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Home My WebLink AboutApplication and WC OF 'YAk �,� _�` ;.�`�o TOWN OF YARMOUTH BHa�f 0 :._- )`3 1146 ROUTE 28, SOUTH YARMOUTH, MASSACHLJSETTS 02664-24451 - �. s, ^,'� :'r Telephone(508)398-2231, ext. 1241 Health �'"t"`t Faz(508)760-3472 �„ Division R��E!V�� i.�Y i" REC'D To: YannouthBusinessEstablishments STup -r 5�-�-oP S�PE2 �Z`f2Z From: Bruce G. Murphy, Director � �� Yarmouth Health Department� �f l: � 7 �r��Q Date: November 7, 2014 HF"� Subject: Increase in License/Permit Fees Please be awaze that the Yazmouth Board of Health, under the direction of the Yarmouth Boazd of Selectmen, has raised a number of license and pernut fees issued through the Yarmouth Health Department, effective January 1, 2015. Attached is the Yarmouth Business License/Pernut Applicarion for 2015. You will note that the fees listed are the fees effective January 1, 2015. These fees will be due if you complete and submit the application after January 1,2015. However, if you fully complete the application, and submit it to the Yarmouth Health Department with a11 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 fi 9S�oc� 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. $225.00 228.op Other fees owed but not listed above: Total fees owed for your establishment: 32 .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 prior to DeCember 31, 2014. [77iose establishments which open in the spring will be allowed to provide food and/or pool certiftcations prior to opening, however, you must note "Will provide in the spring prior to opening" on the application.J BGM/maf 5 ts�'Z4 ZZ � �� TOWN OF YARMOUTH BOARD OF HEALT „� (�(c�(�p�J[��o k�� APPLICATION FOR LIC � I - ��`�� _�� 9=- �9�EC'] * Please complete form and attach all n��'��9,��i�ts b: ece ber�� 2'0�4`��4 Failure to do so will result in th�eturC��+yb�appTiE�dtion p cke��LTH DEPT. ESTABLISHMENT NA E. �f o i' Y �-�I ZZ TAX ID: � LOCATION ADDR� �I'S 6�. • Q f I� TEL.#: �D • ,3� MAILING ADDRESS: t1= U�i1 21� - E-MAILADDRESS: 55r1e.�5-ro .2`�22..3-fn�-ema..1U ✓� G,�e.P • Cc.nv. OWNER NAME� � l�a Su r�0.r a�. �-C CORPORATION NAME_ (I�APP`ICABI,� �� rslv S kw�ar -a`� 0.n� �LC.- MANAGER S NAME: K + fk � TEL.#: 'SO � •� / MAILING ADDRESS:1�j�6J l�CD +n �R- U (a �h 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 operatars 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 all times. Please list the employees below and attach copies of their certifications to this form.The Health Department wi11 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 m st provide new copies and maintain a file at your establishment. 1. ,�k-��.. �.�.U►._ �I l,Y:�.____ 2. PERSON IN CHARGE: Each f od e�blishment mus have a, t least one Person In Charge (PIC) on site during hours of operation. 1. l�Y%��_ 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 Deparhnent will not use past years' records. You must provi ne copies and intain a file at your establishment. 1. "" - �'� � 2. 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 all times. Please list your employees trained in anti-chokmg procedures below and attach copies of employee certifications to this form. The Health Deparhnent 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 _SWIMMING POOL$110ea LODGE $55 _TRAILERPARK $I05 _WHIRLPOOL $IIOea FOOD SERVICE: LICENSE REQUIRED 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 $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,OOOsq.ft. $150 —FROZENDESSERT $40 �TOBACCO $110 NAMECHANGE: $15 AMOUNTDUE _ $ .395��0 ***"*PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** �� Z�•� �c�5Z53�r5 ��lz �r�l � AT3MINISTRATIClN . ' r Under Chapter I 52, Se�tion 25C,Subsection 6,the Town of Yazmouth is naw required to hold issuance or renewal of any license or permit to operate a business if a persan or campany daes not have a Certificate of Warker's Compensation Insurance. THE AT'I'ACHED STATE W012KL,R'S COMPENSATION INSURANCE AFFIDAVIT MIIST BE C�MPLETED AND SIGNED, QR CERT. OF INSUR.ANCE ATTACHBD OR � WOI2KER'S COMP. AFFIDAVIT SIGNED ANL? ATTACHED Town of Yazmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEf1SE CHECK APFI20PRIA"t'ELY ZF PAID: YES NO ` M4TELS AlYD OTHF.R T,4DGING ESTABLISIiMENTS 'i'RANSIENT OCCUPANCY: For purposes of the limitarions of Motel or Hotel use,Transient occupancy shall be limited to the temporary and short tezm occupancy,ordinarity and customarily assaciated with matei and hotei use. Transient occupants must have and be able to demonstrate that they maintain a principal place of residence elsewhere.Transient occupancy sha11 generalIy refer to cantinuous occupancy of not more than thirry(30)days,and an aggregate of not mare than ninety{40)days within any six{6}manth period. Usa af a guest unit as a residence or dwelling unit shall nok be considered transient. Oc�upancy that is subject to the collection