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Home My WebLink AboutApplication and WCf , , O��'9R �� -�'` _\'�o TOWN OF YARMOUTH e��f � � —.� � `� 1146 ROUTE 28, SOUTH YARMOUTH, MASSACH[JSETTS 02664-24451 - � N �,� Ee� $ Telephone(508)398-2231, ext. 1241 �A C Nf Fax(508) 760-3472 Division To: Yannouth Business Establishments 5 K�ppE12 f��5-rp�U�qf�f- From: Bruce G. Murphy, Director � �'� Yannouth Health Department� � { .� y . ! �.,- )15 Date: November 7, 2014 I'r^,i TH G�pT Subject: Increase in License/Permit Fees Please be awaze 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. 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 applica$on after January 1, 2015. However, if you fully complete the application, and submit it to the Yarmouth Health Department with all required cer[ifications 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 Swiinming Pools $ 80.00 Public WhirlpooUVapor Baths $ 80.00 Tobacco Sales $ 95.00 Motels $ 55.00 Food Service 0-100 Seats $ 85.00 Food Service Over 100 Seats $150.OQ - �-?s � o0 y._ �a�. 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: � �pp.op coMnw��c.•, FunzE,.� DESSEi2T Total fees owed for your establishment: $ 2�o.C� 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 springprior to opening"on the application.J BGM/maf . � i - SK-tPPOz-�i. . . � � TOWN OF YARMOUTH BOARD OF HEALTH ' �p�j�;� '> a JQ15 �� APPLICATION FOR LICENSE/P.E �' : �� * Please complete form and attach a11 necessar7� . cumen s y ece er ,Q�4�-----"—� Failure to do so will result in the returt�;��yot)x:applicati pac cet. ESTABLISI-IMENT NAME: l e i ,-uf" ID: LOCATION ADDRESS: {�S� S ou�-h S h n n i� /J R 1 vZ TEL.#:�5 03 `� yy- '%�/0�, MAILING ADDRESS: /.S 1 .C"o ut/� .� � a/.` � d P 1 V t' S. I//( d,�,Mr�c/�/�, ..v� ki C��,L �/ E-MAILADDRESS: SK ,"pp�� CA�eC_ oD � AoZ-. C-o�-i OWNER NAME: �! L n u �. i7 e L.,�a,v-e�/ CORPORATION NAME (IF APPLICABLE): Y3 ��A Gh ✓!E i,v -� ,uC - MANAGER'S NAME: A N� D �L t . � TEL.#: / - -�'3�•" '.��j 2 MAILING ADDRESS: � �1 C c� � � 6� rrW I�J l� �' H 12 ,M nU�h f J+-t N C? ��G�f . 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. _ - L 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 Tile 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 estabiishment. i. �� J�-a� � z. PERSON IN CHARGE: Each food establishment must have at least one Person In Chazge (PIC) on site during hours of operation. 1. 2. ALLERGEN CERTIFICATIONS: All food servic8 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 �le at your establishment. 1.�L� ✓��c...�,J=/ 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-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. i. Q��` � `�� a. 3. 4. r ` RESTAURANT SEATING: TOTAL# OFFICE USE ONLY � LODGING: LICENSE REQUIRED FEE PERIGIIT# LICENSE REQIDRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $1t0 INN $55 CAMP $55 SWIMMINGPOOL$IlOea LODGE $55 TRAILERPARK $105 WHIRLPOOL $110ea. FOOD SERV[CE: '. LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �. 0-100 SEATS $125 CONTINENTAL $35 NON-PROFIT $30 ' �>100 SEATS $200 �3�C6J �COMMON VIC. $60 �� WHOLESALE $80 —RESID.KITCHEN $80 RETAIL SERVICE: ��. LICENSE REQUIRED FEE PERMIT# LtCENSE REQUIRED FEE PERMIT# LICENSE REQU[RED FEE PERMIT# �� <50 sq.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 '� =<25,000 sq.ft. $150 �FROZEN DESSERT $40 ��Ol� _TOBACCO $110 ; NAME CHANGE: $15 AMOUNT DUE _ $ �300.C�c� � *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*•*** �� _ _ _ �.,,_ �� , : 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� I, OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yazmouth 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 ciosing. FOQD SERVICE SEASONAL FOOD SERVICE OPENING: All food service establishxnents 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 obtamed at the Health Departrnent,or from the Town's website at www.y.armouth.