HomeMy WebLinkAboutApplication and WC o�qR
� . -� �'� T O W N O F Y A R M O U T H Board of
�` ry -' �y� HC31
0' - -;" 1146 ROUTE 28, SOUTH YARMOUTH, MASSACHCJSETTS 02664-24451 -
Health
�.`s,� E�e`;'"-� Telephone(508)398-2231,eaR. 1241 Division
A°" Fa�c(508) 760-3472
To: YarmouthBusinessEstablishments SF*��oop SAn;s
From: Bruce G. Murphy, Director
U �1 _
Yarmcruth Health Department� ��`•V '� '; 2014
Date: November 7, 2014 HEALTH DEPT.
Subject: Increase in License/Pernvt Fees
Please be aware that the Yazmouth Board of Health, under the direction of the Yarmouth Boazd
of Selectmen, has raised a number of license and permit fees issued through the Yannouth
Health Department, effective January 1, 2015.
Attached is the Yazmouth 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 Januazy 1, 2015.
However, if you fully complete 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) urior 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
Public WhirlpooUVapor Baths $ 80.00
Tobacco Sales $ 95.00
Motels $ 55.00
Food Service 0-100 Seats $ 85.00 4�85.00�
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: �co O.00 c a.�r.o� �,c.
Total fees owed for your establishment: I�5�GO
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
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� � . TOWN OF YARMOUTH BOARD OF HEALTH �
� � APPLICATION FOR LICENSE/PERIVFIT -�2�1 �3�
* Please complete form and attach all necessary docume`n�"s by-Dece ber�Y'��14?Ol4
Failure to do so will result in the return of your application p c et��LTH DEPT
ESTABLISHMENT NAME: S �S TAX ID:
LOCATION ADDRESS: � 0 6 6 �our� z� TEL.#: S2P- s'�i"�-36�4
MAILING ADDRESS: /[�6 6 /Lo r� � �' ��lrtin� � M e4 Oi66 4
E-MAIL ADDRESS:
OWNERNAME: �AvC- �6Gow�7'to —
CORPORATION NAME(IF APPLICABLE):
MANAGER'S NAME: �f9uL t�oGrw�72a TEL.#: `�d"�— PI�P-.�fY3
MAILINGADDRESS: � !a !+�l �cc fLr,qo L= S�9.vn�. iz6�, M/� aZd�.�7
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. 2.
Pool operators must list a ' im of two employees currently certified in basic water safety, standazd First Aid
and Community Cardiop lmonary 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 new copies and maintain a �le at your establishment.
1. � �/ �� /'`�"SU!� 2. Sa M�i1�79'N C UYL�
PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
1. � �'P"r0- /�`'tf11a/v . 2. l�6,�r-i9''Td17�a� �u'Yl/Z�
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. �NI��tih9'�U (�GIZ/�M 2. /v {��Li C� �N�o N
d
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-chokmg procedures below and
attach copies of employee certifications to this form. The Hea(th Department will not use past years' records.
You must provide new copies and maintain a file at your piace of business.
1. c�.Lt�fd�NYw ��yLx� 2. '�/?+lfc°d� V I V a <TJ�1�rr�v
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$110ea.
LODGE $55 TRAILERPARK $105 _WHIRLPOOL $il0ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
�0-IOOSEATS $125 #(��O�o� CONTINENTAL $35 NON-PROFIT $30
>]00SEATS $200 �COMMONVIC. $60 r_n�-f _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
=<25,000 sq.ft. $150 _FROZEN DESSERT $40 _TOBACCO $110
NAME CHANGE: $15 AMOUNT DUE _ $ l Q S/ - 0 0
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM****• ��" �/���
C,/C.�'�7ij( �/��/��
ADIYIINISTRATION '
Under Chapfer 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 campany does not have a Cerkificate of Worker's
Compensation Insurance. THE ATTACHED STATE WORKLR'S COMPENSATION INSURANCE
AFFIDAVIT MUST SE COMPLETED AND SIGNEI>, (}R
CERT. OF INSURANCE A'I'TACFIBD
CIR
WORKER'S COMP.AFFIi?AVIT SIGNED AND ATTACHED
Town of Yarmouth taxes and liens znust be paid priar to renewal or issuance of your pennits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES NO _
M4TELS AND OTHER LODGING ESTABLISHMENTS
TRAN5IENT OCCUPANCY: Far purposes of the Iimitations ofMotel or Hotel use,Transient occupancy shali be
limited to the temporary and short tezm accupancy,ordinarily and castomarily associated with motel and hotel use.
