HomeMy WebLinkAboutApplication and WC Y
�{°���`�� TOWN OF YARMOUTH H��f �
� —, � "3 1146 ROUTE 28, SOUTH YARMOUTH, MASSACHiJSETTS 02664-24451 -
�. 4,r �;� :'r Telephone(508)398-2231, ext. 1241 Di�n
r"°"` Fa�c(508)760-3472
To: Yannouth Business Establishments O�DE C Do�1 —�
From: Bruce G. Murphy, Director �
Yannouth Health Department� 'r';,V �? 4 ZU14
Date: November 7, 2014 HEALTH DEPT.
Subject: Increase in License/Pernut Fees
Please be awaze that the Yannouth Boazd of Health, under the direction of the Yazmouth Boazd
of Selechnen, has raised a number of license and permit fees issued through the Yarmouth
Health Department, effective January 1, 2015.
Attached is the Yarmouth Business License/Permit Application 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 certificarions 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 W1urlpooUVapor Baths $ 80.00
Tobacco Sales $ 95.00
Motels $ 55.00
Food Service 0-100 Seats $ 85.00 � 85.00
Food S�rvice Over 10U 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: � bc�aot� connoN��c .
Total fees owed for your establishment: ��45.00
NOTE: To be entitled to pay the current 2014 rates listed above, your
business application, food and/or pool certi�cations, along with worker's
compensation information must be received, or mailed (postmarked) on or
pClor to Decembet' 31, 2014. [Those establishments which open in the spring will be
allowed to provide food and/or pool certif:cations prior to opening, however, you must note
"Will provide in the springprior to opening" on the application.J
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�,�� TClWN OF'YARMOUTFI IiQARD OF HEALTH
� APPLICATION FQR LICENSElPERMI������,�� ���y F� ��l4
* Please cornplete form and attach atl necessary doqiu��fits yil�ece '` IS 2014.
Failure to do so will result in the retur�af yo�ir appliaation p�ie �T,
ESTABI ISHMENT NAME��Q �-7.� � C�d -� S T X ID �-.
LocA�oN arr�r.Ess: �� SQ r�r-rt S� so N�2mD r��-� ��r�L# so� 3�'� �? 7�
MAILiNG ADL7RESS: YS S Cc�NT�/1- 7� 77 it/.�tlls�'27�.�3- D�:l0 3 9
E-MAII,ADDRESS:�r m cn r-r-o N O P�-m,�i�- �Om
OWIVEI2 NAME: �"D tlitJ u1 LD 7'y?��tJ �2 . .
C012PQRATIQN NAME¢F'APPLICABLE}:
MANAGER'SNAME: �. /'Y) iGh��/�-' (� -77� TPL#� a,/S� `J/o �/
Ma�,nvG�D�ss: �1s3 s C��r�n S� oa-ro 39�
POOL CERTIFICA'I'IONS:
'The pool supervisor must be certified as a Poal Opera#or,as required by State]aw. Please list the designated
Pool Operator(s) and attach a copy of the certificatian to this form.
1. �. -
Pool operatars must list a minimnm of two empioyees currently cerkified in basic water safety,standard First Aid
and Cornmunity Cardiopulmonary Resuscitation (CPR), having one certified employee on premises at all times.
Piease list the empiayees belaw and attach capies of their certifiaations to this form.The Health Department wili
not use past years' records. You must provide new copies and maintain a file at your place uf business.
z� z.
3. 4.
FOOD PR4TECTI4N MANAGF.,RS - CERTIFICATIt}NS:
All food service establishments are required to haue at least one full-tirne arnployee who is certified as a Food
Protection Manager, as defined in the State Sanitary Code for Food Service Estabiishments, 1d5 CMR 590.00d.
Piease attach copies of cerkification to this apglication. The EIealth Department will nat ase past years'records.
You must provide new copies and maintain a file at your esYablishment.
i._�lLDT/�� /nIL/1��� �/IT7�N 2.
