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Home My WebLink AboutApplication and WC� � � � � � � �: : �°��'A�� TO WN OF YA � � RMOUTH Boardof ,".� _ � � Health � :._ � '� 1146 ROUTE 28, SOUTH YARMOUTH,MASSACHIJSETTS 02664-24451 - � #,,,s � ��`` 'r Telephone(508)398-2231,ext. 1241 Health 1"`"E Fax(508) 760-3472 Division � To: Yarmouth Business Establishments S�4s�D� Co�� From: Bruce G. Murphy, Director G� a�GC�DMCD Yarmouth Health Department� �� 5 � 2014 i Date: November 7, 2014 HEALTH DEPT. � � - _ _ _ Subject: Increase in License/Permit Fees - -- --- - - ; - _ _ : _ ; Please be aware that the Yarmouth Board of Health, under the direction of the Yarmouth Board 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 are 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 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 Public WhirlpooUVapor Baths $ 80.00 Tobacco Sales $ 95.00 Motels $ 55.00 �SS.oO Food Service 0-100 Seats $ 85.00 _��nd�e�}�e-4-}�g�=��€a�s-- -- _ ___$_1_�9�90_._— _--— ---- --- ---- - T.' ' � 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: 55-00 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 springprior to opening"on the application.J ' BGM/maf �,,,�,,,, .•-. � = � _.... ., .,... a�:� �� Q�� ` ✓ � TOWN OF YARMOUTH BOARD OF HEALTH �� ;5 2014 � � APPLICATION FOR LICENSEf�E _T�ZA �r- : � * Please com lete form and attach all necess oc eri�s��'D �� •T. Failure to do so will result in the ret of yo�r.app�ic ti . ESTABLISHMENT NAME: G� AX ID: LOCATION ADDRESS: 3� U 0 E � S• EL.#: 5�0 '39�- S33 MAILING ADDRESS: 5a��_ E-MAIL ADDRESS: OWNER NAME: t� CORPORATION NAME (IF APPLICABLE): v Y1GIA SSaL " MANAGER'S NAME: TEL.#: - -ZS 3 MAILING ADDRESS: � POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Ope ator(s) and attach a copy of the certification to this form. 1. _ 2. 1 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. 1 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. I j 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 st provide new copies and maintain a file at your establishment. ' 1. 2• PERSON IN CHARGE: Each fo establishment must have at least one Person In Charge (PIC) on site during hours of operation. '; � ; , _ _ - _ _ 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 ew copies and maintain a file at your establishment. � 1. 2. i 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 Heatth Department will not use past years' records. You mus provide new copies and maintain a file at your place of business. 1. PV 2. 3. 4. RESTAURANT SEATING: TOTAL# I OFFICE USE ONLY LODGING: i LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# � _B&B $55 CABIN $55 �MOTEL $110 ��OZ( i INN $55 CAMP $55 SWIMMING POOL$110ea. G _LODGE $55 TRAILER PARK $105 _WHIRLPOOL $110ea. i FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $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 VENDING-FOOD $25 <25,000 sq.ft. $150 =FROZEN DESSERT $40 TOBACCO $110 — �.. .. .... — �`;'?`'�. _ _ NAME CHANGE: $15 �� •� ' F�AMOUNT �UE _ $ I� O.OO *****PLEASE TURN OVER�D'"CO]G[Pt:EZ'E�B�SIDE OF FORM***** ^�-t i� �� .�1�3`� C��' � _ - ., I � ;_� ADMINISTRATION = � R Under Ck�apter 1��,Section ZSC, 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� OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED TowY of Yarmouth 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. i POOLS � t 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. i POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days o� � closing. ' -- - _ . F40D S�RvICE 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 Yarmouth Health Department by filing the j 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.varmouth.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 COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. --- _._ _— _ _ _; i NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETIJRN ; THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 15, 2014. ` I PAINTING, NEW � ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., i " EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR � TO COMM. NCEMENT. RENOVATIONS MAY REQUIRE A SIT PLAN. I ' SIGNATURE: �u�.l VC � DATE: I 3 i PRINT NAME& TITLE: �I ,YISZ. d wG�'G� d �an a Rev. 11/03/14 � � � i i � , � NOTICE N �' � NOTICE . i � w TO ' TO � : a : � ' EMPLOYEES -0 �= EMPLOYEES � T �� i �; 01 M Sv� � The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDEP�TTS ' 600 Washington Street, Boston, Massachusetts 02111 __ _ - __f 17-727�900 -- htt�:{/www.rn�s�.gov/dia _ _ _ _ __ M As required by Massachusetts General Law,Chapter 152,Sections 21,22&30, this will give you notice that I(we) have provided for payment to our injured employees under the above mentioned chapter by msunng wtth: THE TRAVELERS INSURANCE COMPANIES NAME OF INSURANCE COMPANY P.O. BOX 1450 MIDDLEBORO MA 02344-1450 � ADDRESS OF INSURANCE COMPANY (IEUB-2493L94-5-14) - 06-01 —14 TO 06-01 —15 POLICY NUMBER EFFECTIVE DATES �� BRIGHT AGENCY INC PO BOX 424 o� �..� � MILFORD MA 017570424 �— NAME OF INSURANCE AGENT ADDRESS PHONE# o� SEASIDE RENTAL ASSOCIATION 135 SOUTH SHORE DRIVE �� SOUTH YARMOUTH �� MA 02664 o,� 7��(D7n : .. ,__.. p, �]']�T�+ __. ___.r-..�,,.-------�-------_..__,_..�.— ,:, �-- �, '�-�`�EN�3Y�!?.: _.. . . . . . ., . ......,...,f��i�i�"3+�- _. .. .. ,�.� . .."_... . . .. � .. . . . #n � EMPLOYER'S WORKERS COMPENSATION OFFICER (IF ANY) DATE o� � '= MEDICAL TREATMENT � ^— The above named insurer is required in cases of personal injuries arising out of and in the course of �= employrnent to furnish adequate and reasonable hospital and medical services in accordance with the �= provisions of the Workers' Compensation Act. A copy of the First �teport of Injury must be given to the �= injured employee. The employee may select his or her own physician. The reasonable cost of the services a� provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably •� connected to the work re(ated injury. In cases requiring hospital attention, employees are hereby notifiect that the insurer has arranged for such attention at the ��_�- '� , ��; � �. . * - ___-------- __.--- NAME OF HOSPITAL ADDRESS o�e� W2oP��o2 TO BE POSTED BY EMPLUYER