HomeMy WebLinkAboutApplication and WC r
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°� �R� TOWN OF YARMOUTH Bo�dof
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� '" �, Health
� —� � 1146 ROUTE 28, SOUTH YARMOUTH,MASSACHLJSETTS 02664-24451 -
�: �,�T ' �;'� '� Telephone(508)398-2231,ext. 1241 1�s n
T'�z"�' Fax(508)760-3472 �
To: Yarmouth Business Establishments �� Ou-r���1��C ,
From: Bruce G. Murphy, Director C� ' o
RGGC�OMC�D
Yarmouth Health Department
JAN 06 ?.015
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 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 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 affidavit) 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 Whirlpool/Vapor Baths $ 80.00
Tobacco Sa1es $ 95.00
Motels $ 55.00
Food Service 0-100 Seats $ 85.00 �
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Food Service Over �60 �eats $1 bU.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 ab ve: o. o c�M��tc.
Total fees owed for your esta.bli ent: �l�5•
NOTE: To be entitled to pay the current 201 rates listed above, our
business application, food and/or pool certific tions, along with wor 's '
compensation information must be received, o 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 apening" on the application.J
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�► TOWN OF YARMOUTH BOARD OF HEALTH ,
� � APPLICATION FOR LICENSE/PERN�IT�,20� -
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�"'" * Please complete form and attach all necessary doc�.rn er l� 2014. ;
Failure to do so will result in the return of yc�r app�a�t4�-�� et:�`' '
ESTABLISHMENT NAME: OU TAX ID: ` I
LOCATION ADDRESS: Co I U (��A TEL.#: �dS �03��`�� I
MAILING ADDRESS: lo f p o�� c�� o�,(w�o p(k I'1'1 . 7
E-MAIL ADDRESS: n C �cc, u ,r.6m
OWNERNAME: �t ���. �u
CORPORATION NAME (IF APPLICABLE): �I A,�IC-S D��iG,[,k ��
MANAGER'S NAME: Dna✓B�r� TEL.#: 6 (o,� �a- :
MAILINGADDRESS: Il� �� (��1 �i VN-OV 0 V►'1t4 0�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 certification to this form. �
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1 _ 2 _ ,
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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. �4
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
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 i
Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. j
Please attach copies of certification to this application. The Health Department will not use past years'records. k
You must provide new copies and maintain a file at your establishment. ;
1. ��L�'t� �b (��vl Lj 2. 2t L�L �G�(�'cL�.b :
PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
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1. ���L�C �6 r1 Ot���G, 2. ���.t.L ��li'"�l.�''�t _ i
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. �i a n� ��.�ak� 2. P��.r Co��,�n 5 i
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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 '
atta.ch 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, 1 O V�� (J��a.. 2. (�h`G���55G� W�C.I����
3. � h.a- � 4.
RES
TAURANT SEATING: TOTAL# j�
_ _ r
OFFICE USE ONLY
LODGING: '
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# i
B&B $55 CABIN $55 _MOTEL $110 �
INN $55 CAMP $55 _SWIMMING POOL$110ea. �
LODGE $55 TRAILER PARK $105 _WHIRLPOOL $I IOea.
FOOD SERVICE:
LICENSE REQUIRED FEE P RMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
I 0-100 SEATS $125 ���� CONTINENTAL $35 NON-PROFIT $30
>]00 SEATS $200 �COMMON VIC. $60 _�9 _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 _VENDIN
=<25,000 sq.ft. $150 —FROZEN DESSERT $40 _TOBA O $110
NAME CHANGE: $15 �UNT DU = $ I,4�•O�
���������
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM****
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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 1NSURANCE ATTACHED V
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 ti/ N�
MOTELS AND OTHER LODGING ESTABLISHMENTS �
TRANSIENT OCCUPANCY: For purposes of the limitations of'Motel or Hote1 use, Transient occupancy sha11 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 thiriy(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 ha�e 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
closing.
FOOD SERVICE t
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
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.
