HomeMy WebLinkAboutApplication and WC � � ..
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� . �` _ �`�o TOWN OF YARMOUTH Boazdof
� - ��y� Health ,
� — `" 1146 ROUTE 28, SOUTH YARMOUTH,MASSACHLJSETTS 02664-24451 - �-�
� <� �������:x Telephone(508)398-2231, ext. 1241 Div si n �
Fas(508) 760-3472
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To: Yannouth Business Establishments 2�� P.�D #� I o �q�
UtC U 1 ?014
� HEALTH DEPT.
From: Bruce G. Murphy, Director
Yannouth Health Department�, ,p
Date: November 7,2014 � �32��31
Subject: Increase in License/Permit 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 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 effecrive 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 Yarxnouth Health
Department with all required certifications 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
Public WhirlpooUVapor Baths $ 80.00
Tobacco Sales $ 95.00
Motels $ 55.00
Food Service 0-100 Seats $ 85.00
Food Service Over 1G0 Seats $160.00
Retail Food Service <25,000 sq. ft. $ 80.00 8 0.00
Retail Food Service>25,000 sq. ft. $225.00
Other fees owed but not listed above:
Total fees owed for your establishm t: O.0
NOTE: To be entitled to pay the current 2014 rates listed above, your
business application, food and/or pool certifications, along with worker's
compeusation 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 and/or pool certifcations prior to opening, however, you must note
"Will provide in the spring prior to opening" on the application.J
BGM/maf
� � ` ObC�DD
� TOWN OF YARMOUTH BOARD OF HEALTH
k��� APPLICATION FOR LICENSE/PERMIT - 2015 , /Ut(; � � 2Q 14
e,,,. C�1a'v2��3�
* Please complete form and attach all necessary o uments y ece ber 15 20I4.
Failure to do so will result in the return of your application p ketHEALTH DEPT.
ESTABLISHMENT NAME: � � TAX ID:
LOCATION ADDRESS: 1�i YY1li �n K} TEL.#:
MAILING ADDRESS: C� Ot �(os ��S� n � /
E-MAILADDRESS:`�LCae u .4 i'i-ftur , Cuti.
OWNER NAME: r� �.-.r•
CORPORATION NAME IF APP ICABLE):
MANAGER'SNAME�� os � �GeK- TEL.#:
MAILING ADDRESS:
POOL CERTIFICATIONS:
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.
_ . - -- - - _
_ __ _ _ _ �
L _ 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 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.
1. 2•
3. 4.
FOOD PROTECTION MANAGERS - CERTIFICATIONS:
All food service establishments are required to have at least one full-time emp]oyee who is certified as a Food
Pmtection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000.
Please attach copies of certification to this application. Tbe Health Department will not use past years'records.
You must provide new copies and maintain a file at your establishment.
1. 2.
PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
L __
ALLERGEN CERTIFICATIONS:
All food service establishments are 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 Department will not use past years' rewrds. You must
provide new copies and maintain a file at your establishment.
1. Z•
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 Department will not use past years' records.
You must provide new copies and maintain a file at your place of business.
1. Z•
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 7'RAILERPARK $105 _WHIRLPOOL $110ea.
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 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. $I50 I�.�i�2( —FROZENDESSERT $40 _TOBACCO $110
NAMECHANGE: $15 AMOUNTDUE _ � I5Q-OO �
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** ��\C� ���` e�
��1o�2'�b3`� l��tll�
, �
ADMINIS'I'RATI()N �
Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal
of any licensa'or perniit to operate a business if a �aersan or company does not have a Certificate of Worker's
Compensation Insurance. TFIE ATTACHEll S'I'ATE WQ12KI:R'S COMPENSATION INSUILANCE
AFFTDAVIT MUST BE COMPLETED AND SIGNED, OR
CERT. OF iNSURANCE ATTACHED
OR
WORKER'S COMP. APFIDAVI'I SIGNED AND A'1"TACHED
1'own of Yarmouth taxes and liens rnus#be paid prior to renewal ar issuance ofyour permits. PLEASE CHECR
APPI,ZOPIZIAfiELY IF PAID:
YES�_ NO __
MOTELS ANA dTHF.R LODGING F�STABLISIINIENTS
TRANSIENT OCCUPANCY: For putposes of the limitatiot�s of MoCel or Hotel use,"i ransient occupancy shait be
limited to the temporary and shart term occupancy,ordinarily and customariIy associated with motel and hotel use.
Transient accupants must have and be able to demanstzate that they maintain a principal p3ace af residence
elsewhere.Transient occupancy shall generally refer to continuous occupancy of not rnore than thirry(30)days,and
an ag�regate of not more than ninety(90)days within any six(6)month period. [Jse of a�uest unit as a residence or
dwelling unit shall not be considered transient. Occnpancy that as subject to Lhe callect3an af Raom Occugancy
�xcise,as defined in M.G.L. c. 64U or$30 CMR 64G, as amended, shall generally be considered Transient.