PERSON I1V CHARGE: GiJ r c�L P�D✓{�(N SP�lNG- P�ItJ,Q To OP�?U[NG _
Each food establishment rnust have at least ona Person Tn Charge (PTC) an site during hoixrs of operatian.
l. z.
ALI.ERGEN CERTTFICATI(�NS;
All food service establishrnents are required to hava at least one full-tirne emplayee who has Allergen certification,
as definad in the State Sanitary Code for Food Service E�tablishments, Ip5 CMR 590.009(G}(3}(a). Please attaeh
copies of certificatian to this appiication. The Tleaith Department wili not use past years' recards. You must
provide new copies and maintain a file at your estabtishment.
1. �oaar,��/ m� �e�,� C�`�rn�' a.
FIETMLICH CERTIFICA"1'IONS;
All food service establishments with 25 seats or more must have at least one employee txained in the Heirnlich
Maneuver on the premises at all times. Please list your employees trained in anti-choking pracedures below and
attach copies of emplayee certifications to this form. The Health Department will not use past years' reeards.
Xou must provide new capies and maintain a file at your place of business.
1. 2,
3. 4.
RESTAURANT SEATING: TOTAL# � �—'
O�'FICE USE ONLY
L4DGING:
LICHNSE REQUIRED FEE PrRMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRP,D FEE PERMIT#
B&B $55 _CAB]N $SS MOTEL $110
_INN $55 CAMP $55 SWI,i�iMING POOL$t i0ea
_LODGE $55 �'PRAII.,ERVARY.. $105 �,_ =WHIFU.POOL $110ea. __
FOOD SERVICE:
LICENSE REQUIREl7 FEE P�RMIT# LICGNSE REQUIRED FEE PERMIT N LICBNS6 REQ UTACD FEE PERMIT#
I O-i00SEAT5 $125 ! 6G, CONTINENTAL $35 NON-PROFIT $36
_>I00 SEATS $2p0 _ �COMMON VIC. $6p �;��"� �WHOC,ESALE $80 "—
—RESID.tC[TCHEN $80
RETAIL SERVICE:
LICENSE REQ(71RED FEE PERMIT� LICENSE REQIJ[RE6 FEE PERMIT# LICENS6 REQIJIRED FEE PERMTT H
_<50 sq.ft. $50 >25,OtY0 sq.ft. $2$5 VENI7ING-F06D $25
_<25,000 sq.fl. $150 �'ROZEN DESSERT $40 �TOBACCO $110 „
NAMECHANGE: $lS ANTOUNTDUE _ $ ISS�OO
*****PLEASE TURN QVER AND COMPLETE OTHER SIDE OF FORM**�*t*�* +���'� " ���'��
l'+�L"i� 5.�� {��� � t�
ADMINISTRATION
� .r� . �n � r.. �• -
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 WORK�R'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR
CERT. OF INSURANCE ATTACHED
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yannouth taxes and liens must be paid priar to renewal or issuance of yow permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES � NO
MOTELS AND OTHER LODGING ESTABLISHMENTS
TRANS�ENT OCCUPANCY: For purposes of the limitations ofMotel or Hotel use,Transient occupancy sha11 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 shall 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 standazd plate count
by a State certified lab, and submitted to the Health Department three (3) days priar to opening, and quarterly
thereafter.
POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of
closing.
FOOD SERVICE
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
obtazned 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 Board of Health.
OUTDOOR COOHING:
Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited.