S
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,_pr�aration,or display of any food product by a retail or food service establishment is prohibited. ,
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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 y
EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR �
TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
DATE: I a l r�}`��(�-1 SIGNATURE: ���
�
PRINT NAME&TITLE: �6 n���r�k� D W Y�Gi2-
Rev. 11/03/14
� � � The Commonwealth of Massachusetts
Department of Industrial Accidents
� Office of Investigations
� 1 Congress Street, Suite l00 '
Boston, lVfA 02114-2017 '
www.mass.gov/dia '
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Le�iblv '
Business/Organization Name:�� (�J�3(J�.�L �
Address: ��O I �6 U l�14
m
City/State/Zip: Gt;�h�t.OU� o a�� Phone #: �g ,3(��(���b
Are ou an employer? C eck the appropriate boz: Business Type(required): ;
1.� I am a employer with�employees(full and/ 5. ❑ Retail
or art-time).* 6. [�RestaurantlBar/Eating Establishment �
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2. I am a sole proprietor or partnership and have no �, � Office and/or Sales(incl.real estate,auto,etc.)
I
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. insurance required)* 11.0 Health Care '
4.❑ We are a non-profit organizaxion,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 workers'compensation policy information.
**If the corporate o�cers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an '
organization should check box#L
I am an employer that is providing workers'compensation insurance for my employees Below ds the policy information.
Insurance Company Name: I'f��J�L��q
Insurer's Address: ��D D C��GU I'\ �p�O IL`'� �(i J �G '
City/State/Zip: �j V 1�/l L 1^�Y� D�� � � ;
Policy#or Self-ins. Lic. # Q����'1�a�� Expiration Date: ��I�I��
Attach a copy of the workers' compensation policy declaration page(showing the policy number and ezpiration da'te).
---- �'�ure tasecurE r.o�erage as requirEd under_SectiQn�5 A of M('Ti,c._�_can lead_tcztl�e ir�po�tion_of criminal�enalries_of a ` _ '
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 I
of up to$250.00 a day against the violator. Be advised that a copy of this sta.tement may be forwarded to the Office of ',
Investigations of the DIA for insurance coverage verification. '
I do hereby certify,under the pains and penalties of perjury that the information provided above is true and correct.
Signature: �//�i��'��'� Date: I�Ia'R��I I
Phone#: �Ug �l� ��R �
Official 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): ',
l.Board of Health 2. Building Department 3.City/Town Clerk 4.Licensing Board 5. Selectmen's Office
6.Other
� � ��� ��
��a����
Contact Person: Phone#:
www.mass.gov/dia
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NQ'�'ICE ��
NO�iCE
TO T�
EMPLOYE�S � EMPLOYEES
The Commonwealth af Massachusetts
DEPARTl�IENT OF INDUSTRIAL ACCIDENTS
b00 Washingtou Street,Boston,Massachusetts 02111
617-727-4900-http://www.mass.gov/di�
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 meationed chapter by
insuring with:
Arbella Protectian Insurance Company
?�iAME OF INSURA�CE COMPANY
_ 1100 Crown Colony Dri�e,Quincy,MA 02169
ADDRESS OF INSLR�iNCE COMPANY
#9124871214 12J04/14-12/04/1S
POLICY NUMBER EFFECTIVE DATES
Rogers & Gray Insurance Agency. 434 Route 134 South Dennis,MA 02660
'�A?viE OF INSURANCE AGEhT ADDRESS
Siack's Outback,Inc.
DBA Jacks Outback II 161 Main St. RT frA BLDG 2 Yarmouth ort,MA Q2675
EMPLOYER ADDRESS
EMPLOYER'S WORKERS C`fNv(PENSATIO�OFFICER(IF ANY) DATE
MEDICAL TREATMENT
The above named insurer is required in cases of personai injnries arising out of and in the course of
employment to furnisl� adequate and reasonable hospital aad medical services in accordance with the
provisians of t�e VVorker's Compensation Act.A copy of t�e First Report of Iajury mast be given to the
injured empioyee. T�e employee may select his or her own physician.The reasonable cost of the ser-
vices providecl b�the treating physician will be paid by the insurer,if the treatment is necess�ry and
reasonably co��ecier� to the work relatea imjur��, I�cases requirin���pj�attention,employees are
hereby notifiecl that the insvrer has arranged for such attention at the
Name of Hospital Address
SC�►����
TO BE POSTED B� EMPLOYEI�-