POOLS
P40L C}PENING:A11 swimming,wading and whirlpools whsch have been ciosed for the season rnust be inspected
by the Health Department prior to openittg. Contact the Health Depazkment to schedule the inspection three (3)
days prior to opaning. PLEASE NO"I`F,: People are NOT allowed to sit in the pool area until the poal has been
inspected and opened.
POOL WATER TESTING: 'The water mtut be tested for pseudomanas,total colifonn and standard plate count
by a State certified lab, and submitted to the Health Department three (3) days prior to opening, and quarteriy
thereafter.
PQ{}L C'LOSING:Every outcloar in ground swimming pooi must be flrained or covered within seven{7}days of
closing.
FOOI) SE1�vlC'E
SEASONAL FOC1D SERVICE OPENING:
All food service establishments must be inspected by the HeaIth Department prior to opening. Please contact the
ITealth Department Co schedule the inspection three (3) days prior to opening�
CATERiNG POLICY:
Anyone who caters within the Town of Yarmoixth tnust notify the Xannouth HeaTth Department by filing the
required Temporar� Food Service App3icatian form 72 hours priar to ihe catered event. These farms can be
obtained at the Health Department,ar from the Town's website at www.yarmouth.ma.us under Health Department,
Downlaadable Forms.
FROZEN DF.SSF,RTS:
Frozen desserts must be tested by a State certified lab prior to openin�and monthly thereafter,with sample results
submitted to the Health Depariment. Failure to do so wiil result in the suspension or revocation ofyour Frozen
Dessert Permit until the above terms have been met.
OUTSIDE Cr1F�S:
Qutside cafes(i.e.,outcloor seating with waiter/waitress service),must have prior approval from the Board of Health.
OUTD0IJR COOHING:
Outdaor cooking,preparation,or dispIay of any food product by a retail ar faod service establishment is prohibited.
NOTICE:Permits run annually from January 1 to December 3 L IT IS YOUR KESPONSIBILITY'1"O RLTURN
THE CQMPLETBD R.ENEWAL APPLZCATION{S}AND RI;QIIIR�D FEE{S} BX DECEMBER 15,2014.
ALL RENOVATTONS TQ ANY FOOD EST�I.BLISHMENT, M01'EL OR POOL (i.e., PAINT'INC'ir, NEW
F,QL7IPMEN'I", ETC.},MUST BE REPORTED T'O AND APPROVED BY THE BOARD OF H�ALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY 1tEQUIRE A SIT��LAN.
DAT&: SZGrr.�TUt�: ��C����r<_u_,�
PRINT NAME & TI1"LE: �(Yii��{ �. � rSk= v ic t �vcS�c?A,t
Rev. lftp3l{4
Florio, Mary Alice
From: Florio, Mary Alice
Sent: Monday, March 09, 2015 3:08 PM
To: 'Tana Sweigart'
Subject: RE: Proof of Workers Compensation Insurance - Rite Aid #10194
Thank you, but on the form the "Business Type (Required)" section is supposed to be completed, and the form must be
signed and dated.
Thank you for your attention to this matter.
MaryAlice Florio, Principal Office Asst.
Yarmouth Health Department
1146 Route 28
South Yarmouth, MA 02664
508-398-2231, ext. 1241
From: Tana Sweigart [mailto:tsweigartCo�riteaid.com]
Sent: Monday, March 09, 2015 3:05 PM
To: Florio, Mary Alice
Subject: RE: Proof of Workers Compensation Insurance - Rite Aid #10194
Please let me know if you need anything else. Thanks and have a great day!
7'wna.Swe�:ga�^t
Licensing Coordinator
Rite Aid Corporation
tsweigartCa�riteaid.com
Phone 717-731-6539
Fax 717-730-7762
With us, iYs always personal!!!!
From: Florio, Mary Alice [mailto:MFlorioCo�yarmouth.ma.us]
Sent: Monday, March 09, 2015 2:42 PM
To: Tana Sweigart
Subject: Proof of Workers Compensation Insurance - Rite Aid #10194
Tha�k you for submitting the 2015 application for your establishmenYs retail service food service license issued through
the Health Department.
However, prior to issuing the license to you, we are required under Massachusetts State Law, Chapter 152, Section 25C,
Subsection 6, to have you submit a completed State Worker's Compensation Insurence Affidavit form, or to have you
submit a Certificate of Insurance from your insurence agency indicating that your State Worker's Compensation is in
effect.
i
Please complete the attached affidavit form and return it to our office, or have your insurence agency send us a
certificate of insurance showing Worker's Compensation coverage. Even if you do not have employees,the affidavit is
still required to be completed and signed.
As soon as our office receives the required information regarding your worker's compensation coverage, we will be able
to process the license.
If you have any questions on the above, please feel free to contact the Health Department at (508)398-2231, ext.
1241. Thank you for your anticipated cooperation.
MaryAlice Fiorio, Principal Office Asst.
Yarmouth Health Department
1146 Route 28
South Yarmouth, MA 02664
508-398-2231, ext. 1241
2
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