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Home My WebLink AboutApplication and WC . , '��°��R'�[ T O W N O F Y A R M O U T H Bo�d of — Health � -� ' y 1146 ROUTE 28, SOUTH YARMOUTH,MASSACHLJSETTS 02664-24451 - �. t, o'� :r Telephone(508)398-2231,ext. 1241 Health t t,CMf`` Fa�t(508) 760-3472 Division To: Yarmouth Business Establishments CppE��5 lN p�Gc�OC�7GDD From: Bruce G. Murphy, Director J�1�V 13 2015 Yarmouth Health Deparhnent HEALTH DEPT. Date: November 7, 2014 s p� e c,r��,��, ?�� Subject: Increase in License/Permit Fees e,,. e:�,�c� 4„��;!L ,� Please be awaze that the Yazmouth Boazd of Health, under the direction of the Yazmouth 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 Yannouth 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 l, 2015. However, if you fully complete the application, and submit it to the Yarmouth Health Department with a11 required certifications and worker's compensation coverage information (certificate of insurance OR completed �davit) 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 , pC� Public WhirlpooUVapor Baths $ 80.00 Tobacco Sa1es $ 95.00 Motels $ 55.00 �5S•C�O Restaurants 0-100 Seats $ 85.00 - Res�nrants Over i 00 Seats - $'.6�.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: $135.00 NOTE: To be entitled to pay the current 2014 rates listed above, your business application, food and/or pool certifications, along with worker's compensation information must be received, or mailed (postmarked) on or prioe to DeCember 31, 2014. [Those establishments which open in the spring will be allowed to provide food andlor pool certtfzcations prior to opening, however, you must note "Will provide in the springprior to opening" on the application.J BGM/maf : C1a PE TR-A JE�EGZ� a TOWN OF YARMOUTH BOARD OF HEALTH �� APPLICATION FOR LICENSE/PERMIT-2015 * Please complete form and attach all necessary documents by December 15 2019. Failure to do so will result in the return of your application pac et. ESTABLISHMENT NAME: TAX ID: - I LOCATION ADDRESS: — . ocYYY��- TEL.#: 5O$- 16 MAILING ADDRESS: � � C'r'lS�M �(`(� -026�1 E-MAILADDRESS: vel e� -•�tiW� OWNER NAME: CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: S �n G• 1n c� � TEL.#: '� � � �� MAILINGADDRESS: � G'��M611. ^M - O2G�1 POOL CERTIFICATIONS: IU. P�V� M7E G�`�� W�� P�OL �� 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. - — f -- -- 1. �\ � - 2. 1'� � Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cazdiopulmonary 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 establishxnents 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. 1. Z• PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. _ 1 _ _ Z _ _ 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 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. 1. 2• 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# L CENSE REQUIRED FEE P RMIT# B&B $55 CABIN $55 �MOTEL $t10 �15T0�S� INN $55 CAMP $55 �SWIMMINGPOOL$1(Oea i�lT_O LODGE $55 TRAILERPARK $105 _WHIRLPOOL $110ea . FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# L[CENSE 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 PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq.ft. $50 >25,000 sq.ft. $285 VENDMG-FOOD $25 =<25,OOOsq.ft. $l50 —FROZENDESSERT $40 _TOBACCO $110 . NAME CHANGE: $l5 AMOUNT DUE _ $ � ZZO.O O � *•***PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*•*** i � � ADMINISTRATION Under Chapter 152, Section 25C,Subsection 6,the Town of Yazmouth 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 