HomeMy WebLinkAboutApplication and WC � TOWN OF YARMOUTH BOARD OF HEALTH �r ,�7 Z
� � APPLICATION FOR LICENSEJJC�c���i�s��� C;V�J' .;_ . �_Q��C_
* Please complete form and attach all necessary t�,y ec b r 1 DEPT.
Failure to do so will result in the retu�irof}�i�%p�fT�'cation pac .
ESTABLISHMENT NAME: y r h d� TAX ID: - �
LOCATION ADDRESS: 5S �6�1 ��riY S• Q;vh�b k- TEL.#: U •'�`� • IZ3
MAILING ADDRESS:� S �UGK � • �t1w M+� Z I(, Ca �
E-MAILADDRESS:SSi1e 'tare . U22•S�'re �ing eY-C� Gt o�cl •
OWNERNAME: } 1w r ar�, Z
CORPORATION NAME (IF APPLIC BLE): 1..� ' �SIw n�Ay�" dlr D�,ri� GL
MANAGER'S NAME: ���h— �'i1 '� TEL.#:
MAILING ADDRESS:13� �6G l��n p U2 (� >n
POOL CERTIFICATIONS: �I j�"
The pool supervisor must be ce ified 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 minimum of two employees currently certified in basic water safety, standard First Aid
and Community Cardiopulmonary 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. 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 ew copies and maintain a file at your establishment.
�.JD�,�, (,.� �II I � �.
PERSON IN CHARGE:
Each foo establishment must have at least one Person In Charge (PIC) on site during hours of operation.
� �.s.� ti- I,J 11 � I � z.
ALLERGEN CERTIFICATIONS:
All food service establishments are required to have at least one fuil-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
prov� e new copies and maintain a file at your establishment.
�. �d � l� il � i � z.
HEIMLICH CERTIFICATIONS: N' �"
All food service establishments with �5 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-chokmg procedures below and
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#
B&B $55 CABIN $55 MOTEL $110
� INN $55 CAMP $55 SWIMMINGPOOL$110ea.
LODGE $55 TRAILERPARK $105 � _WHIRLPOOL $IlOea.
FOOD SERVICE:
LICENSE REQUiRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# .
0-100SEATS $125 _CONTINENTAL $35 NON-PROFIT $30
—>100 SEATS $200 COMMON VTC. $60 WHOLESALE $80
—RESID.KITCHEN $80
RETAIL SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQU(RED FEE P RMIT# LICENSE REQUIRED FEE PERMIT#
<50 sq ft. $50 L>25,000 sG.ft. $285 �j 5 VENDING-FOOD $25
=<25,000 sq.ft. $150 � —FROZEN DESSERT $40 _TOBACCO $1l0
NAME CHANGE: $15 AMOUNT DUE _ $ Z`�5-00
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM****• ��—�d d z�-s�
e��a 5z`i 3�i5 i�i7'l�l
ADMINISTRATI0IV � '
Under Chapter I 52,Section 25C, Subsection 6,the Tawn of Yarmouth is naw required to hold issuance or renewal
of any iicense or permit to opecate a business If a persan or coinpany does not have a Certificate of Warker's
Compensation Insurance. THE ATTACHED STATE WOI2KER'S CUMPENSATION INSURANCE
A�FIDAVIT MUST BE COMPLETED AND SIGNED, OR
CERT. OF INSURANCE A'CTACHED
OR
WOIZKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yannouth ta�ces and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPKOPRIATELY IF PAID:
XES NO
MOTELS AND 4THER LOI}GING ESTABLI3HMENTS
TRANSIEN7'OCCUPANCY: For purposes of the limitations ofMotel or Hotel use,Transient oocupancy shall be
1'smited to The temporary and short term aecupaney,Qrdinarily and euseamarily associated with motel and hotel use.
Transient occupants must 'have and be able to den�onstrate that they rnaint�in a principal place af residence
elsewhere.Transient occupancy shall generally refer to continuous occupancy of not more than thirty(30)days,and
an aggregate ofnot moxe than ninety{90)days tivithin any six{6}manth periad. Use ofa guest unit as a residence 6r
dwelling unit shall not be considered transient. Occupancy that is subject to the callection af Room Occupancy
Excise, as defined in M.G.I.. c. 64G or 830 CMR 64U, as amended, shall genexally 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�-tealth Departrnent to schedaie the inspection three(3)
days priar to opening. PLEASE NOTE: People are NOT allawed to sit in the poo] area until the pao] l�as been
inspected and opened.
POOL WATER 7"ESTING: The water must be tested for pseudomonas,total coliform and standard plate count
by a State eertified lab, and submitted to the Hc�aith Department three {3) days priar to opening, and quarterly
thereafter.
POOL CLOSING: Every outdoor in ground swimming pool must be drained ar coverad within seven(7)days of
closing.
Ft30D SERVICE
SEASONAL FOQD SERVICE OPENING:
Ali foad service estabiishments must be inspected by the I3ealth Department prior to opening. Please oontact the
Health Department to schedule the inspection three (3) days prior to opening.
CATk',RING POLICY:
Anyone who caters within the Tawn af Yannouth musi natify the Yarmauth Health Department by filing the
required Temporary Food Service Application form 72 hours prior to the catered event. These farms can be
obtained at the Health T3epartment,or from the Town's website at www.varmauth.ma.ns under Health Department,
Downloadable Forms.
