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��°� ��`�� TOWN OF YARMOUTH H��f +�
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� -- '_ _�1"'3 1146 ROUTE 28, SOUTH YARMOUTH,MASSACHUSETTS 02664-24451 "
�\''', ~ �I� Telephone(508)398-223 i,ext. 1241 Health
>r"°"`� Faat(508)760-3472 Division
To: YazmouthBusinessEstablishments 3�vE (��{},�G�--tsAssoua��noN
From: Bmce G. Murphy, Director
Yarmouth Health Department
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Date: November 7, 2014
Subject: Increase in License/Permit Fees
Please be awaze that the Yarmouth Boazd of Health, under the direction of the Yatmouth Boazd
of Selectmen, has raised a number of license and permit fees issued through the Yazmouth
Health Department, effective January 1, 2015.
Attached is the Yannouth Business License/Permit Applicarion for 2015. You will note that the
fees listed aze 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 Yazmouth Health
Department with all required certifications and worker's compensation coverage information
(certificaYe of insurance OR completed affidavit) prior to December 31. 2014, you will be
allowed to pay the 2014 rates for the following licenses:
Cutrent 2014 Fee
Public Swimming Pools $ 80.00 �p:0v
Public WhirlpooUVapor Baths $ 80.00
Tobacco Sales $ 95.00
Motels $ 55.00
Restaurants 0-100 Seats $ 85.00
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:
. Total fees owed for your establishment: SO.00 r ,
NOTE: To be entitled to pay the current 2014 rates listed above, your
business application, food and/or pool certificafions, 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
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� TOWN OF YARMOUTH BOARD OF HEALTH
� � APPLICATION FOR LICENSE/PERMIT -2Q��,5f�6e{S S�g�°�
` * Please complete form and attach all necessary documents b`y December I S, 2014. �
Failure to do so will result in the return of your appTicarion packet.
ESTABLISHMENT NAME: �v� /�.F/G�7S SSGri�7TGv TAX ID: �
LOCATION ADDRESS: 134 h" O�l� ,A-1� TEL.#: ,SDd'-39y D7ff�
MAILINGADDRESS: !� �OX 79T vi� Y��I'iAv� �/i3 4�GGy
E-MAIL ADDRESS:
OWNER NANIE:
CORPORATION NAME (IF APPLICABLE):
MANAGER'S NAME: TEL.#:
MAILING ADDRESS:
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.
-__ _- -_,____ _____—�__
1. C��h/�s76����s' 2.
Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid
and Community Cazdiopulmonary 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. L✓.4/VhD �� �0/J/Zb 0�/J.rh�T/� 2. �
3. 4.
FOOD PROTECTION MANAGERS - CERTIFICATIONS: i
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. Z•
PERSON IN CHARGE:
Each food establishment must have at least one Person In Chazge (PIC) on site during hours of operation.
---� ------- --_ _ _ --- . 3 _ . .
ALLERGEN CERTIFICATIONS:
All food service establishments aze 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. 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 I
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.
1. 2.
3. 4.
RESTAURANT SEATING: TOTAL#
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED�FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# j
B&B $55 _CABIN $55 M07'EL $1l0 '�,
INN $55 CAMP $55 �SWIMMINGPOOL$li0ea '
LODGE $55 TRAILER PARK $105 WHIRLPOOL $110ea
FOOD SERVICE:
LICENSE REQUIRED FEE PERMTT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
0-100 SEATS $l25 _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 PERM(T# LICENSE REQUIRED FEE PERMIT# �
<50 sq ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 �
<25,OOOsq.ft. $I50 _FROZENDESSERT $40 _TOBACCO $ll0
NAME CHANGE: $l5 AMOUNT DUE _ $ � '�.�
*•***PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM�*,��* id p UO�IXJ �'.
4 1 � C�Wi P �o Y�
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az��nvisa��Tiarr
Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required ta hold issuance or renewal
of any license or permit ta operate a business i£a person or company does not have a Certificafe of Worker's
Campensation Insurance. TFIE A3'TACAEL? STATE WOItKl?.R'S COMPENSATI4N INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR
CERT. 4F INSURANCE ATTACHED
OR
WORKER'S COMP. AFFII3AVIT SIGNED AND ATTACHED
7'own of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATEI.Y IF PAID: ,/
YES i/ N4i
MOTELS AND OTHFR I.ODGING F.STABLiSHMENTS
TRANSIENT OCCUPANCY: For purposes of the limitatioi�s oi"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.
