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Home My WebLink AboutApplication and WC f s . ; �°�� FYARMOUTH Boardof `� � R _ s ��, TOWNO � : � Health �; � Q -�. _ �`� 1146 ROUTE 28, SOUTH YARMOUTH,MASSACHLJSETTS 02664-24451 Health �'; �.� �a+� . Telephone(508)398-2231,ext. 1241 Division �� T f�z"�` Fax(508)760-3472 ' ar� c�� To: Yarmouth Business Esta.blishments ��LC-�(Z(M ��ES VII,C.A6E �� g 2Q1� From: Bruce G. Murphy, Director C� HEALTH DEPT. Yarmouth Health Department� Date: November 7, 2014 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 a11 required certifications and worker's compensation coverage information (certificate of insurance OR completed �davit) nrior 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 �8o Yoo Public WhirlpooUVapor Baths $ 80.00 Tobacco Sales $ 95.00 E Motels $ 55.00 � Food Service 0-100 Seats $ 85.00 � Fo�l S�-i:,e Over �00 Sea�� -- - -- -_ �1b{3:�J_ , ____---- _ 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: Tota1 fees owed for your establishment: �SO.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.J ' BGM/maf ,� � I �_�_.._----__.__�_.._.o-- � , , � � TOWN OF YAR�IOtJTH BOARD OF HEALTH � � APPLICATION FOR LICENSE/PER.1kIIT-201 ��4 �°'�DEC 19 1014 ' �""P * Please com lete form and attach all necess docu�.en eem er � p � y� �� 'DEPT. i Failure to do so will result in the return of your application pa ESTABLISHMENT NAME: i f►m ( f � G� TAX ID: � - LOCATION ADDRESS: �I 6 ��v��,I,IJ �� TEL.#: MAILING ADDRESS: �.O ."`1��F .'��,3 ��UQ�1n'lo � y!'Jq. �11�(j�/ E-MAIL ADDRESS: /vo nQ, OWNER NAME: CORPORATION NAME(IF QPPLICABLE): MANAGER'S NAME: .,� Q�Q TEL.#: / – MAILING ADDRESS: �D i�4 POOL CERTIFICATIONS: �Q �� `j(�,(�ICl/��C e, 6'�➢ � "�. The pool supervisor must be certifi'�d as a ool Operator,as require by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. — --_ ------- 1. -- — _ 2 _ � Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid ' and Community Caxdiopulmonary 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 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 n w c pies and maintain a file at your establishment. ' 1. 2. PERSON IN CHARGE: Each food es blis ent must have at least one Person In Charge (PIC) on site during hours of operation. 1. _ _ 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 n w pies 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 a11 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 p vide 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 _c�P $55 MOTEL $110 I� $55 .�SWIMMING POOL$I l0ea p /' �' _LODGE $55 _TRAILER PARK $105 _WHIRLPOOL $110ea. ' I FOOD SERVICE: r LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# � 0-100 SEATS $125 _CONTINENTAL $35 NON-PROFIT $30 , >]00 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: $�s AMOUNT DUE _ $ l!t� _p U I ****�PLEASE TURN OVER AND COMPI,,ETE OTHER SIDE OF FORM***** �C � � ��r O� ___________ ____ c�� a� t�� 1 . , , ADMINISTRATION '� i _. � 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 f OR � ' . AFFIDAVIT SIGNED AND ATTACH� � WORKER S COMP Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: � ,` � YE�J N� � MOTELS AND OTHER LODGING ESTABLISHMENTS f TRANSIENT OCCUPANCY: For purposes of the limitations ot 1vlotel or Hotel 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 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 f 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 axea until the pool has been inspected and opened. i POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standaxd 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. FQOD SEItVICE� ', i 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 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 tertns have been met. 4 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 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 ESTABAND APPROVED BY�THE OARD OF HEAL HGPRIOR ' ; EQUIPMENT,ETC.),MUST BE REPORTED TO � TO COMMENCEMENT. RENOVATIONS MAY REQUT A SITE PLAN � SIGNATURE: ; DATE: I � � ' pRiNT NAME&TITLE: � � '� . � Rev.11/03/14 " ' � The Commor�wedl�'h ofMassachusetts Department of Industrial Accidents L: - Office of Investigations ' 1 Congress Street, Suite 100 Boston,MA 02114-2017. www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses A licant Information Please Print Le 'bl � p �� Business/Organization Name: r!J'� C r-�� 1 � � � l �J l', Address: � �I�-�U� � Ir� �O r� U ��U�7 �� a�� City/State/Zip: �� Phone#: 9�� '��y Are you an employer? Check the appropriate boz: Business'I�pe(required): 1.❑ I am a employer with employees(full andl 5. ❑Retail or part-time).* 6. ❑ RestaurantlBar/Eating Establishment - --- ---- . - - - — - - - --- 2. I am a sole proprietor or partnership and have no �, � 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 corporation and its o�cers 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.❑ Health Care 4.❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.0 Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#1. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: Insurer's Address: City/State/Zip: Policy#or Self-ins.Lic. # Expiration Date: Attach a copy of the workers' compensation policy declaration page(showing the policy number and ezpiration 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-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 forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify, nder the pains and p alties ofperjury that the information provided above is true and correct. Si ature: Date: � l Phone#: 1 � Official use only. Do not write an this area,to be completed by city or town officiaL 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: ______.__..____ __ .__ ._____._--}s�rone#: www.mass.gov/dia