WOItKER'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 taaces 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 ofMotel 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 thirly(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 Deparhnent 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 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 Yazmouth must notify the Yarmouth Health Departrnent 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 CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. OUTDOOR COOHING: ' Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. NOTICE:Permits run annually from Januaty 1 to December 31. IT I5 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 j TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. � DATE: SIGNATURE: PRINT NAME& TITLE: . Rev. 11/03/14 �,, � '� The Commonwealth ofMassachusefts Department oflndustrialAccidents � Offace oflnvestigations ' I Congress Street, Suite Z00 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Apulicant Information Please Print Leeiblv Business/Organization Name:�� ,.Y�e.�-Qra� . `�1� . ___ Address: �Q'a- �Q,�Y� SC' .� • City/State/Zip: , d.'� � Phone #: -�-� O� -� �"1 - �i�11 6 Are you an employer? Check the appropriate box: Business Type(reqnired): 1.❑ I am a employer with employees(full and/ 5. ❑ Retail or�art-rime).* 6. ❑ RestaurantBaz/EatingEstablishment - 2.❑ I am a sole proprietor or partnership and have no 7. � pffice and/or Sales(incl.real estate, auto, etc.) employees working for me in any capacity. [No workers' comp. insurance required] 8• ❑ Non-profit 3.❑ We are 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. inswance required]* 4.❑ We aze a non-profit organization,staffed by volunteers, 11.❑ Health Caze 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 wodcers'compensation policy infotmation. **If ihe coiporate officecs have exempred themselves,but the corpora[ian has other employees,a workers'compeasarion policy is required md such an organiTation should check box#I. I am an employer that is providing workers'compensation insurance for my employees. Bel�is the policy informatioa Insurance Company Name: ��C_� \Pe1 Q�.^ �Yl S!l\1C1�'Yl C,E� ��S�M � Insurer's Address: ��-1. M�_'Y�_��' City/State/Zip: y �<tS^(Y�Cst�\� . '6Y�'� - � `�6 � � � Policy#or Self-ins.Lic. # �C �C�d q��O �1a3 Expiration Date: � - �2 '� �� Attach a copy of the workers' compensation policy declara8on page(showing the policy nnmber and expiration date). , Failure�o secure cov_erag_e as_required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ' _ _- - _ - — - + fine up to$I,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 Investigations of the DIA for insurance covemge verification. I do hereby certify,under the pa' s and Ities of perjury that the injormation provided above is tr e and correct. Si ature: Date: '�1 �� ' ` Phone#: ' - G6a�. Officia!use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# , Issuing Authority(circle one): 1.Board of Hea1tL 2. Building Department 3.City/Town Clerk 4.Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone#: www.mass.gov/dia �� . • � - CERTtF(CATE OF LBABILITY tNSt1t�NCE ��- � 4 7FIB I�RTHACATE IS �S&1Fp AS A 91A1TER OF iNFORlAA7ION OM.Y AND CONF�tB t� RIBHTS l�i SFIE �27'�11CI17E� HGL1f5R Ti93 � CERT�CA7E OOES NOT AFFHtId0.TIVELY �2 NECiATN�Y AEEND, E7RB�1D OR Al'f�t St� � � � AUTHOi�D BELOW. THIS C�ATE OF H�URANCE OOES N6T CONS7lTifiE A CONTRACT BETW�I TH& I�UR7G WSUR621a� R@PRESENTATNE OR PRODUCBi.APAS 7 Ws Cftif iFlCA'[E H6LOHL ilta uid6eeb fs an . Pu } must �deesar7• i� the temis snd coadBtarre oF Hm po9�I. certetn PoBei� maY �B m� ando� A �aM w� th(s �e do� mt w�ar �tgFffi to tl�e � oarNfltete holderin dw Of such w�uraemeM(s} aaenueat � P99L SC� � B�GBL E�SORaNC6 H�S �C ya : 508—T71-6381 pu.