of Room Occupancy Bxcise, as defined in M.G.L. c. 64U or 830 CMR 64G, as amended, shall generally be considered Transient. POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed fpr the season must be inspected by the Heaith Deparhnent prior ta opening. Confact the Hea]Yh Department to schedule the inspectian three{3) days priar to opening. PI,EASE NOTE: People are NOT allowed to sit in the pool area until the pool has been inspeeted and opened. POOL WATER TESTING: The water must be tested Por pseudomonas,total coliform and standazd plate count bp a Stacc certified lab, and submTtted to the Health Departtnent three (3) days prior to opening, and quarterly thereafter. POdL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. Ft30D S�:RVICE SEASONAL FOOD SERVICE OPENING: All faod service establishments must be inspected by the Health I7epartment prior to opening. Please contact the Fiealth Department to schedule the inspection tlaree (3) days prior to opening. CATERING POLICY: Anyone cvha eaters within the Tawn of Yarmouth must notify the Yarmouth Heaith Department by filing the required Temparary Food Service Application form 72 hours prior to the catered event. These forms can be abtained at the Health Departmen#,or from the Town's website at w�vrv.varmauthma.us under Health Department, Downloadable Forms. FROZEN DESSk:RTS: Frozen desserts must be tested by a State certified lab priar to opening and monthly thereafter,with sample results submitted to fhe F-Iea11h Department. Failure to da so will resutt in the suspension ar revocation of your Frpzen Dessert Permit until the above ternns have been met. OUTSIDE CAFES: Outside cafes{i.e.,outdoor seatSrtg with waitertwaitress service},must have priar approval fron�the Board of Health. OUTD04R COOKING: Outdoor caoking,preparation,or display of any food product by a retail or faod servioe establishrnent is prohibited. 1VOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPQNSIBILITY TO RETUILN THE COMPLETED RENEWAL APPLTCATION(S) AND FtEQUIRED PEE(S) BY DECEMBER 15, 2014. ALL RENOVATIONS TO ANY FOOD E5TABT.ISHIvIENT, MOTEL OR POOL {i.e., PAINTING, NEW EQUIPMEN'T, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HBALTH PRIOR TO COMMEIdCEMENT. RENOVATTdNS MAY RE tTIRE�TE PLAN. L7ATE: { � SIGNATURE: � PRINT NAME& TITLE: �.II� aSE I i �t C4 n5� V�-C G ti P �. Rev. 11/03/14 �. The CommonwealtkofMassachusetis Departmerzt of Industrial Accidents Office oflnyestigations ' I Congress Street, Suite 100 _ Boston,MA 021I4-20I7 www.mass.gov/dia Workers' Compensaflon Insurance Affidavit:General Businesses A�plicant Information Please Print Le�ibiv BuSinOSs/Oiganizatlon Name:The Stop & Shop Supermarket Company LLC � Address: 1385 Hancock Street � City/State/Zip:Quincy, MA 02169 PhOne#:$00-288-8�t5 Are you an employer? Check the appropriate bog: Business Type(required): 1.❑a I am a employer with employees (full and/ 5. ❑■ Retail or part-time).* 6. ❑ RestaurantBaz/Eating Establishment 2.0 I am a sole proprietor or partnership and have no �. � Office and/or Sales (incl.real estate,auto, etc.) employees worldng for me in any capacity. [No workers' comp; insurance required] 8� ❑ Non-profit 3.❑ We are a coiporation and its officers have exercised 9. ❑Entertainment their rigli£of exemption per c. 152, §1(4), and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]** 4.❑ We aze a non-profit organization, staffed by volunteers, 11.❑ Health Care with na employees. [No workers' comp. insurance req.] 12:❑ Other � *Any applica¢t[hat checks box#I mus[also fill ou[the sec[ion below showing their workers'compensation policy infomiation.� . � , **I£the corporate of&cers have exempted themselves,but tLe cmporation has oiher employees,a workers'compensation policy is requ'ved and such an � organization should checkbox#L . � � .- � � � � I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Instirance Company Name: MAC RISK MANAGEMENT, INC. (TPA) Insurer's Address: 1385 HANCOCK STREET City/State/Zip: QUINCY, MA 02169 Policy#or Self-ins. Lic. # Se�f �nSUCdIlC2 # 576 Expiration Date:August 1, 2015 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Secrion 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-yeaz imprisonment, as well as civil penalries 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 Offiee of Invesrigations of the DIA for insurance coverage verification. I do hereby certify, under the pains and penalties ofperjury that the information provided above is true axd carrect Si ature• � � ��/ .(if–l-�i�i`— Date• fo�Ui/ZO/'� � . � Phone#:617-770-8708 Offuial use only. Do not write in this area, to be comp[eted by city or town offci¢I. City or Town: PermitlLicense# Issuing Autharity(circle one): 1. Board of Health 2.Building Department 3. City/Town Clerk 4. Liceusing Board 5. Selectmen's Office 6. Other Contact Person: Phone#: � . . . . � - ,,,,,,,,,,,,,��,,,,.,ia:, . . � .