HomeMy WebLinkAboutApplication and WC r �
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�� --�` n �`�� TOWN OF YARMOUTH Ha�f
�`� � ' `'3 1146 ROUTE 28, SOUTH YARMOUTH,MASSACHUSETTS 02664-24451 -
`• `7TI�`MftOF` � � Telephone(508)398-2231,ext. 1241 Div s�n
Fas(508)760-3472
To: Yazmouth Business Establishments N-o�y TR� �BoR�T
From: Bruce G. Mutphy, Director � G�-='�r���%'u�
Yazmouth Health Department�
Fta �s �0,5
Date: November 7, 2014 HEALTH DEPT.
Subject: Increase in License/Pernut Fees
Please be aware that the Yannouth Board of Health, under the direction of the Yarmouth Boazd
of Selectmen, has raised a number of license and pemut 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 Januazy 1, 2015.
However, if you fully complete the application, and submit it to the Yarmouth Health
Deparirnent with a11 required certificafions and worker's compensation coverage information
(certificate of insurance OR completed affidavit) prior 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 �z� �I�o.pp
PublicWhirlpooUVaporBaths $ 80.00 � s�o.m
Tobacco Sales $ 95.00
Motels $ 55.00 � SS.00
Food Service 0-100 Seats $ 85.00
Food Service Over 100 Seat§ $16�.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 establishme : �2g�oo
NOTE: To be entitled to pay the current 2014 rate listed ve, your
business application, food and/or pool certitications, a 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 andlor pool certifications prior to opening, however, you must note
"Will provide in the spring prior to opening" on the application.J
BGM/maf
� • a TOWN OF YARMOUTH BOARD OF HEAL � '�n''�'�"�c���
��� APPLICATION FOR LICENSE/PERMITC� f�y n� t����1
* Please complete form and attach all necessary documents by Dece ber 1 S 2014.
Failure to do so will result in the return of your application p c ek1EALTH DEPT.
ESTABLISHMENT NAME: � �'-'`F "Tt2-��— ��+�U'7 TAX ID• `� - (
LOCATION ADDRESS: 41Z �nn` '� TEL.#: -1, � (p CD�
MAILINGADDRESS: w`z-5'� v N/L dZCu-l�
E-MAIL ADDRESS: � 0.- Lc7 i c�v��
OWNER NAME: \-�
CORPORATION NAME(IF APPLICABLE):
MANAGER'S NAME: F� �' l TEL.#: ZE'�� '--I �C o,�
MAILING ADDRESS: '� �`M�
POOLCERTIFICATIONS: CG�-T� � �E P1�01/t�DED
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.
i. `S��-�- �,��'(L\�� z.
Pool operators must list a minimum of two employees currently certified in basic water safety, standazd 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.
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OOD PROTECTION MANAGERS - CERTIFICATIONS:
A food service establishments aze required to have at least one full-time employee who is certifi s a Food
Pro ction Manager, as defined in the State Sanitary Code for Food Service Establishments, 1 MR 590.000.
Pleas ttach copies of certification to this application. The Health Department will not past years'records.
You mu rovide new copies and maintain a file at your establishment.
1. Z•
PERSON IN CHARG
Each food establishment t have at least one Person In Chaz (PIC) on site dwing hours of operation.
1. ___ 2. - _
ALLERGEN CERTIFICATIONS:
All food service establishments are required a least one full-time employee who has Allergen certification,
as defined in the State Sanitary Code for od Service blishments, 105 CMR 590.009(G)(3)(a). Please attach
copies of certification to this applica � n. The Health Depa ent will not use past years' records. You must
provide new copies and maint ' a file at your establishmen .
1. 2.
HEIMLICH CERT CATIONS:
All food servic stablishments with 25 seats or more must have at least one employ trained in the Heimlich
Maneuver o e premises at all times. Please list your employees trained in anti-choking ocedures below and
attach cop' of employee certifications to this form. The Health Deparhnent will not use p t years' records.
You m provide new copies and maintain a file at your place of business.
1. 2•
4.
RESTAURANT SEATING: TOTAL #
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# L CENSE REQUIRED FEE PERMIT#
B&B $55 CABIN $55 �gW�MMINGP00L$tlOea�I�pZp
_ OL DGE $55 _TRA[LERPARK $$OS �WHIRLPOOL $110ea.��
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERM[T#
0-100 SEATS $125 _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. $150 —FROZENDESSERT $40 _TOBACCO $110
NAME CHANGE: $15 AMOUNT DUE _ $ �F'�0.00
**'**PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM****"
i
ADMINISTRATION
I7nder Chapter 152,Seation 25C, Subsection 6,the Town of Yarmouth is now required to hold issuanoe or renewal
of any license or permit ta operate a business if a persan or con�pany does npt ave a Certificate of Worker's
Compensation Insurance. TkIE ATTACHED STATE W4RKER'S CO 1'ENSATIQN INSURANCE
AFFTDAVIT MUST SE COMPLETT�aD AND SIGNED, OR
CI;RT. OF INS(JRANCE ATTACHEI}
OR
WORKER'S COMP. APFIDAVIT SIGNED AND ATTACHED
Town of Yannouth tanes and liens rnust be paid prior to renewal or issuance of your permits. FLEASE CHECK
APPROPRIA'CELY IF PAID:
YES NO
MOTELS AND OTHF..R I.ODGING ESTABLISI-�MENTS
TRANSIENT QCCUPANCY: For purposes of the limitations of Motel or Hote]use,Transient accupancy sha11 be
limited to the temporary and short term occupancy,ordinarily 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
eisewhere.Transient occupancy shall generally refer ta continuous occupancy oFnot mare than tlurty{30)days,and
an aggregate of not more tiaan ninety(90)days within any szx(6)manth period. Use of a guest unit as a resrdence or
dwel(ing unit shall not be consSdered transient. Occupancy that is snbject Yo the collection of Room deeupancy
Excise,as defined in M.G.I,. c. 64G or 830 CMR 64G, a5 amended,shall generally be considered Transient.
