664-24451 "
� 4��T+1CN�t'e�' � Telephone(508)398-2231,ext. 1241 ��5�
Fax(508) 760-3472
To: YarmouthBusinessEstablishments GQ�T Is�PaW �qr-F��(
From: Bruce G. Murphy, Director �
Yazmouth Health Department�
Date: November 7,2014
Subject: Increase in License/Permit Fees
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Please be awaze that the Yarmouth Boazd of Health, under the direction of the Yarmouth Boazd
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 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 Yarmouth Health
Department with all required certifications and worker's compensation cov
(certificate of insurance OR completed affidavit) rior to December 31 20 4 }F�Cti#�`�D
allowed to pay the 2014 rates for the following licenses:
JAN 2 9 2015
Current 2014 Fee
Public Swimming Pools $ 80.00 HEAITH DEPT.
Public VJhirlpool/Vapor Baths $ 80:00 ���
Tobacco Sales $ 95.00
Motels $ 55.00
Food Service 0-100 Seats $ 85.00 85-60 ��3��
-----__� ^�o:��.��^_�er,3�4Seats __._ ____ e,�-_—�_ n n.,n_-___- --_:-
Retail Food Service Q5,000 sq. ft. $ 80.00
Retail Food Service>25,000 sq. ft. $225.00
Other fees owed but not listed above:
Total fees owed for your establishment: 85.00
NOTE: To be entitled to pay the current 2014 rates listed above, your
business application, food and/or pool certifications, along with worker's
compensation information must be received, or mailed (postmarked) on or
prior to December 31, 2014. [Those establishments which open in the spring will be
allowed to provide food and/or pool certifications prior to opening, however, you must note
"Will provide in the spring prior to opening" on the application:]
a
� `« TOWN OF YARMOUTH BOARD OF HEALT��86 � � o
��� APPLICATION FOR LICENSE/P�$MI�-29�5 3 p
� � _ � JNN 13 ZU15
* Please complete form and attach all neces�aryc:do um�nt�byDec b r IS 20I4.
Failure to do so will result in the ret�;of�5ur�mp�4ltC�tion�fac t. HEALTH DEPT
FCTART i4HMFNT NAMF• ��R��7 Sca-,v9 8a�� TAX ID:
LOCATIONADDRESS:-f<G ��T/�fST �"•j✓giemo rr-, p��9. �dc TEL.#:.�oSr-��o _oQa�
MAILING ADDRESS: m �'
E-MAIL ADDRESS: '—
OWNER NAME: +9�� � R
CORPORATION NAME (IF APPLICABLE): —
MANAGER'S NAME:C��'�' � �u�B�!3�✓!C ___ TEL.#:,1-0�-77�eY3�o
MAILING ADDRESS: �3 CH 9- [= S i �✓.0 r .� ga-6o '
POOL CERTIFICATIONS:
The pool supervisor must be certif►ed 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. �r/A --- _ _ _ 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. /'t��l 2.
3. 4.
FOOD PROTECTION MANAGERS - CERTIFICATIONS:
All food service establishxnents aze required to have at least one fixll-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. LtaJZi �j1.ti28An11C 2.
PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
1. �sirZ: ���aa�AL _ 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. 2•
HEIMLICH CERTIFICATIONS: ,
All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich ,
Maneuver on tYte 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.
1. /✓�� 2.
3. 4.
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 $t10
INN $55 CAMP $55 SWIMMINGPOOL$ll0ea
LODGE $55 _TRAILERPARK $105 _WHIRLPOOL $110ea.
FOOD SERVICE:
L7CENSE REQUIRED FEE P IT}� LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
I 0-100 SEATS $125 �� R '�S _CONTINENTAL $35 NON-PROFIT $30
—>100 SEATS $200 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 >25,000sq ft. $285 VENDMG-FOOD $25
_Q5,000 sq.ft. $150 —FROZEN DESSERT $40 � _TOBACCO $t l0 ,
NAMECHANGE: $15 AMOUNTDUE _ $ IZS•OO '.
**•**PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** �
!
,�w -
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 WOI2KER'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR
CERT. OF INSURANCE ATTACHED �/
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 N�
MOTELS AND OTHER LODGING ESTABLISHMENTS
TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy sha11 be
limited to the temporary and short term occupancy,ardinarily 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 I
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 azea 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
thereafrer.
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 Yarxnouth Health Department by filing the
required Temporary Food Service Application form 72 hours priar 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 ar revocation.of your Frozen
Dessert Permit until the above terms have been met.
OUTSIDE CAFES:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health.
OUTDOOR COOHING:
Outdoor cookin2,nre�aration,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 AND APPROVED BY THE BOARD OF HEALTH PRIOR i
TO COMMENCEMENT. RENOVATIONS MAY�T.RE SITE PL .