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 resuit in the suspension or revocation of your Frozen Dessert Perxnit 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 Boazd of Health. OUTDOOR COOHING: i 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., PEIINTING, NEW , EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR , TO COMMENCEMENT. RENOVATIONS 'vIAY REQUIRE A SITE PLAN. ' DATE: SIGNATURE: ,, PRINT NAME&TITLE: � Rev.11/03/14 � ' � � The Commonwealth ofMassachusetts r Department of Industrial Accidents Office of Investigations I Congress Street, Suite I00 Boston,MA 02114-20I7 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Le¢iblv Business/OrganizationName: 7�1,e S'K��ppe2 rt �Sfctr�RA.rli __ _ Address: /S a. So�.�-h S' !� on� D2• s. Yib�E'HIou7'�i City/State/Zip: s'. 0 4't il aau�/i'hone #: So rS'- 3 9y-'%y0G Are you an employer?Check the appropriate box: Business Type(required): 1.[�I am a employer with employees (full and/ 5. ❑ Retail __ orpart-time).* ____ __ 6. �'RestauranUBaz/EatingEstablishment - - - - 2.❑ I am a sole proprietor or partnership and have no 7, � Office 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 corporarion and its officers have exercised 9. ❑ Entertainment their right of exemption per c. I 52, §1(4),and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]* 11.❑ Health Care 4.❑ VJe aze a non-profit organization, staffed by volunteers, 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 workecs'compensation policy information. **If the cocporate officers have exemp[ed themselves,but the corporation has otha employees,a workers'compensation policy is required and such an organi��tion should check box#1. I am an employer that is providing workers'compensation insurance for my employees. Be[ow rs the policy information. Insurance Company Name: M Pt l�.e t a�'C. M e rr c h�.uts ui'C G�o Yp.Z n.c . Insurer's Address: Dn �o X �s 9 �a a- 9�� a BRain-�-n�Q .�l J4 � �� g�^ �— City/State/Zip: �2 a t A/'f"2-G? i ✓t'1 X� Q a/ �.5 Policy#or Self-ins.Lic.# � /�D DS�43�,L 7 8 I!S Expiration Date: / o/ /6 Attach a copy of the workers' compensation policy declaration page(showing the policy number a d eapirafion date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a — —___— _ _ _ - fine up to $1,500.00 and/or one-yeaz imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be fonvazded to the Office of Invesrigations of the DIA for insurance coverage verificarion. I do hereby cenify,under the pains andpena[ties ofperjury that the information provided above 's true and correcx �jJ� Si ature: ��%//1�� Date: � �2r I�� Phone#: __ '7 7 y �3 d' � �t��' Offictal use only. Do not wrue in this area,to be completed by city or town o�ciaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2. Building Department 3.City/Town Clerk 4.Licensing Board 5. Selectmen's Office 6.Other Contact Person: Phone#: www.mass.gov/dia CERTIFICATE OF LIABILITY INSURANCE °"'�""'°°^""�' 02l0212075 THIS CERTIFlCATE IS ISSUm AS A YATIER OF INFORYATION a1LY AND CONFERS NO WC�FITS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFlRNATN�Y OR NEGATIVELY ANEND,E7fTEND OR ALTHt Tt�CO�AGE AFFORpEp BY THE POIJCIES BELOIN. THIS CERTIFICATE OF It�URANCE DOES NOT CONSTITUTE A CONTRACT 661NIEEN THE IS�IING IN8URER(S�AUTHORI�D