T'ransient aceupants must have and be able to demonstrate that they maintain a principal place of resitlence
elsewhere.Transient occupancy shall generally refer to continuons occupancy ofnot rnore 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
dweiling unit shall nat be considered transient. Occupancy that is subject ta the callection of Raam Occugancy
Excise, as defined an M.G.L. a 64G ar 834 CMR 64G,as amended, sha11 generally be considered Transient.
rao�s
P40L OPENING;AII swimming,wading and whirlpools which have been ciosed for the seasan must be inspected
by the Health Departrnent prior to opening. Contact the Health Dapartment to achedule the inspection three(3)
days prior to opaning. PLEASE NOTE: People are NOT allowed to sit in the pao] area until the pool has been
inspected and opened.
POOL WATER TESTING: The watez must be tested for pseudomonas,total coliform and standard plate oount
by a Stafe certified lab, and submitted to the Health Department three (3) days prior to opening, and quarterly
thereafter.
PQOL CLOSING:Every autdaor in ground swimming pooi must be drained or covered within seven{7)days of
closing.
FC1013 SERVTCE
SEASONAL FOUD SERVICE OPENING:
All food service estabtishments must be inspected by the Health DeparUnent priar to opening. Please contaet the
Health DepartmenY to schedule the inspectian three(3)days priar to opening.
CATERING POLICY:
Anyone who caters within the Town of Yazmouth rnust notify the Yarmouth Health Depar[ment by filing the
required T'emporary Foad Service Application form 72 haurs prior ta the catered evant. These forms can be
obtained at the Health Department,or fram the Town's website at www,varmouth.ma.us under Health Deparhnent,
Downlaadable Forms.
k'ROZEN DESSERTS:
Frozen desserts must be tested by a State certified lab prior to opening and rnonthly thereafter, wzth sample results
submitted to the I-�ealth Department. Failure to do so wilI resuIt zn the suspension or revocation of your Frozen
17essert Permit until the abave 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 COOHING:
� Outdoor cooking,preparafian,or display of any faod product by a retail or food serviae establishment is prohibited.
NOTICE:Permits run annuaTly frorn January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN
THB COMPLETED RENEWAL APFLICATION{S}AN17 REQtJIRED FEE(3}BY DECE�RBElZ l5, 2014.
ALL I2ENOVATIONS TQ ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT,ETC.}, IviUST BE REPC}IZTED Td ANI}APPR4VED BY THE BOARD t}F HEALTH FRIOR
TO COMMENCEMEPdT. RENOVATTONS MAY REQUIRE TE PLAN.
DATE: //-/�i-iY SIGNATC7RE: �./-��
PRINT NAME&TITLE: cj'�f 1LP�d /.Q �G,rl,PiSL� ��1.�S �LL/.�'�tlf /�6"IG,blis��'SttC
xeb,3 uoaria
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- � � � The Commonwealth ofMassachusetts
Department oflndustria[Accidents
Office oflnvestigations
I Congress Street, Suite 100
Boston, MA 02I14-201�
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Le�iblv
Business/Organization Name: t�LU� �D�/C /y/"/GifrS /,�SS'D�i/-776ix
Address: l' � �U)( 741 /�f� ,B�U�z �G`Gd( �02-b
City/State/Zip:SO�i�f �2,e/�ovT,H- ��Ii� d�GG Phone #: 5���-39��G7�t�
Are you an employer? Check the appropriate box: Business Type(required):
1.❑ I am a employer with employees(full and/ 5. ❑ Retail
or�art-timg�._*__ _� 6. RestauranUBaz/Eatin Establishment
2.❑ I am a sole proprietor or partnership and have no �, � pffice 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 aze a corporarion and its officers have exercised 9. ❑ Entertainment
their right of exemprion per c. 152, §1(4), and we have 10.❑ Manufacturing
4.[�o employees. [No workers' comp. insurance requiredJ*
We aze a non-profit organization,staffed by volunteers, 11.0 He�lth Caze
with no employees. [No workers' comp. insurance req.] 12_u�er /✓D/'����✓N.P/LS /�SSOt/�#-TlD/�
•Any applicant that checks box#]must also fill out the section below showing their workers'compensalion policy infom�ation.
**If the coipomte officers have exemp[ed themselves,but the corporation has other employees,a workers'wmpensalion policy is required md such an
organization should check box#1.
I am an employer thal is providing workers'compensation insurance for my employees. Below is the policy injormation.
Insurance Company Name:
Insurer's Address:
City/State/Zip:
Policy#or Self-ins.Lic. # Expirafion Date:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and eapiration 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-yeaz 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
Inuestigations of the DIA for insurance coverage verification.
I do hereby certify,und he pains and penalties ofperjury that the information provided above is true and correct.
Sianature: �l� �� �l��.b� � - l'O/�/�if-D Date: �/�`��`f
�
Phone#: �C��`-3���ZlJ.Z.Z
Official use only. Do not write in this area,to be campleted by city or town offuiaG
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2. Building Department 3. City/1'own Clerk 4.Licensing Board 5. Selectmen's Office
6.Other
Contact Person: Phone#:
www.mass.gov/dia