HomeMy WebLinkAboutApplication and WC OF�Y'9R
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0 =. �`3 1146 ROUTE 28, SOUTH YARMOUTH,MASSACHLJSETTS 02664-24451 - �
�. �,r �a�' � Telephone(508)398-2231,ext. 1241 Health
lRCNE Fa7c(508) 760-3472 Division ��'
To: Yannouth Business Establishments HA aPy F,s�+ 6At�'R`i ��Cr,�O��D
From: Bruce G. Murphy, Director � �E� �3 2014
Yannouth Health Deparhnent�
HEALTH DEPT.
Date: November 7, 2014
Subject: Increase in License/Permit Fees
Please be awaze that the Yannouth Boazd of Health, under the direction of the Yarmouth Board
of Selectmen, has raised a number of license and permit fees issued through the Yazmouth
Health Deparhnent, 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 January 1, 2015. These fees will be due if you complete and
submit the applicafion 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 compieted �davit) arior to December 31, 2014, you will be
allowed to pay the 2014 rates for the following licenses:
Current 2014 Fee
Pubiic Swimming Pools $ 80.00
Public WhirlpooUVapor Baths $ 80.00
Tobacco Sales $ 95.00
Motels $ 55.00
Food Service 0-100 Seats $ 85.00 �S-oo
Food Servicz Ovzr 1G0 Seats �IoG.GO
Retail Food Service Q,5,000 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 establislunent: Q5 od
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 andlor pool certifzcations prior to opening, however, you must note
"Will provide in the spring prior to opening" on the application.J
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���a TOWN OF YARMOUTH BOARD OF HEALTH ����� yv��
APPLICATION FOR LICENSE/PERIVIIT -���
`°' * Please complete form and attach all necessary documen 13�e�� er 15f�O1C�3 :'
Failure to do so will result in the return of your appiication pac etH��� DEPI.
ESTABLISHMENT NAME: eT L TAX ID: -
LOCATION ADDRESS: 3 u Gv o/' <�7A 02107 TEL.#: 77 -�2 7Z
MAILING ADDRESS:/-�3 /i',�,.�/o(�A yGrmu�h l�i>/'t /YIA UZIo'7 S
E-MAILADDRESS: �vs(yn6Urban,�C �� �qs�-. ✓l-c
owNERNAME: Ros�i� Rur— b�t)r�n�ci � u✓ha.�� �v,�,;i�L arb<�n,�
CORPORATION NAME IF APPLICABLE): /� p�i �;sh ��i ,(Cer� L�Gj.
MANAGER'S NAME: ,Q ( �-i D. C'�nc�, �� TEL.#: ��y sy v-�2 �2
MAILINGADDRESS: /13 Ovi-eloA ycrr�o�Y� u�f /�1/� U2G7S
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 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 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 file at your establishment.
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PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
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ALLERGEN CERTIFICATIONS:
All food service establishments are 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 Sle at your establishment.
1. �Ml�Gf L • �SLfr�J' �h�C 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-choking 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 p(ace 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 $55 SWIMMINGPOOL$IIOea.
_LODGE $55 TRAILER PARK $105 WHIRLPOOL $110ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
�0-100 SEATS $125 ���5� _CONTINENTAL $35 NON-PROFIT $30
_>I00 SEATS $200 COMMON VIC. $60 WHOLESALE $80
—RESID.KITCHEN $80
RETAIL SERVICE:
LICENSE REQUIRED FEE PERMIT# W CENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
<50 sq ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25
<25,000 sq.ft. $150 _FROZEN DESSERT $40 TOBACCO $110
NAME CHANGE: $15 AMOUNT DUE _ $ � 2S•OO
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** 'i 8 J�'-�C QZr C ((�
�'C�' (,�7J� ��d��� I
ADMINISTRATION
Under Chapter 152, Section 25C,Subsectiou 6,the Tc�wn of Yermouth is n�w required to hold issuance ar renewal
af any license or pernzit ta operate a business if a person or company does not have a Certificate of Worker's
Compensation Znsurance. TIiE ATTACHED STAT'E WOI2KF:R'S COMPENSATI4N INSUFtANCE
AFFIDAVIT MiJST BE COMPLF.TED AND 5IGNED, OI2
CI;RT. dF iNSURANCB A"CTACHED
OR --
WORKER'S COM.P. AFFIDAVIT SIGNED ANI�A'T'TACHED�
Town of Yannouth taxes and liens rnust be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES�__ NO
MOTELS AND �THER T.ODGING ESTABLISH. NiENTS
TRANSIFNT OCCDPANCY: Foc pucposes of the limitations oi'Motel or Hotel use,Tr�nsicnt aecupancy sha11 be
lirnited to the temporary and shart term accupancy,ordinarily and customari,ly associated with matel and hotel use.