REPRESBiTATNE OR PROpUCHt,AND THE CERTIFICATE HOLpER. IA�WtTAWT: HMe certllk:a0a holtlar is an ADDRWNAL YiSUR�.fM polky(Ns)miut be erMo�aed. If SUBROGA710N IS WANm.sableet to fMtxms mW caMitlorm ofths po0qr,artain PdkMs maY►epWre a�erMorawns�k.A�on Ws certlflmEa doea not ea�fx Nphls to IM cettlNcaEs holder in qeu af suth s � � David Schofield SehofieW Insurance Services � 508 376-5464 F� 5p8 376-54B8 1702 Main Street � dschofie hofieldi�urenceservices.com Millis MA 02054 � w � a w wucs � e: Beachview Ine.DBA The Skipper Restaurant 152 South Shore Drive Sarth Yartnarth MA 02664 : MA RMail Mercharrts WC Grou Inc. COVERAGE,4 CERTIFICATE NUA�R: REVIS�ON NUYBER: THIS IS TO CERTIFY THAT 7HE POUCIE$OF INSURANCE L1STE0 BELpW HpVE BEFN ISSUm TO THE INSURED NAhEDABOVE FOR THE POLICY PERIOD INDICAiED. lb7VNTHSTANDING ANY REpUIREMENT.iS2M OR CONDITION OF ANY COlITRACT OR OTHER DOGUMENT WI7H RESPECT TO WHICH THIS CERTFlCA7E MAY�ISSU�OR MAY PERTAIN.THE INSURMICE AFFORD�BY h1E POLICIES�SCRIBED HEREIN IS SUBJECT TO ALL 7HE TERMS, IXCLUSIONS AND CONDITIONS OF SUCH POLIC�S.LJA�6TS�1Rd MAY HA�BE�i REDUCED BY PAID CLAMAS. rmEaFweuuxc� °�� ung ae�uutNeurr fACHO RR@I CMO.�2Cwt CaBFlWL LIR&LIfV MINGE W RBt�FD CIAAASM�DE ❑OCCUR IXP aM f aoesaivanoviwuar ncc�cntE s �aer r�rt �O' wc s �uraros.E weurr cw�eu+�srrc��aer ANYAUTO 900N.YVLIIMYrywprson) f � � 900lVIMIURY(ParamOrY) 9 FIW�MITOS � PROPHifVOMUGE t S 11�PH1111l�B �.� FAGI �� fE S MIOPoI6K001lBISR7qN WCSfATL OR� NID BiLOyERB•L11�NJTy X E ��occwo�r n N+A 014U05032678115 01/Ot/2095 07/0112076 EL n�r 500000 M�b��i0a � EL WSEASE-EA 5W OOO EL -voucruwr 600000 n�noxa�avernta�miwc�Tcxsrv�q.�la�.mwcaww+.�emaxr�w..t.sa.sa.,s.on.pernpiw� CERTIFlCATE HOLDER CANCELLATION Town of Yarmouth ��T►��ES BE GxCe.►ID e� 1146 Roule 28 � � �� • �� ' � � w nCCORo11HCE YYtM iNE PGt.IGY PROv�IDqB. South Yarmouth,AAA 02664-4492 �wnq��t�twe <MS> — `�� 1986-2010 ACORD CORPORpTpN. AH riphls reserved. ACORD�(T070J08) TM ACORD nams and bgo ae rpiaberad mub of ACORD r � NOTICE NOTICE TO TO EMPLOYEES EMPLOYEES The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 1 Congress Street, Suite 100, Bostoq Massachusetts 02114-2017 617-727-4900 - http://www.state.ma.us/dia As required by Massachusetts Geaeral Law,Chapter 152, Sections 21,22�30,this will give you�tice that I(we)have provided for payment to our injured employees under the above-mentioned chapter by insiuing with: MA Retail Merchants WC Group Inc. NAME OF INSURANCE COMPANY PO Box 859222-9222 Braintree,MA 02185 ADDRESS OF INSURANCE COMPANY 014005032678115 1/O1/2015 - 1/O1/2016 POLICY NUMBER EFFECTIVE DATES Schofield Insurance Services, 1102 Main Street Millis,MA 02054 508-376-54f NAME OF INSURANCE AGENT ADDRESS PHONE# The Skipper Restaurant 152 South Shore Drive South Ya�uth,MA 02664 IIvIPLOYER ADDRESS ENIE'LOYER'S WORKERS' COMPENSATION OFFICER(IF ANY) DATE MEDICAL TREATMENT The above named insumx is required ia cases of peisonal injuries arising out of and ia the co�se of employme.nt w finnish adequste and reasonable hospital and medical services in accordance with the pmvisions of the Workers' Compensation Act A copy of the Fust Report of Injury must be given to the injured employee. The employee may select}ris or her own physician. The reasonable cost of the ser- vices provided by the treating physician will be paid by the insurer,if the h+eaimem is necessary and reasonably connected to the work related injury. In cases requiring hospital atte�ion,employces are hereby notified that the insurer has arranged far such atte�ion at the NAME OF HOSPTl'AL ADDRESS TO BE POSTED BY EMPLOYER