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Home My WebLink AboutApplication and WC o� 'Y'`�R �,� � _ �� TO WN OF YARMOUTH H��f 0 -_ { "'3 1146 ROUTE 28, SOUTH YARMOUTH, MASSACHiJSETTS 02664-24451 - `' �. 4,, E.�' $ Telephone(508)398-2231,ext. 1241 D��q`n ' r�`"` Fas(508)760-3472 ry(,�S�C C 2��4 HEALTH DEPT. To: Yannouth Business Establishments ST. P�us� S�-oo�- From: Bruce G. Murphy, Director � R E C E ► V,�_ � ';y Yarmouth Health Department� � I�� 19 4�14 � Date: November 7, 2014 sT. plus x SCH��+� � Subject: Increase in License/Permit Fees Please be awaze that the Yarmouth Boazd of Health, under the direction of the Yannouth Boazd 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 Januaty l, 2015. These fees will be due if you complete and submit the application after January 1,2015. However, if you fixlly complete the application, and submit it to the Yarmouth Health Department with all required certifications and worker's compensation coverage informaUon (certificate of insurance OR completed affidavit) arior 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 Food Service Over 100-Seats - $160.00 I�oAo 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: 9 (�o.00 �MON dic . Total fees owed for your establishment: $220.00 NOTE: To be entitled to pay the current 2014 rates iisted 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. �7'hose 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 springprior to opening" on the application.J BGM/maf _ SpXS � � TOWN OF YARMOUTH BOARD OF HEALTH - �� APPLICATION FOR LICENSE/PE IT - 2015 IC�V 1 O 2014 � ��s��s +�° * Please complete form and attach all necessaiy doeumen s by Dece ber I S 2014. Failure to do so will result in the retrYtt�of�Quz�pplic�tion� cke . EPT. ESTABLISHMENT NAME: fi !�I us X ��l G1UI TAX ID: � __ LOCATION ADDRESS: ��1 t9�0U �aG c�U1�4t, ��mp� TEL.#: `Sd� � �!/� MAILING ADDRESS: � 1 �,,nitl �d E-MAIL ADDRESS: 11'��D � SP k 5C h vv I . OWNERNAME: Uml.u� f.�'Ftialrc �°�sno,� 0'( II �°�u-e� CORPORATION NAME IF APPLICABLE): MANAGER'S NAME: � � Y! r TEL.#: �JU � g-(9 / � MAILING ADDRESS: �9 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 - - -- - Z _ 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 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�le 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. i. �h I� rt"(I� C�- z. nn15 rmc�h �y i(mar sehvpl � S�"�ef "�ovd s'�w�ees PERSON IN HAR E: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. i. -�-�e, ��rti. �'--- ---- - -- -_ _2_ __ 1-�nh�S�IG-�inu�h �P�/luir�ISQhoJ� bh�naf '�vUd S¢vUCes ALLERGEI� CERTIFICATIONS: All food service establishments aze required to haue 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. � U'e l�I� /� 2. �4 `�',iC�R� i�or�`''�u.� �� 1-n o+ �va+ sennU� 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 Department will not use past years' records. You must provide new copies and maintain a �le at your place of business. i. C7"�.� ► �hcX�-p�(,n �1� 2. I►lC1,JM,�►� �r1r.�., � 3. � 4. RESTAURANT SEATING: TOTAL# (3� _ OFFICE USE ONLY LODGING: � - ---- - - ---- � � — LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $1l0 INN $55 CAMP $55 SWIMMING POOL$110ea. _LODGE $55 _TRAILERPARK $105 _WHIRLPOOL $ll0ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 CONTINENTAL $35 NON-PROFIT $30 �>100 SEATS $200 �7 �COMMON VIC. $60 � _WHOLESALE $80 —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 NAME CHANGE: $15 AMOUNT DUE _ $ Z60-OO *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** �� `�O � ��sz�� ►�/�� . ADMINISTRATION Under Chapter 152,Section 25C,Subsection 6,the Town af Yarmouth is naw required to hold issuance or renewal of any licanse or permit ta operate a business if a person or cotnpany does not have a Certificate pf Worker's Compensation Insuranee. TFIE ATTACHED STATE WOitKER'S Ct?MPENSATION IIVSURANCE AFFIDAVIT MUST BE COMPI,ETED AND SIGNED, 012 CER'I'. OF INSURANCE ATTACHED OR / WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED t� Town of Yannouth taYes and liens rnust be paid prior to renewal or issuance of your permits. PLEASE CH�CK APPROPRIATELY IF PAID: �S J N� MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCIJPANCY: For purposes oftne limitations of Motel or Hotel use,Transient ar;cupancy shall be limited to the temporary and shart 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 af residence elsewhere.Transient oecupancy shall generally refer to continuous occupancy of not more than thirty(30)days,and an aggregate af not more than nrnety(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 af Raom Oceupancy Excise, as defned in M.G.L. c. 64G or 830 CMR 64G, as amended,shall generally be cansidered Transient. P(3QL OPENING:Al(swimmang,wading and whirlpoals which have been closed for the season must be inspected by the Health Deparhnent prior to opening. Contact the