FR07EN DE3SEItTS:
Frozen desserts must be tested by a State certified lab priar to apening and monthly thereafter,with sample results
submitted to the I-Iealth Department. Failure to da sa will result in the suspension ar revocation af your Frozen
Dessert Permit until the above terms have been met.
OUTSIDE CAF�`S:
C}utside cafes(i.e.,outdoor seating with waiterlwaitress service),must have prior approval fram the Board af Health.
OUTDOtJR COOKING:
_ _(?utdpor cooking,�reparation az dis_pl_ay of an�food product by a retail ar food servioe establishment is prohibited.
NOTICE:Permits nul annually from January 1 to December 31. I'I'I3 Y417R ItESPONSIBILiTY TQ RET[IRN
THE COMPLETED RENEWAL APPLICATIOIV(S) AND REQUIRED FEE(S)BX DECEMBER 15, 2014.
ALL RENQVATIONS TO ANY PO(JD �STABL[SHMENT, MOTEL flR POOL (i.e., PA:INTING, NJsW
EQUIPMENT, ETC.), M[JST BE REPQRTED TO AND APPROVED BY THE BOAT2.D OP HEALTH PRiOR
TO COMMENCEMENT. RENOVATIONS MAY REQt7IRE A SITF,PLAN.
DATE:_1/��SIGNATLJRE: 6 ��'"�
PRINT NAME & TITLE:�I 7 S5e- ( � � y� '�r1 � � p �
xcv. uiosna
t
,,� The Commonwealth of Massachusetts
Departmeizt of Industrial Accidents
Office oflnvestigatians
' I Congress Street, Suite 100 _
Boston,MA 02114-2017
„ www mass,gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Leeib�v
BuSinesS/OiganizahOn Name:The Stop & Shop Supermarket Company LLC �
AddreSs: 1385 Hancock Street
City/State/Zip:Quincy, MA 02169 Phone#:800-288-&t1.5 .
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. ❑ RestauranUBar/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 corporation and its officers have exercised 9. ❑Entertainment
Their rigfit of exemption per c. 152, §1(4), and we have 10.❑ Manufacturing
no employees. [No workers' comp. insurance required]** 11.0 Health Caze
4.❑ We aze a non-profit organizarion, stafFed by volunteers,
with no employees. [No workers' comp. insurance req.] 12:Q Other
'My applicant that checics box#1 must also fill out the section below showing the'v workers'compensation policy infoima[ion.- . � , �
**If the corporate officers have exemp[ed themselvu,but the cotpotation has other employees,a workers'compensation policy is requved and such an
� � organizafion should checkbox#L � - � - � .
I am an emp[oyer that is providing workers'compensation insurance for my empZoyees. Below is the policy informaSon.
Insurance Company Name: MAC RISK MANAGEMENT, INC. (TPA)
Insurer's Address: �385 HANCOCK STREET
City/State/Zip: QUINCY, MA 02169
Policy#or Self-ins. Lic. # Self Insurance # 576 E�uacion Date:august �, 2015
Attach a copy oF the workers' compensation policy declarafion page(showing the policy number and eapiration date).
Failure to secure coverage as required under Section 25A of MGL a 152 can lead to the imposirion of criminal penalties of a
fine up to $1,500.00 and/or one-year 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 forwazded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify, under tlie pains and penalties ofperjury that the information provided above is hue and correct
Signature� �.���,(i�-1-�iti� Date• 1o%7i�20�`�
Phone#:617 770-8708
Official use onZy. Do not write in this area, to be completed by ciry or town afficial.
City or Town: Permit/License #
Issuing Authority(circle one):
1. Board of Hea1tH 2.Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office
6. Other
Contact Person: Phone#:
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�°� ��`�o TOWN OF YARMOUTH Boazdof
� -� �=���� Health �
� —._. �`3 1146 ROUTE 28, SOUTH YARMOUTH, MASSACHLJSETTS 02664-24451 -
F.\< � � '� Tele hone 508 398-2231 ext. 1241 Health
•�r""'E�el p Fax(508) 760-3472 Division
To: Yarmouth Business Establishments STaP tS(+OP SUpE'(LMF�KKrc'l"
� G,3C�C�L OMGD
From: Bruce G. Murphy, Director �E� � ] 2��4
Yarmouth Health Department�
Date: November 7,2014 HEALTH DEPT.
Subject: Increase in License/Permit Fees
Please be awaze that the Yarmouth Boazd of Health, under the direcfion of the Yannouth Board
of Selectmen, has raised a number of license and permit fees issued through the Yazmouth
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 Januazy 1, 2015. These fees will be due if you complete and
submit the application after January l,2015.
However, if you fully complete the application, and submit it to the Yannouth Health
Department with all required certifications and worker's compensation coverage information
(certificate of insurance OR completed affidavit) nrior to December 31, 2014, you will be
allowed to pay the 2014 rates for the following licenses
Current 2014 Fee
Public Swiimning Pools $ 80.00
Public WhirlpooUVapor Baths $ 80.00
Tobacco Sa1es $ 95.00
Motels $ 55.00
Food Service 0-100 Seats $ 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 $225.�
Other fees owed but not listed above:
Total fees owed for your establishment: �2Z5.00
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
priol' to DeCember 31, 2014. [Those establishments which open in the spring will be
allowed to provide food ancUor pool certifications prior to opening, however, you must note
"Will provide in the spring prior to opening" on the application.J
BGM/maf