Transient accupants must have and be able to deinonstrate that they maintain a principal place of residence
elsewhere.Transient occupancy shall generally refer to continuous occupaaicy of not more than thiriy(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 residenoe or
dwelling anit shall not be considered transient. Occupatzcy that is subject ta the callection of Room Occupancy
Excise, as defined in M.G.L. c. 64G or 834 CMR 64G, as amended, shall generally be considered Transient.
rao�.s
POdL OPENING:All swimming,wading and whirlpaals which have been closed for the season must be inspected
by the Hea7th De�arUnent prior Yo opening. Contact the TIealth Departrnent to schedule the inspectipn three(3)
days prior to openin�. PLEASE NOT}3: Pcople are NOT a]]atived to sit in Tlte paol area until the poal has been
inspected and opened.
PO4L WATER TESTING: The water must be tested far pseudomonas,total colifonn and standard plate count
by a State certified lab, and submitted to the Health Department three (3) days priar to opening, and quarterly
thereafter.
P(?QL CLf}SI1VG. Every outdoor in ground swimming pooi must be tirained or cavered within seven{7}days of
olosing.
FO011 SF,R�ICF.
SEASONAL FOOD SERVICE OPENING:
AII food service establishments must be inspected by the Eieatth Departmeni prior ta opening. Please contact the
Health Department to schedule the inspection three(3) days prior to opening.
CATERiNG P4LICY:
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the
reqnired Temparary Faod Service Application farm 72 hours priar to tbe catered event. These forms can be
abtained at the Health Department,ar from the Tawn's website at www.vanmouth.nia.us under Health Department,
I�ownloadable Farms.
FROZEN DESSERTS:
Frozen desserts must be tested by a State certified lab priar to opeixing and rnonthly thereafter,with sample results
submitted to the Health Department. Failure to do so witl result in the suspension or revocation of yoixr Frazen
Dessert Permit until the above terms have been met.
OUTSIDE CA��;S:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Boazd af Health.
OUTDOOR COOHING:
Out�car eooking,preparation,or d�r:play of any faod proeluct by a retail ar food service establishment is prohibited.
NOTICE: Permits run annually from January i ta December 31. IT IS YOUR RE3PONSIBILITY TO RETURN
THE CdMPLETED REN�WAL APPLICATIOI�i{S}ANT}REQUIRED FEE(S}BY DECEMBER 15,2di4.
ALL RENOVATIONS TC) ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTFNG, NEW
�QUFPMENT, ETC.}, MUST BE REPORTED Td AND APPRQVEL}BY THE BOAItD t>F HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY FtEQUIRE A SITE PLAN.
DaTE: l Z (2 ( l�f sIGNATURE: �:��r,Y� Q��{�2..,�z.�
PRLNT NaME�Yi TTTLB:�vs l�t� IJ � 8 Lf r bGr/?k �U-v wn er
Rev. III03t1R
' � The Cornmonwealth ofMassachusetts
Department of Industrial Accidents
Offzce oflnvestigations
I Cangress Street, Suite l00
Boston, MA 02II4-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Le¢iblv
Business/Organization Nasne: �u�OV �S Gi Y�G,�f/ n fGQ .
�'
Address: � rI,3 ��I,t�2 (p �
City/State/Zip:yCl/'l'r1Ul�'/'GJ/'U✓� !/yl r� D�7 S Phone #: 77�/— �`J�/— S�Z7 Z
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. �RestauranUBaz/Eating Establishment
- - - _ —
2. I am a sole proprietor or paRnership and have no 7, � 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.LrJ We aze a corporation and its officers have exercised 9. ❑ Entertainment
their right of exemption per c. 152, §1(4), and we have 10.❑ Manufacturing
no employees. [No workers' comp. insurance required]* I 1.0 Health Caze
4.❑ We aze a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp. insurance req.] 12.❑ Other
*Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information.
••If the corporate officers have exempted themselves,but the corporauon has other employees,a workers'compensation policy is required and such an
organization should check box#1.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information.
Insurance Company Name:
Insurer's Address:
City/State/Zip:
Policy#or Self-ins. Lic. # Expiration Date:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and ezpiration date).
Failure to secure coyerage as required under Section 25A of MGL c._152 can lead to the imposition 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 forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby cem ,under the pains and pena[ties ofperjury that the information provided above is true and correct.
Sienature• �"�/��//�'( J �4�(iLf.fJPiti(YL Date• ��Z/ %�-/
Phone#: 7 7`t —`�G1`l — �Z7 Z
Official use on[y. Do not write in this area,ta be completed by city or tawn officiaL
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board oF Health 2. Building Deparhnent 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office
6. Other
Contact Person: Phone#•
www.mass.gov/dia