'1"ransient occupants must have and be able to dernonstrate that they maintain a principal place of residence
elsewhere»Transient occupancy shall generally refer to continuous occupancy ofnot more than thiriy(3d)days,and
an aggregate of not mare than ninety(90}days within any six{6}month period. Use of a guest unit as a reszdence ar
dwelling unit shall not be considered Yransient. Occupancy that is subject to the callection af Room Occupancy
Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall genetally be considered Transient.
POOLS
POOL OPENING:All swimming,wading and whirlpools which l�ave been closed for the season rnust be inspected
by the Health Department prior to apening. Contact the Iiealth L7epartmant to schedule the inspectian three{3}
days prior to opening. PLEASE NOTF: People are NOT allowed to sit in the pool area until the paol has been
inspected and opened.
FOOL WATER TESTING: "Che water must be tested for pseudomanas,total coIiform and standard plate cc�unt
by a State certified lab, and snbmitted ta the Heaith De�artment three (3} days priar to opening, and quarterly
thereafter.
POOI�CLOSING: Every outdoar in ground swimming pool rnust be drained or covered witkun seven(7)days of
closing.
FC}OlT SERVdCE
SEASONAL F'OC1D SERVICE OPENING:
All foad service establishments must be inspected by the Health Deparkment prior ta opening. Please contact the
Health Department to schedule the inspection three (3} days prior to opening.
CATERIIVG POLICY:
Anyone who oatars within the Town of Yarmouth must notify the Yarmouth Health Department by filing the
requ�red Temporary Food Service Application forrn 72 hours priar.to the catered event. These forms can be
obtained at the Health T3epartment,or from the Toum's wehsite at wwtiv.yarmouth.ma.us under Hc;aIth 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 yaur Frozen
Dessert Permit until the above terma have been met.
OUTSIDE CAFES: •
Ontside cafes(i.e.,outdaor seating with waiteriwaitress service},snust have pzior apprava]fram the Baazd of Health.
OUTDOC7R COQKING:
Outdoor caoking,preparation,ar display of any food product by a retail or food service establishment is prohibited.
NOTICE:Permits nm annually from January 1 to December 31. IT IS YOUR l2ESPflNSIBII.ITY TO RETURN
THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 15, 2014.
ALL RENOVATTONS TO ANY FQOD ESTABI,ISHMENT, MOTEL OR POOL {i.e., PAINTING, NEW
EQUIPMENT, ETC.),M[JST BE REPORTED TO AND APPROVED BY THfi BOARD OF HEALTH PRTOR
TO COMMENCEMENT. RENOVATIOIVS MAY REQUIRE A SITE PLAN.
UATF.: SIGNATURE:
FRINT NAME&TITLE:
Rev.1 V03/14
NOTICE � NOTICE
TO , TO
EMPLOYEES EMPLO�EES
The Com�nonwealth of Massachusetts
DEPARTMENT OF INDUSTRIAL ACCIDENTS
600 Washington Sixeet, Boston, Massachusetts 02111
617-727-4900 - http:Uwww.mass.gov/dia
As required by Massachusetts General Law, Chapter 152, Sechions 21,22&30,this will give you notice
that I(we)have provided for payment to our injured employees under tfie above-mentioned chapter by
insuting wittL
MA Retail Merchants WC 6roup Inc.
rr�oF arsuxarrcE co�ra,�vY
PO Hox 859222-9222 Braintree, MA 01285
ADDRESS OF INSURANCE COMPANY
014005U32775114 1/O1/2014 - 1/O1/2015
POLICY NUMBER EFFECTIVE DATFS
Rogers & 6ray Insurance Agency 434 Route 134 South Dennis, MA 0266U
NAME�F INSURANCE AGENT ADDRESS PHONE#
Seafoo0 Sae's 1006 Rte 26 South Yar�auth, MA 02664
EMPLOYER ADDRESS
EMPLOYER'S WORKERS' COMPEAiSATION OFFICER(IF AN� DATE
MEDICAL TREATMENT
The above named ins�uer is required in cases of personal injuries arising out of and in the cou�e of
employment to furnish adequate and reasonable hospitai and medical services in accordance with the
provisions of the Workers' Campensation Act. A copy of the Fiist Report of Injury mast be given m the
injured employee. The�ployee may select his or her own physician. The reasonable casY of the ser-
vices provided by the tresting physician will be paid by the insurzr,if the treatment is necessary and
reasonably connected to the work related injury. In cases requiring hospital attention,employees are
hereby notified that the insurer has azranged for such attention at the
NAME OF HOSPITAL ADDRESS
TO BE POSTED SY EMPLOYER