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Home My WebLink AboutPermit Application. o�.Yq� � .�` _ �� TOWN OF YARMOUTH Boazdof � -�h=- C Health 0 -- .�- � ��" 1146 ROUTE 28, SOUTH YARMOUTH, MASSACHCTSETTS 02664-24451 - �. �, �,�'$ Telephone(508)398-2231, ext. 1241 Div sion �ACNE Fas(508) 760-3472 � To: Yarmouth Business Establishments S�s�aF Com��tS From: Bruce G. Murphy, Director � ��`^��MCDD Yarmouth Health Department� Ut� �,5 2��4 Date: November 7, 2014 HEALTH DEPT. Subject Increase in License/Permit Fees Please be aware that the Yarmouth Boazd of Health, under the direction of the Yannouth Board of Selectrnen, has raised a number of license and pernut fees issued through the Yannouth Health Department, effective January 1, 2015. Attached is the Yannouth Business License/Permit Application 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 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 WhirlpoollVapor Baths $ 80.00 Tobacco Sales $ 95.00 Motels $ 55.00 �SS.oO Food Service 0-100 Seats $ 85.00 Fecsl R..:.._ �_�.3��Ys- _. - _ — $169.90 - — —— _ 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: Total fees owed for your establishment: S5-oo 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. (Those 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 spring prior to opening" on the application.J BGM/maf __ _ , . G3[�A4S��rn " a TOWN OF YARMOUTH BOARD OF HEALTH �(; Q S ZO�4 �� APPLICATION FOR LICENSE/PER��5� �"°" * Please complete form and attach all necessary tCoc ents y D em � .T. Failwe to do so will result in the return of your applicaho . ESTABLISHMENT NAME: G- TAX ID: LOCATIONADDRESS• ��CJ SDUT7� S}f'0 E � �• M(M�EL#• 50S-39g-ZS33 MAILING ADDRESS: 5a.1'n� E-MAIL ADDRESS: O WNER NAME: I� CORPORATION NAME (IF APPLICABLE): V nd,o SSoL' " MANAGER'S NAME: TEL.#: �ZS' 3 MAILING ADDRESS: A � POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Ope ator(s) and attach a copy of the certification to this form. l.�l�l,f'h � �• � Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cazdiopulmonary 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. l. 2• 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments aze 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 Establishxnents, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years'records. You� st provide new copies and maintain a file at your establishment. 1. 2• —r PERSON IN CHARGE: Each fo ¢ establishment must have at least one Person In Chazge (PIC) on site during hours of operation. 1 � - ___ __ _ _ — 2. _ i. i 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 far 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 ew copies and maintain 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 Department will not use past years' records. You mus provide new copies and maintain a Tile at your place of business. 1. V�l iZ� 2. 3 —C'— 4. RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABM $55 �MOTEL $110 ��5—OZ/ —INN $55 CAMP $55 _SWTMMING POOL$t l0ea. LODGE $55 _TRAILERPARK $105 _WH[RLPOOL $IlOea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 _CONTINENTAL $35 NON-PROFIT $30 >]00SEATS $200 COMMONVIC. $60 WHOLESALE $80 — — —RESID.KITCHEN $80 RETA►L 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 <25,000 sq.fi. $150 —FROZEN DESSERT $40 _TOBACCO $I10 NAME CHANGE: $15 AMOUNT DUE _ $ �1 Ci. �CJ *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM**`** ��1G� � ��/'�� 73� � Z(�(�� , AllMINISTRAT'IQN Under Clzapter 152,Section 25C, Subsection 6,the Tuwn of Yarmouth is nc>w required tn hold issuance or renewal oF any license or pemiit ta operate a Husiness if a person or company does not have a Certificate of Wor[cer's Campensatian Insurazxce. THE ATTACAEI) STA"I'E WO.