raa�,s
1'OQL OPENING:All swimming,wading and whirlpools which have been clased for the season must he izzspected
by the Health Department prior to opening. Contact the Health Department to schedule the inspection three(3)
days prior to opening. PLEASE NOTL: People are NOT allowed to sit in tha pool area until the pool has been
inspected and opened.
PQOL WATTR TESTING: The water must be tested fcrr pseudomonas,tota!coli£orm and standard plate count
by a State certified lab, and submitted to the Health Department three (3) days prior to opening, and quarterly
thereafter.
1'OOL CL{}SING: Every outdaor in ground swimming paal rnust be drained or covered within seven(7)days of
closittg.
FOOD SERV�CE
SEASONAL FOOD SERVICE OPENING:
AlI faod service establishments must be inspected by the Health Department prior to opening. Ptease contact the
Heaith Department ta schedule the inspection three (3)days prior to opening.
CATERING POLICY:
Anyane who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the
required Temparary Foad Service Application form 72 haurs priar to the catered evenC. These forms can be
obtained at the Health Department,ar fram the Town's website at www.varrnouth.ma.us under Health Department,
Dowziloadable Forms.
FROZEN DESSERTS:
Frazen desserts must be tested by a State certified lab prior to ogening and rnonthly thereafter,with sample results
submitted to the Health Departrnent. Failure to do so will result in the suspension or revocation of your Frozen
llessert Permit until Che abave terms have beeQ met.
t}UTSIDE CAF�S:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health.
OUTD04R COOHING:
Outdoor cooking,preparation,ar dispIay of any faod product by a retail or food service establishment is prohibited.
NOTICE:Permits run annually from January 1 to December 31. Ifi IS YOUR RESPONSIBILITY'1"O RETURN
'I'HE CdMPLETED RENEWAL APPLICATION(S}AND REQL7IREI3 FEE(S}BY DECEIviBER 15, 20i4.
ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW
�QUIPMENT,ETC.},MUST BE REPORTEL}Z`{}t1NL}APPROVED BI'THE BOARD C?F HEALTH PRTQR
TO COMMENC�MENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
DATE: SIGNATURE:
PRiNT NAME&TI`I'LE:
R�, 1i�a3n4
~ � The Commonwealth ofMassachusetts
Department oflndustrial Accidenis
� Office oflnvestigalions
1 Congress Street, Suite I00
Boston, MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legiblv
Business/Organization Name: xoLt,Y zxEE cormortzrricn�t TxusT
ACIdT'OSS: 412 Main Street
City/State/Zip: wesc Yarmouth, MA 02673 Phone #: 508-771-6677
Are you an employer?Check the appropriate box: Business Type(required):
1.❑ I am a employer with employees(full and/ 5. ❑ Retail
or part-time).* __ _ _ 6. ❑ RestauranUBaz/Eating Establishment
2.❑ I am a sole proprietor or partnership and have no �, � 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.❑ We are a corporarion and its officers have exercised 9. ❑ Entertainment
their right of exemprion per c. 152, §1(4),and we have 10.0 Manufacturing
no employees. [No workers' comp. insurance required]* 11.0 Health Caze
4.❑ We aze a non-profit organization, stafFed by volunteers,
with no employees. [No workers' comp. insurance req.] 12.� Other Homeowners Assn.
*Any applicant that checks box#I must also 511 out the section below showing their workers'compensadon policy infoimation.
•*If the coxpomte office:s have exempted themselves,but the corporation has other employees,a workers'compeusation policy is required and such an
organization should check box#1.
I am an employer that is providing workers'compensation insurance far my employees. Be[ow is the po[icy information.
Insurance Company Name: HUB International New England, LLC
Insurer's Address: Z99 Ballardvale Street
City/State/Zip: Wilmington, MA 01887
Policy#or Self-ins. Lic.# WC 003-60-3399 Expiration Date: 8/1/2015
Attach a copy of the workers' compensation policy declaration page(showing the policy nnmber and espiration date).
Failure to secure covQrage as requir�d under Section 25A of MCTL c. 15_2 can lead to the imposition of crimin�l penalfies 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
Investigations of the DIA for insurance coverage verificafion.
I do hereby cert�,under the pains and penalties ofperjury that the informa8on provided above is true and correct.
Sienature: Date:
Phone#:
Official use on[y. Do not write in this area,to be completed by city or town officiaG
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