HomeMy WebLinkAboutApplication and WC 41"
TOWN OF YARMOUTH Board of
-- � Health
J `1 1146 ROUTE 28, SOUTH YARMOUTH,MASSACHUSETTS 02664-24451
N Egg¢,r Telephone(508)398-2231,ext. 1241 Health
Prot`"E Fax(508)760-3472 Division
To: Yarmouth Business Establishments Pay A tE 6Q-t
{
From: Bruce G. Murphy, Director
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 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, ifou fully y com 1
p ete 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 3L 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 Sales $ 95.00
Motels $ 55.00
Restaurants 0-100 Seats $ 85.00 $85.o0
Restaurants Over 100 Seats $160.00
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: G,o oa co oN\tic•
Total fees owed for your establishment: t tis.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.]
BGM/maf
.0-- TOWN OF YARMOUTH BOARD OF HEALTH
fli i APPLICATION FOR LICENSE/PE ' T-,20t5
*„ _ ,��{021 - t3 E`
J * Please complete form and attach all necessary •ocuments by December 15, jO l4.
Failure to do so will result in the return of your application packet.. .--
ESTABLISHMENT NAME: I.*VA L la 6Z.a.r.7 v RA vT d►.O4).Lit TAX ID:
LOCATION ADDRESS: q/5 mer: '+ SPA.0 .y�►r r79,/h 04t+�C'TEL.#: 5'0 a-Asir �B8
MAILING ADDRESS: �!..w-c a+‘ -6are - � j
, E-MAIL ADDRESS: g2Pe9y463. b . of. Q6_ 5 "..:,.r.4„+ -.
OWNER NAME: 40 S.T•C.e C C int IA ) I t. 4�• %.
CORPORATION NAME (IF APPLICABLE): 14.i3. 'P?t-2-+4fi-p..)c-
MANAGER'S NAME: friCZ,t,t f o L o r+0-$2 TEL.#: $1.8-7ZL-2/gr
MAILING ADDRESS: f o gos.vV Pt Y 13..hw•'4 10,..J- rr►44 o I.&? ?
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.
I 1 2.
Pool operators must list a mini 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 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
Code for Food Service Establishments, 105 CMR 590.000.
Protection Manager, as defined in the State Sanitary
g �
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.
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PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
1. coo L 6 l-I? 0->7 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 new copies and maintain a file at your establishment. .)
1. i)1P0( 6-o ..W\2- 2. w `
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. �p '
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3. / 4.
RESTAURANT SEATING: TOTAL# ?'
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
B&B $55 CABIN $55 MOTEL $110
_INN $55 CAMP $55 _SWIMMING POOL$110ea.
LODGE $55 TRAILER PARK $105 WHIRLPOOL $110ea.
FOOD SERVICE:
LICENSE REQUIRED FEE P. RMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
0-100 SEATS $125 /5•-003 CONTINENTAL $35 _NON-PROFIT $30
>100 SEATS $200 _j__COMMON VIC. $60 4 --�- 3 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 AMOUNT DUE = $ i 8 S-00
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The Commonwealth of Massachusetts
Department of Industrial Accidents
z_ =
� Office of Investigations
_mini
q. 1 Congress Street, Suite 100
Boston, MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name: Q..D`//A L OQ-G srt Ay 44 CJI- t 64 1'4,, E.
Address: TVS r.:n 4g) 4$411-
City/State/Zip:
)4City/State/Zip: yppor erio X44- O24 K Phone #: ,g'08 36„?-r'%2. S
Are you an employer? Check the appropriate box: Business Type(required):
1.❑ I am a employer with employees(full and/ 5. 0 Retail
or part-time).* 6. 711 Restaurant/Bar/Eating Establishment
2.0 I am a sole proprietor or partnership and have no 7. ❑ Office and/or Sales(incl.real estate,auto,etc.)
employees working for me in any capacity.
[No workers' comp.insurance required] 8. Non-profit
3.X We are a corporation and its officers have exercised 9. 0 Entertainment
their right of exemption per c. 152, §1(4), and we have 10.❑ Manufacturing
no employees. [No workers' comp. insurance required]** 11.0 Health Care
4.❑ We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp. insurance req.] 12.0 Other
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
**If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an
organization should check box#1.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information.
Insurance Company Name: CT v Ael> /4)$&.' ø# cr G""'/'1t,.
Insurer's Address: P.D• isa 1441 W i j�t�• -''�a.wr e.41-4/PV.
City/State/Zip: )�.�t.9j.–Rj,a vim__ 0/ ,e-ft›,,..Lo
Policy#or Self-ins. Lic. # 1T 6WCi tj6 et/t7I Expiration Date: ` �///2,'y
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure-coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of
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,under the pains and pe s-. ofp•rjury that the information provided above is true and correct.
> _ � Date: ,-///e.2,/#ature: �/i �—� v p
Phone#: �' d" 3e 2, -22 8 CS
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):
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
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MEDICS , TREATMENT
The ab a .rx t ins'tarer.is required izx cases of persox al injuries arising Gaut of and in tine course of
erttpi ent to f itnish adequate *nd reasonabie'h:ospitial and medical Se ces izt.accordance with the
pr w.ist tx of t u 'W'orkers Carttpen atlon r�ct., . .:Copy of.the First Report of Thjx�ry must be.ga*en t0 the
h,iured eznppo 4e 'The a mployee m,a select, his or her owsn ph rsician The reasonable cost of the set
rtkees pr' vI led by the treating phys:t an will be paid by the:i urer, if the treatmcz t i.R necessary'astd •• .
e :bt connected to:the work related injur In cases'r ,,*i.t.ing hospital attentions. employees are-
herebyj noti pdtttat the-insurer has arranged for•such attention at'the
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TO E SSE Y EMPLOYE