� 08—T71-0663 .. 34 P9►A7 STRBffiT � � @VffitI80N.�T L4EST YARMODTS M& 02679 ��m , @�p�G00�GgE MAlea @78tIRfiD �ARR89�S Bt1C�jE �Y9= COYQGIdt.7.0II �0: . 1 &ZDDH9RCH LBNF+ o�e: � �D: 3oSbmok, ffi� 02963 �� mwmetn: COVERAGES CEklIFICATE M1BI�R: REtliBION I� THIS T 7FE POLIC� USf� BB.OW HAVE ISSU� � Tiff WQM.A7H1. NOl1VRHSTAP�IMG ANY RBCU6iBdBdi'. TERM OR CONDRION � ANY CONiRJ1CT OR 6ffSt �t'1.NdH�t! WRH � 'N YYF9di TF� CERTIFICATE MAY 8E ISSIIED OR WlY P@tTNN. TF� IN6URANCE AFFOROF� BY 'ft� POIJGff8 DESCR� H�d A4 SIIB.�CT TO ALL 7HE T88AS, � IXClUS10NS AEID C.ONDR10t��StICFf PdJCif�.LNfliS SHOWN NAY HAVE BEB�1 R�Uf�BY PA�CW k18• un m�e�uS�Wes mn euim rmaveao�e P�aTrrvl �*ni ��s ae�a+n�unennr �unxe� s C�IBAHZCW.Ca@BtPLUPH9IIY � a 8 � ❑� A�F�WqamP�B S P618WUI.8MVBYIWY 8 I�BiPLA� g Pp�aRIS-�AGB 5 f3BdLM�7E{8tllAPPL@S PHt 5 POIJGY 'p1:T � �ffidelElAAI' RViaEAO&lBtN&!!I•! ' ��p� S AMlAUfO �.YNAAlYWmO�N $ ALLWNNEDAUIOS . H�.YWAkNW�� s 6CI�lE.�AVI0.4 �� 3 �� 5 tlON-0YNi�AUf08 S 10181�3ANA8 � E�CiI� S • IXE�S VAB ' POBRE8R18 S 5 �� S f�IBi0IX7 S 8 WORI�iSCOEi�@78p9�i � �JpQQf$({� lBHiS At�5�4CYEHBW8l1r! YfN . . �, -� ELEWIACC�7f $ LD�i�� g1pp.W�1 ❑ 87A . EL�_MBWDYff 5 1�0��0� IM�awYmb9 uK,,��m. � - E,i,�_�uer s 500,000 . oasanwtw�+�ovawmamm -- oese�avnoxoroama�otmrwea�ervem.�t�ncam+m.amnmmxoommsmmmaumw��u . � �a—ye� " - . � CANCEI.lAT[ON '4'ocea OPH�osf�.e � - ' ' Cage.�save9es� � sxom.n axr ov n��aeave o��, m va[ic�s ee crwca�.� � �.�ae64A1gY� Ax�eaexewrtxrt��roc�xowsiol aonce mm.�. eE osnre�v w R�dag�[ua�ea'� / '+N�ffsemo�B�adE�6'13 � . r� j � 11gF1�.41@58NE ae0t�25��D - �aacot4�at�sreasagoaas�� r • �+\ , �i NOTICE N � NOTICE TO � a TO : EMPLOYEES 4� EMPLOYEES 7 `4 .�M SV6 V� The Commonwealth .of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston, Massachusetts 02111 617-727-4900 — http://www mass.gov/dia As uired by Massachusetts General Law,Chapter 152,Sections 21,22&30,this will give you nodce that I�(we) have provided for payment to our injured employee.c under the above mentioned chapter by msuring with: TFE TRAVELERS INSURANCE CWAPANIES NAME OF INSURANCE COMPANY P.O. BOX 7450 MIDDLEBORO MA 02344-1450 ADDRESS OF INSURANCE COA�fPANY (7PJUB-6800245-0-14) 05-22-14 TO 05-22-15 POLICY NUMBER EFFECITVE DATES � m� SCHLEGEL & SCHLEGEL INS 34 MAIN STREET �� YIEST YARNpUTH MA 02673 = NAME OF INSURANCE AGENT ADDRESS PHONE# .� a� BRIDGE OVER CORPORATION 1 SIDDHARTH LAPE '� I�LBROOK � .� MA 02343 � EMPLOYER ADDRESS � � s EMPIAYER'S WORKERS COMPENSATION OFFICER(IF AN� DATE „'�� MEDICAL TREATMENT ^� The above named insurer is requ'ued in cases of personai injuries arising out of and in the"course of �� employment to furnish adequate and reasonable hospital and medical services in acmrdance with the � provisions of the Workers' Compensarion Act A copy of the First Report of Injury must be given to the � injured empio}�e. The employee may select his or her own physician. The reasonabie cost of the services provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably •� connected to the work related injury. In cases requiring h�pital attention, emptoyee.s are hereby notified that the insurer has arranged for such attention at the NAME OF HOSPTTAL ADDRESS � �oP,� TO BE POSTED BY EMPLOYER