HomeMy WebLinkAboutApplication and WC r-.�.�`�..�-- _ - ._ __ __..—.._._ ___ __ .
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� TOWN (JF YARM (JUTH Bo�of
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��-_. ,,,�� 1 i 45 R4UTE 28, S4UTH YARMQtTTH,MASSACHUSETTS 42664-2445 i "
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���,, E.,, Telephone(508)398-2231,ext. 1241
r"`"` Fax(SA8}760-3472 Divisian
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To: Yarmouth Business Estabtis2unents . 11tl� U 1 `LU14
Prom: Bruce G. Murphy, Director �� , HEALTH DEPT.
Yacmouth Health Department�
Date: November 7. 2014
Subject: Increase in LicenseJPermit Fees
$ __. ----.
Please be awaze that the Yazmouth Board of Health, under the flirection of the Yarmouth Board
af Selectmen, has raised a nwnbez of lzcense and permit fees issued throueh the Yatmouth
Health Department, effective January 1.�O1�. V
Attached is the Yarmauth Business License Permit Application for 3Q1�. You will note that the
fees listed aze the fees effective Januan I. '_015. These fe�s «ill be duz if you complete and
submit the applicatian after January 1. 301 i.
Ho���e�zr, if �ou fully complete the application. and submit i: to the i'azmouth Health
Depanment �ezth all required cert�catians and u•orl:er's campensati�n ct�tiera�e informatian
(cer�it5catz Qf inswance OR completzd affida�=iti prior to December 31. 201A. vpu will be
allo.�ed to pa. the 2014 rates far the foilo«zns licenses:
��� Curent?�1=� F�e
Public Swimming Pools S fiti.�Q
, Puhlic R'hirlpool't'apar Baths S 8C'�,�i�� �
Tobacco Sales S 9:.04
\Satels � SS.00
Food Servzce 0-100 Seats $ 85.00 : ;�
Faod Service Over 144 Seats $160.40
Retail Food Service <25,000 sq. ft. $ 80.00
Retail Food Service>25,000 sq. ft. $225.00
Qther fees owed but not listed above:
Total fees owed for your establishment -
ti�OTE: To be enfifted to pay the current 2014 rates listed above, 3-our
business application, foad andlor pool eeriifications, alang with warker's
campensation information must be received, or mailed (postmarked) on or
priol' to Deeembet 31, 2014. [Those establishments whzch apen in the sprrrag ��ill be
allowed to provide food andlor poot certzfications prior to opening, hawever, you must rzote
"Wi2X provide in the spring prior ta opening"on the applicafianJ
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w TOWN OF YARMOUTH BOARD OF HEALTH D�
��� APPLICATION FOR LICENSE/PERMIT -2�] � DEC O 1 2014
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�'"' * Please complete form and attach all necesSary docuinen s by Dece ber .EPT
Failure to do so will result in the retiirii of your appTication p
ESTABLISHMENT NAME: � TAX ID: � � .
LOCATIONADDRESS: �� 1'YIQI✓l� ���rP(1L.ifC �veS� r��mn�;�TEL.#:��i;�5-�71 - ?��3�j
MAILING ADDRESS: � ' ^ � "�
E-MAIL ADDRESS: � � 2 > �-
OWNER NAME: ���'L��R �t-t� ' �'��
CORPORATION NAME (IF APPLICABLE):
MANAGER'SNAME: C'l� C't��C'�/� TEL.#: SC�� --7-1I -'���
MAILING ADDRESS:
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 certi ' to this form. ._ __ _ __ __ _. ___ __ _ ____
- -- -
1. �2.
Pool operators must list a minimum of two employees currently certified in basic water safety, standazd First Aid
and Community Cazdiopulmonary Resuscitation (CPR), having one certified employee on premises at a11 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. n ;_� 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. ��C-�,� ����- �''2-� 2•
PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
_ _ _ - -- - -- -
� -_..y �_ ..- —._ _�_ _ _ . _ _ _ _
1. ----. 2•
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.
l. �,�� 2.
HEIMLICH CERTIFICATIONS:
All food service establishments with 25 seats ar 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-chokmg procedures below and
attach copies of employee certifications to this form. The Health Department will uot use past years' records.
You must provide new copies and maintain a Tile at your place of business.
1. lV� �- 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 CABIN $55 MOTEL $110
—I1V1V $55 CAMP $55 _SWIMMING POOL$110ea
�LODGE $55 _TRAILERPARK $105 _WHIRLPOOL $ll0ea.
FOOD SERVICE:
LICENSE R$QUIRED 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
=QS,OOOsq.ft. �� �$150 . —FROZENDESSERT $40 _TOBACCO $I10 ��
NAME CHANGE: $15 . . AMOUNT DUE _ $ Z�IO.00
**•*"pLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** (.Q,c.�di�OO��
C` > 1331 tl�d���l�{
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 INSURANCE ATTACHED ��I' `
OR ,
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED�� �
Town of Yannouth tases and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID: /�
YES ��n 'NO
MOTELS AND OTHER LODGING ESTABLISHMENTS
TRANSIENT OCCUPANCY: For purposes ofthe limitations ofMotel or Hotel use,Transient occupancy shall be
limited to the temporary and short term occupancy,ordinazily 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 sha11 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, sha11 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 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 CLO5ING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of
closing.
FOOD SERVIC�
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
obtamed 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 terms have been met.
OUTSIDE CAFES:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Boazd of Health.
OUTDOOR COOHING:
_ _ Outdoor cookin�preparation,or displa}�of�food product by a retail or food service establishment is prohibited.
NOTICE:Pernuts 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
EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. _
DATE: j (�( . ��SIGNATURE: i�,'
PR1NT NAME & TITLE: �TI �4\%I�:� ��
Rev. I1/03/14
� � � The Commonwealth ofMassachusetts
Department oflndustrialAccidents
Office oflnvestigations
I Congress Street, Suite 1 DO
Boston, MA 02114-20U
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
A�plicant Information Please Print Le¢iblv
Business/Organization Name: _��Y� a� Le�nl i S R�4
Address: ���'i 1�c%�i �'1 P � ✓2�'��J-e .
City/State/Zip:M1V�1��5� �(_ti�M.D�� C��b�n hone#: �� --I�
Are you an employer? Check the appropriate box: Business Type(required):
1.❑ I am a employer with employees(full and/ 5. ❑ Retail
. or part-rime).• _ -- 8. �Restaurantf�at/Eating�Staliti�timent — - -
2.� I am a sole propne3of or partnership and have no � � -- �
7. O�ce 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 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-profit organization,staffed by volunteers, '/ l l
with no employees. [No workers' comp. insurance req.] 12.[�Other l � a G C. -5 1 ID� "
•Auy applicant that checks box#1 must also fill out the section below showing their workers'cospensation policy infotma[ion.
**If the coxporate officers have exempted themselves,but the corpora[ion has other employees,a workers'compensation policy is=equired and such an
organization should check box#1.
I am an employer that is providing workers'compensation insuran for my employees. Be[ow 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 decl ration page(showing the policy number and ezpiratioa date).
__ Failure to secure covera e as e ' ecti can lead to th�imposition of criminal penalties of a _
fine up to $1,500.00 and/or one-yeaz imprisonment,as wel,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 forwazded to the Office of
Investigations of the DIA for insurance coverage verificafion.
I do hereby certify,under the pains and penalties of perjury that the information provided above is true and correct.
Signature: \l `�-tl/.G�%�� Date: f � G I - «.l ,
Phone#: ���
Official use on[y. Do not write in this area,to be comp[eted 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