DATE: Ia���I�`� SIGNATURE:
PRINT NAME &TITLE: �ATU �I�k- ���
Rev. 11/03/14
� � TheCom»zonwealthofMassachusetts '
Department oflndustrialAccidents
Office oflnvestigations
' 1 Congress Street, Suite 100
Boston,MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Aanlicant Information Please Print Legiblv
Business/Organization Name: (�(t-�1-T �-���►S� ���2'� .
Address: �� �0�l-� g I
City/State/Zip: S ��fl'R-!�'�-U1�Lb� m � Phone #: ��� �� �p _ �b��
Are you an employer? Check the appropriate box: Business Type(required):
1.[�I am a employer with o� employees(full and/ 5. ❑ Retail
or part-rime).* 6. ❑ RestaurantBaz/Eating Establishment
_ — - -
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 capacrty.
[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 10.❑ Manufacturing
no employees. [No workers' comp. insurance required]*
4.❑ We aze a non-profit organization, staffed by volunteers, 11.❑ Health Caze v
with no employees. [No workers' comp. insurance req.] 12.� Other nJ�K-C`T�-( I�-�7/�)L,
*Any applicant that checks box#1 must also fill out the sec[ion below showiag the'v workexs'compensation policy information. .
••If the co:porate officeis have exempted themselves,but the corporation has otha employees,a workers'compensation policy is required md such an
organization should check box#I. .
�'I am an employer that is pro,vidring workers'compensation insurance for my emp[oyees Be[ow rs the policy injormation.
Insurance Company Name: W� S'('� �jf���•
Insurer'sAddress: �D. ��jX�l � �C�
� .
City/State/Zip: G�.�✓,�L�19'+f D,��f/,3 �
Policy#or Self-ins. Lic. # /!1 L!l C.�DS� � 93ro Expiration Date: .� i �
Attach a copy of the workers' compensation policy declaration page(showing the poticy number and ezpiraHon date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
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fine up to $1,500.00 and/or one-year 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
Invesrigations of the DIA for insurance coverage verification.
I do hereby certify,under the pains andpenalties ofpery'ury that the information pravided above is true and correct
Sienature: ��'�- Date: �a������
Phone#: �d " �6� ' O t�07
Offuial use only. Do not write in this area,to be comp[eted by city or town offaciaL
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2. Building Department 3. City/Town Clerk 4.Licensing Board 5. Selectmen's Office
6.Other
Contact Person: Phone#:
www.mass.gov/dia �
_ _ ___ . _
. _ _ _
Security Natianal insurance Campany
_ . . ._ _ ._..
A Stock lr��ComPa�Y
WORKERS.COMPENSqTION WC���� g
, AND EMF�t.OYERS ltABiLiTY
INSURANCE POL(CY INFORMATION PAGE
Ncci Cak:4p533
f. [nsured:
�B��k PoucY Numberc SWC194UT88
DBA:Crreat Is)and Bakery
����S�� X Individua3 p���r
Bacs River.MA 02664 — _ P
_ Corporation
�her warkp3xes not shown abave: —
Sce Eztension of Infartnation Pago Federa!`Cas ID: 043422408
Pendncer. Itisk Cd:
____ ._ _. . _.
AmTmst Nmth qmericy,Ine_ Renewal of: W WC3p51956
do Cowan Insurance Agency,Inc.
_ 359 MaiiiSgeei. - - - _-
_ _ __Ifavethill,MA!►i830 _._ _ _ . _ __
_- -__ - ---
2- The Policy puiod is from 3/112014 to 3/11/2015 12:01 am.at the insured's maiting address.
3. A. Workers Compensatfon Insurance:Part pfle of tt�poiicy applie.i ta the Workers Campensation Law of
rhe siazes listed hae:Massac}wseics
B. Employers Liability Insurance:pazy Two of the policy applies to work in each state Iisred in item 3.A.
The fimits of atr liability under pazt Two are:
State Balily Injury by Accident Bodily tnjury by Disease Salily Injeiry by Disease
$I�.O(IO each accident $500,000 policy Gmit $100,000 each employee
C. Ehher Stazes Iosurancc:Pazt'Fhcee of the policy appFies to t6e states,if anp,listed here:
r411 states except ND,OH,WA,WY and State(sj Designaied in Item 3A.
D. This palicy incfudes these endoise�nts and sctiedutes:S�Exbension oI Iuforntation Page
4. y'he premium�oc Uus palncy will lie dete�mineil by Qur 1Nanuxls of Rutes,Classificaiions,Raies and Raang
Ptans•AII infama[ion requiied betow is subject to verification and change by audi[
See Eatensiou.of fnfQnRadOR P3ge .. ._ __ . _
TOTAL ESTIMAT�ANNiJAL PRE1bIIUi�i 2�
STATfi ASSFSSMENT ?I
TOTAL ESTIAiATED CdST 2,f04
Minimum Premium 475
Issiie Date:2JI4l2U14 Counteisigneil by:
Authorized Representaave