NOTICE:Permits 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., PAIN'I'ING, NEW
EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
DATE: SIGNATURE:
PR1NT NAME & TITLE:
Rev. ll/03/14
i k � The Commonwealth ofMassachusetts •
Department of Industriat Accidents
Office oflnuestigations
' 1 Con,�ress Street, Suite 1 DO
Boston,MA 02114-ZOI7
www.mass.govldia
Workers' Compensation Insurance Affida ` nerai Businesses
A licant Information Please Print Le 'bl
BusinesslOrganizatian Name: D Li�� C �7l O(�-S� �D{};iI (,/��j�T���� f��-
Address: �f12 �0 tJ �}j �7"
City/State/Zip: s�" `�rl»'>pytfl /ylA' ��(ol�`f Phone#: �� 3q�/- 7 ���
Are you an employer?Check the appropriate box: Business Type(required):
1.� I am a emptoyer with employees(fuIl and! 5. ❑Retail
°7 P�`�e)�"` 6. �.RestaurantTBazlEating Estabiishment
-- _.
2. I am a soIe propn`eior or partnership and have no -
7. ❑ Office and/or Sales(incl.real estate,auto,etc.)
employaes working for me in any capacity.
[No warkers' comp.insurance required] 8• ❑Non-prafit
3.❑ VJe aze a corporation and ifs officers have exercised 9. ❑Entertainment
their right of exemption per c. 152, §1{4},and we have 1 Q.�Manufacturing
no employees. [No workers' cornp. insurance required]* �� ❑Heafth Care
4,❑ We aze a non-profit organization,staffed by volunteers,
with no employees. [No workers' comp. insurance req.] 12.[� Other
'Any applicant that checks box#I must alsp fill out the sectinn below showing their workers'compensadon policy information.
*'Tf the coiporate offrcecs have exempted thcroseives,bui the coigoration has other employees,a wozkers'compensatioa poGcy is required aud such an
organi�aition should check box#1.
I am nn employer that isproviding workers'compensation insurance jor my employees. Below is thepo[!cy information.
Insurance Company Name:
Insurer's Address:
City/State/Zip:
Policy#or Self-ins.Lic.# Expiration Date:
Atfach a copy of the workers' compensation policy deciaration page(showing the poticy nnmber and eapiration date).
Failure to secure coverage as required under Section 25A of MGL c. I52 can lead to the impersitian of criminal pena}ties pf a
_—. _ -
fine up to$1,500.00 and/or one-yeaz imprisonment,as well as civil penalties in the form of a STOP W(7RK ORI7ER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to ttre Office of
Investigatians of iha DZA far insurance ooverage verification.
1 do hereby certi ,under e pairas and penatties of perjury thai the informailon provBded above as true and carrect.
S' a re: V�l ` .� �- ate: 1 { �f t
Phone#: � " t- � �1 �
Officiat use ortty. Do not write in this area,ta be completed by cdty or town officiaL
City or Town: Permit/License#
Issuing Authority(circle qne):
1.Board af$ea3th 2. Bnilding Depariment 3. CitylTown Clerk 4.Licensing Board 5. Selectmen's Qffce
6.Other
Contact Persan: Phone#:
www.mass.govtdia
r4�p� CERTfFICATE OF LtABILITY INSURANCE °"'�"""°°"""'
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. -� THIS�CERT�ICATE IS ISSUED AS A MATIER OF INFOtmYlAT10N�DNLY AND CONFERB NO RIGHTB UP6N THE CERTIFICATE HOLDER:TH13 -
�; CERi1FICATE-DOES NOT AFFIRMATNELY OR NEGA7NELY AMEND, EXTENU OR ALTER THE COVERAGE APFORDED BY THE POLICIES .� �;
�� ...BELOW..TH13-CERTIFICATE OF INSURANCE DQES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUIN6 I►�URER(8�, AUTHORIZED � '��..
. -.TffiPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. � . .. � '�.
..��IMPQRFANT:.�iF tha certlfl�e holdx Is an ADDRIONAL INSWiED.tM P��f'fMs)must bs endorastl. M SUBROCATION.IS-WAIVED.sWJect.W .
� the txms aM wMidom oT fhe PolicY.cerhin poliebs may requNe an e�oraemeM. A afaEemenf on tMs aitlfieah daes not�earAx ripMs to Me .
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