Health Depaztment to schedule the inspectian three(3) days priar to opening. PLBASE N(}`I`E: People are NOT allowed ta sit in the paol area until the pao] has been inspected and opened. POQL WATER TESTING: The water must be Yested for pseudomonas,total coliforrn and standard plate count by a State cerrtified lab, and submitted Co the Health Department three (3) days priar to opening and quarterly thereafter. P(}OL CLQSING: Every qutdaar in graund swirnming pool must be drained or covered within seven(7)days af closing. FOOD SI;RVICE SEASONAL FOOD SERVICE OPENING: t�ll food service establishments must be inspected by the Health Depariment prior to opening. Please contact the Health DepartrnenY to sehedule the inspection three{3)days prior to apening. CATERIIVG POLICI': Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Aepartment by filing the requ�red Temporary Faad Service Application form 72 hours prior ta the catered event. These forms can be obtained at the Health Department,or from the Town's websita at v✓ww.vannouth.ma.us under Health Department, Downloadable Forms. FROZEN DF,SSERTS: Frozen desserts must be tested by a Statc certified lab prior to apening and monthly thereafter,with sarnple results submitted to the Health Departrnent. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit untii the above terms have been met. CIUTSII}E CAFk:S: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval frorn the Board of Health. OUTDOOR COOHING: Outdoor cooking,prepazation,�r display of any food product by a retail or food service establishment is prahibited. NOTICE:Permits run annuaTly from 7anuary 1 to December 3 I. IT I3 YOUR RESPONSIBILITY TO RI:�'tTRN THE COMPLETED RENBWAL APPLICATIC?N{S)AND REQUIItEI}FEE{S}BY DECEMB�R 15,2014. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MO'I`EL OR POOL (i.e., P.�1IN'T'ING, NEW EQUIPMENI',ETC.},MUST BE KEPt)RTED TQ AND APPRCIVED BY Tl-IE Bt}ARI3 OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY UIRE A 5IT AI�I, ' — ___ � — —-- -- _ - — _. � —- _ _�_--. _ DATE; SIGNATCJRE: U.i PRINT NAME& TITLE: `7`4/2/1;C-� Q,(, t2(� ftev. S1t43114 ' � The Commonwealth of Massacicusetts Department aflndustrial Accidents OJfice af Investigations � I Cangress Street, Suite 1 QO Baston,MA Q2114-2Q17 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Anolicant Infarmation �'� � "US R ��+ Piease Print Le�iblv Buslness/Organization Name: � �US �- SC� �3l} ( Address: 4 �-'O�- CitylStateiZip: Yyt �� Phone#: ��; ��' 6 �! �.. Are you an employer?Check the apprapriate box: Business`i�pe{required}: 1.❑ I am a employer with�,__employees(full and/ 5• ❑ Retail or part-time).� 6. ❑RestauranUBaz/Earing Establishment — - - - 2. I ain a sola propiietor or parmarship and have no 7. �pffice and/or Sales(incl.real estate,auta,etc.} employees working for me in any capacity. (No workers' comp. insurance required] g� ❑�on-profit 3.❑ We aze a corporation and its officers have exercised 9. ❑ Entertainment thair right of exemption per c. 152, §1(4), and we have 10.[] Manufacturing no employees. [No workers' camg. insurance required�* 11.0 Health Caza 4.❑ We aze a non-profit orgacrization,staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12•0 Other 'Any appficant that eBuks box#i must aLso fill out ihe section helow showing ffie'v worke=s'compensation palicy information. �� "*If the cotpomie officers have exempted themselves,but the eorporadon has other employces,a workers'compensation policy is required and sucli an organizetion should check Box#S. I am an e»rployer that is providin worke s'campensutaon insuranee for my employees. Betaw is the poticy information. Insurance Company Name: ��1 �l1 �dt1�,!'�"1GY1lt--� ��!f,4(,SntJ �-�/� v ' Insurer'sAddress: ��',2 �L�� ( �,�Pf� ��D � CitylStatel2ip: �, C� �� t � ��' ��1 � Policy#or Seif-ins. Lic. # �IS��'�(�!_)tb f3t3 ��g��-6 t t{ i�" Expiration Date: �� b�t�l� _ Attach a copy of the workers' compensat3on policy dec}ara6on page{showing the palicy numher and expiratian date}. Failure to secure coverage as required ixnder Section 25A of MGL a 152 can lead to the impdsition of criminal penalties of a fine up to$I,SOD:OU an8lor one-yeariiiiprisonmaist,�s weitas i:ivii'penattias in the farm ofa3`I`OP WflR3:t1RflER az�d a firre af up ta$254.00 a day against the violator. $e advised that a copy of tt�is statement may be forwarded to the O�ce of Invesdga6ons of the DIA for insurance coverage verifica6on. I do hereby certi ,under the ' and p a[ties of perjury that the informafion provPded above is true and correct. e� D e: Phona#: �� ' (gl(c� OfJicia[use only. Do no1 write in this area,to be compteted by city or town officBat City ar Town: Permit/License# Issuiag Authority(cirete one}: 1.Board of Health 2. Building Deparhnent 3.City/Town Clerk 4.Licensing Board 5, 5electmen's dffice 6.Other Contact Person: Phone#: www.mass.gov/aia