HomeMy WebLinkAboutApplication and WC � N�o�ti� �
o�'Y'�R
�.� _� �'�o TOWN OF YARMOUTH Ha�f
�L� "3 1146 ROUTE 28, SOUTH YARMOUTH, MASSACHLJSETTS 02664-24451 -
L• 4'7�jA C„f<0� '�� Telephone(508)398-2231, eact. 1241 Divi�n
Fax(508) 760-3472
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To: Yarmouth Business Establishments M�� 1�4�sT�
� R�c�r�am��
From: Bruce G. Murphy, Director UtC U 8""LU14
Yannouth Health Department�
HEALTH DEPT.
Date: November 7, 2014
Subject: Increase in License/Permit Fees
Please be awaze that the Yarmouth Boazd 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 Deparhnent, effective January i, 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 Yannouth Health
Department with all required certifications and worker's compensation coverage information
(certificate of insurance OR completed affidavit) nrior to December 31. 2014, you will be
ailowed 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 $ 5
Food Service 0-100 Seats 85. �S .0l�
Food Service Over 100 Seats $160.00
Retail Food Service <25,000 sq. ft. $ 80.00
Retail Food Service>25,000 sq. ft. $225.00
Other fees owed but not listed above: 60. Od C�wu�onl �/lc,
Total fees owed for your establishment: �,D
NOTE: To be entitled to pay the current 2014 rates listed above, your
6usiness application, food and/or pool certi�cations, along with worker's
compensation information must be received, or mailed (postmaeked) on or
pClor to DeCember 31, 2014. [Those establishments which open in the spring will be
allowed to provide food andlor pool certifications prior to opening, however, you must note
"Will provide in the spring prior to opening" on the application.J
BGM/maf
. . GiC�C�[�OC�GD \
a TOWN OF YARMOUTA BOARD OF HEALTH
� � APPLICATION FOR LICENS�/P�iV�I��U�s�� DEC U 8 2014
" * Please complete form and attach all neces��c��unen;s b�De- m Pj
Failure to do so will result in the retiiiri of�bui"appCcation a
ESTABLISHMENT NAME: %I � � / ID: � -
LOCATIONADDRESS: '�/5�l i7.,u.rfi2 ? � L✓t��� TEL.#: ��f-�9�0-�1
MAILING ADDRESS:
E-MAIL ADDRESS: N�,¢/( G E�P7 C 2 f+/.uQ- GD.�
OWNER NAME: � � L
CORPORATION NAME (IF APPLICABLE):
MANAGER'S NAME: /l�!'�CEL 4 �/�i ✓d TEL.#: ��-,2$ -D��/
MAii'ING ADDRESS: �i0 1/.v�o,e,�.�.ra. 2�
� �
POOL CERTIFICATIONS:
The pool supervisor must be certi�ed 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.
1. 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 file at your place of business.
l. 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 establishment.
1.���i LC-L 0 1VD I/(� _ 2. %�U�TrI //� ��/f �
PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
1. /�.�� � EL� /I/(� (�t� 2.�� l/ ��/� 1���l�f�lJ
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 Deparhnent will not use past years' records. You must
provide new copies and maintain a file at your establishment.
�. �,�� ��Lo �va v0 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.
�. tilA , � �l n ��r� r�(� a.��� G d 1/�/� ���_
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 $55 SWIMMINGPOOL$IlOea �
LODGE $55 TRAILER PARK $105 _WH[RLPOOL $I l0ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
I 0-100 SEATS $125 �k �0 CONTIIVENTAL $35 NON-PROFIT $30
>]00 SEATS $200 I COMMON VIC. $60 �!�'7 _WHOLESALE $SO
— —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
_QS,OOOsq.ft. $150 —FROZENDESSERT $40 _TOBACCO $110
NAMECHANGE: $15 AMOUNTDUE _ $
•**"*PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** I�'�L I� ����0� '
���N" J�Z1�7 ���`��
i . .
ADMINISTRATION
iJnder Chapter 152,Sectian 25C,Subsection 6,the Town of Yarmauth is now required to hold issuance or renewal
of any lioense or permit to operate a business if a persan or cornpany does not have a Certifiaate of Worker's
Compensation 3nsurance. T�IE ATTACHED STATE WQT2KT,R'S COMPENSATIQN INSI772ANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNEA, OR ,
CERT. 4F INSURf1NCE ATTACHED
OR
WOlZICER'S COMP. AFFIAAVIT SIGNEI7 AND ATTACHED�
1'own of Yarmouth taaces and liens musY be paid prior to renewal ar issuance of your permits. PLEASE CHECR
APPROPRIATELY IF PAID:
YES NO__�__
MOTELS ANA OTHER LODGING ESTABLISFIiVIENTS
TRANSIENT OCCUPANCY: For purposes ofthe limitations of'Motel or Hotei use,Transient occupancy shall be
1'amited ta the temporary and short terxn caccupanay,ordinaziIy and oustomarity�tssociated with matel and hotel use.