[2Ki+'.R'S CGtMPENSATIQN INSUR4NCE AFFTDA:VIT MUST BE COMPLETED AND SIGNED, OR CERT. OF IN�URANCE ATTACHED�_ OR WORKER'S COMP. AFFIDAVIT SIGNED AND A'ITACH�D Town of Yannouth taxes and liens must be paid prior to renewal ur issuance of your permiYs. PLEASE CHECK. APPROPRIATELY IF PAID: YES� NO_ MOTELS AND OTHFR L011GING ESTABLI5HMENTS 'CRANS7ENT OCCUPANCY: For purposes of the limitations of MoCel or Hotel use,Transient vccupancy shall ba limited to the temporary and shart term occupancy,ordinarily and customarily associated with matel and hotel use. Transianl oecupants must have and be able to demanstrate that they maintain a gr3ncipal place of residence elsewhere.Transient occupancy shall generally refer to continuous occupancy of not rnore than tivrty(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 resrdence or dwelling unit shall not be considered transient. decupancy that is subject to the colleetion of Roarn Occupancy Excise, as deiined in M.G.L. a 64Ci or 830 CMR 64G, as arnended, shall generally be considered Transient. POQLS P(}OL dPENING;Al]swimming,wading and whirlpools which hai�e been closed for the season must be 3nspected by the Health Departraent prior to opening. Contact the T Iealth Department to schedule the inspection three(3) days prior to openin�. PLEASE NOTE: People are NOT a1la�ved to sit in fhe pool aa�ea until the pooi has been inspected and opened. POOL WATER'I'ESTING: The water must be tested for pseudomonas,total coliforrn and standard plate caunt by a State certified lab, and submitted to the Health Departrnent three (3) days prior to opening, and quarterly thereafter. POOL CLOSING: Every outdaor in ground swimming paol must be drained or covered within seven{7)days of" closing. FOOI) SLRVICE .___-----e,.___� SEASONAL FOOD SER`VICE OPENING: All food service establishments must be inspected by the I Iealth Depactment prior to opening. Flease contact the Health DepartrnenY to schedule the inspection three{3) days prior to apening. CATERING POLICY: Anyone who caters within the Town of Yarmouth tnust notify the Yarmauth Health Department by filing the required Temparary Faad Service Applicatian f`arm 72 haurs priar to the catered event. These forms can be obtained at the Health Department,or from the Tawn's website at www.,�armouth.ma.us under Health Department, Downlaadable Farms. F120ZEN DESSERTS: Frozen desserls must be tested by a State cerCified lab prior to opening and rnonthly thereafter,with sample results submitted to the Health Department. Faiture to do sa will result in the strspension ar 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. OUTDOCIR COOHING: t)utdoor cooking,prepazation,or display of any faod product by a retai(or food service establishment is prohibited. NOTICE:Permits run annually from January 1 ta December 31. IT IS YOUR 12ESI'ONSIBILITY TO RF,TiJRN THE COMPLETET) RENEWAL APPLICATION{S}AND R�QUIRED FEE{S) BX DECEMBER 15, 2{)i4. ALL RENOVATIONS TO ANY FOOD ESTI3BLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT',ETC.), MUST BE REPORTFD TQ AND APPRC7VEL7 BY THE BCtARD OF HEALTH PRIC?It TO COMM NCEMENT. RENOVATIQNS MAY REQUIRE A SIT PLAN. DATF': J SIGNATURE:��'`'� �� `�� PRINT NAMF.& TITLE:��;��`Ly��d1rJ�' O ��Q��(.��f`Y(pl7t�g2� Rev. tUO3f14 �� V � 7 NOTICE TO EMPLOYEES NOTICE ff17 EMPLOYEES The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston, Massachusetts 02111 -617-727-4900 — http://www.mass.gov/dia a As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this will give you notice that I (we) have provided for payment to our injured employees under the above mentioned chapter by insuring with: THE TRAVELERS INSURANCE COMPANIES NAME OF INSURANCE COMPANY P.O. BOX 1 450 MIDDLEBORO MA 02344-1450 ADDRESS OF INSURANCE COMPANY (IEUB-2493L94-5-14) 06-01 -14 TO 06-01 -15 POLICY NUMBER EFFECTIVE DATES o� BRIGHT AGENCY INC PO BOX 424 MILFORD MA 017570424 NAME OF INSURANCE AGENT ADDRESS PHONE # 135 SOUTH SHORE DRIVE C, SEASIDE RENTAL ASSOCIATION aSOUTH YARMOUTH o� MA 02664 .� F1MPi OYER - AD:L:$..: S �— EMPLOYER'S WORKERS COMPENSATION OFFICER (IF ANY) DATE MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the services provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the NAME OF HOSPITAL ADDRESS TO BE POSTED BY EMPLOYER =599 W20PIG02