Transient occupants must have and be able to demonstrate that they maintain a principal place af residence
elsewhere.Transient occupancy sha11 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
dwetling unit shall not be eonsidered transient. Occupancy that is subject to the callection of Room Occupancy
�.xcise,as defined in M.G.L. c. 64G or 830 CMK 64G,as amended, shall generallp be considered Transient.
POQLS
P40L OPENING:All swimming,wading and whirlpaals which have been ciosed 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 NC}TE: People are NdT allowed to sit zn the poal area until the pool has been
inspected and opened.
POOL WATER'l'ESTING: The water must be tested£or pseudomonas,total coliforrn and standazd plate count
by a State certified lab, and submitted to the Health Department three (3} days prior to opening, and quarterly
Lhereafter. �
POOL CL4SING:Every ontdoor in graund swimming pool must be drained az cavered within seven{7}days of
closing.
FOOD SERVICE
SEASONAL FOOD SERVICE OPENING:
All food service establishments must be inspected by the Health Department prior ta opening. Please contact the
Health Departrnent to schedule the insgection three {3)days prior to opening.
CATERIlYG POLICY:
Anyone who caters within the Town of Yarmquth tnust notify the Yarmouth Health Department by filing the
required Temporary Food Service Application form 72 haurs priar ta the catered event. Thesa forms can be
obtained at the Health Department,or from the Town's website at�wvw.varrnouthma.us under Health Deparhnent,
Downloadable Fatms.
FROZEN DESSERTS:
Fzoun desserts must be tested by a Stata certified 1ab priar to opening and monthly thereafter,wath sample results
submitted to the Health Depaztrnent. Failure to do so will result in the suspension or revocation of your Frazen
Dessert Permit untii the above terms have been znet.
f}UTSID�CAF'ES:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval frorn the Board of Health.
CIUTAOOR COIJKTNG:
Outdoor cooking,preparation,or dispIay of any food product by a retail or food service establishment is prohibited.
NOTICE:Permits run annually from 7anuary 1 to December 31. IT I5 YOiJR 12ESPONSIBILITY TO RETIJRN
THE COMPLETEI3 RENEWAL APPLICATION(S}AND REQLTIRED FEE(S}BY DECEMBER I5, 2014.
ALL RENOVATIONS TO ANY FOQD TSTABLISHMENT, MOTEL OR POOL (i.e., Pt1INTING, NEW
F,QUIPMENT,ETC.}, MUST BB REP(7RTED 1"O AND APPRdVED BY TFIE BOARD OF HEALTH PRIOR
TO COMMENCBMENT. RENOVATIONS IvIAY REQUIRE A SITE PLAN.
L?ATE: �,� f� � �/'�-f SIGNATURE: —�� -�
p�rtT N�vt�&TIT�,E: ��/� C� t�_lt/t?i/r? - �L�frn�E 6� _
Rev,7 U431f 4
' � The Commonwealth ofMassachusetts
Department oflndustrialAccidents
Offace of Investigations
' I Congress Street, Suite Z00
Boston, MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Af�idavit: General Businesses
Auplicant Information Please Print Le¢iblv
Business/Organization Name:�„� p ��� a�
Address: ti 5 9 �, � �
City/State/Zip: ` Phone #: � ��J— �y�(� — 6 J�
Are you an employer? Check the appropriate bog: Business Type(required):
1.� I am a employer with�employees(full and/ 5. ❑ Retail
or part-rime).* 6. �RestauranUBaz/Eating Establishment
2.❑ I am a sole proprietor or partnership and have no �, � Office ancllor Sales(incl.real estate,auto, etc.)
employees working for me in any capacity.
[No workers' camp.insurance required] 8• ❑ Non-profit
3.❑ We aze 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.❑ Health Caze
4.❑ We aze a non-profii organizarion, staffed by volunteers,
with no employees. [No workers' comp. insurance req.] 12.❑ Other
*Any applican[that checks box#1 must also fill out the sectioa below showuig tLe'v workers'compensalion policy information.
*•If the coxporete officecs have exempted themselves,but the corporation has other employees,a workers'compensation policy is=equ'ved and such an
organization should check box#1.
I am an emp[oyer that isproviding workers'compensation insurance for my employees. Below is thepolicy information.
Insurance Company Name: 11/0 R Ff9�� ��n.��.v� /�e/�f.ca.� �.�rcl_ �u�. PO-
Insurer's Address• � �'�/ ./�1,awU� ����r ��C _��..l�t.r�.re✓t
i / n
City/State/Zip: ,� ,l��,,�l — �j.4 — �,Z E� �V
Policy#or Self-ins. Lic. # i�/� �y� R 6�.4 Expiration Date: �.Z �Q 9 �J S
Attach a copy of the workers' compensation policy declaration page(showing the policy number and espiration date).
Failwe 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 penalries 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 forwazded to the Office of
Investigations of the DIA for insurance coverage verificafion.
I do hereby certify,under the pains and�enalties ofperjury that the information provided above is bue and correct.
Si ature: �� ��� / Date: I.� �O R / I"7
Phone#: ,5 n�_ ��'�—� � �/
Official use on[y. Do not write in thds area,to be completed by city or town officiaL
City or Town: PermitlLicense#
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 ..