HomeMy WebLinkAboutApplication and WC �°F �`� TOWN OF YARMOUTH Boazdof
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�. �_`�� Health
� — :� j" 1 l46 ROUTE 28, SOiTTH YARMOUTH, MASSACHiJSETTS 02664-24451 -
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�.`�'' A L Hf�d�i�� Telephone(508)398-2231, ext. 1241 Div s�i n
Fa�c(508)760-3472
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To: YarmouthBusinessEstablishments �ECs�2Dc-t� �ssoc.l�l�RoN '
From: Bruce G. Murphy, Director � G3CsC����'1��°
Yazmouth Health Department� �t� �9 2�14
Date: November 7, 2014 HEq�7H DEPT.
Subject: Increase in License/Permit Fees
Please be awaze that the Yarmouth Boazd of Health, under the direction of the Yannouth Boazd
of Selectmen, kias raised a number of license and permit fees issued through the Yannouth
Health Deparhnent, effective January 1, 2015.
Attached is the Yannouth 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 application after January 1, 2015.
However, if you fuily complete the application, and submit it to the Yarmouth Health
Department with all required certifications and worker's compensation coverage information
(cer[ificate of insurance OR completed �davit) 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 � 80.0�
Public WhirlpooUVapor Baths $ 80.00
Tobacco Sa1es $ 95.00
Motels $ 55.00
Food Service 0-100 Seats $ 85.00
FoockSe�ice-0ver 1flO Seats $160.00 "—
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: �t3o.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 DeCembel' 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 appZication.J
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� TOWN OF YARMOUTH BOARD OF HEALTH �����d��
��� APPLICATION FOR LICENSE/PERM�I�T,�-.�0� ��� D�C O 9 2014
" * Please complete form and attach all necessary docuc�ents by Decem r I S 2014.
Failure to do so will result in the return of ybur a']SpPication pac et. HEALTH DEPT.
ESTABLISHMENT NAME: `I� G,c � � hss :�-� I..� TAX ID:
LOCATIONADDRESS: 15i tLw�.�. Y '�-i- No� `�cum�r� vwt o ,Y TEL#• sv�abz z78�
MAILINGADDRESS: k..n,✓,�w„rkr�,.FM4 oz 1f s �
E-MAIL ADDRESS: -li.�.—� ,� �k� cL.. ,�.k
OWNER NAME:
CORPORATION NAME (IF APPLICABLE): ��U_ �w�} " o � ..,� � r�c o� al.:,. I "
MANAGER'S NAME: �I ti.l.:.e. Sh,i.d,ld.., TEL.#: �o a 3 b Z �-7Kb_
MAILING ADDRESS: <a=.�. �9 a6 0.,�
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. � C.a,d Pu�I � - 2.
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.
1. Z•
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 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.
1. 2.
PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
1. _ _ _ 2. - - __ _-- — — --
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' records. 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. 2•
3. 4.
RESTAURANT SEATING: TOTAL#
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# UCENSE REQUIRED FEE PERMIT#
B&B $55 CABIN $55 MOTEL $ll0
—INN $55 CAMP $55 �SWIMMINGPOOL$110ea. �
LODGE $55 _TRAILERPARK $105 _WHIRLPOOL $110ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# L[CENSE 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
RETA[L SERVICE:
LICENSE REQUIRED FEE PERMIT# UCENSE REQUIRED FEE PERM[T# LICENSE REQUIRED FEE PERMIT#
<50 sq ft. $50 >25,000 sq.ft. $285 _VENDING-FOOD $25
=<z5,000sq.ft. $150 —FROZENDESSERT $40 _TOBACCO $110
NAME CHANGE: $15 AMOUNT DUE _ $ I l C�.1 •��
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** �`�C t`^ t' �G� �`I�
�� �7�� Ia��9���
„ �:
ADMINI5'TRATION
Under Chapter I.52, Section ZSC, Subsection 6,the Town of Yarmouth is now required to hold issuance oc renewaI
of any license ar permit to operate a business if a person or campany does not have a Certificate of Warker's
Compensation Insurance. THE ATTAC:HED STA7'E WORKI?]R'S COMPENSATION INSURANCE
A.FFIDAVIT MLtST BE COMPI.ETED AND SIGNF,D, OR
- CERT. OF INSURANCE ATTACHED
li QR
WQRKER'S COMP. AFFTDAVIT SIGNED AND ATTACHrD
Town of Yarmouth taYes and tiens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
r1PPROPRIATELY IF PAID:
YES� NO
M4TELS AlYi} t7THEB L4DGING ESTABLISHMENT5
TRANSIENT OCCUPANCY: For purposes of the limitations oPNlotel or Hotel use,Transient occupancy shall be
]imited ta the temporary and short term occupancy,ordinari3y and custoinari2y associated with motei and hotei use.
Transient occupants must have and be able to demonstrate that they maintain a principal place of residence
elsewhere.Transient occupaney shaIl generally refer ta continuous occupancy of not more than thirty(30)days,and
an aggregate of nat more than ninet��{90}days within any six(6}month periad. Use af a guest unit as a residence or
dwelling unit shall not be considered transient. Occupancy that is subject to the collection of Room Occupancy
Excise, as de�ned in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient.
POQLS
POOL OPENING: All swimming,wading and whirlpools wluch have been closed for the season must be inspected
by the Health Deparhnent prior to opening. Contact tl�e Health Deparfinent to schedule the inspectian three{3}
days prior to opening. PLEASE NOTE: People are NOT allowed to sit in the pool area until the pool has been
inspected and opened.
POOL WA7'ER TESTING: The water must be tesYed for pseudomonas,totai coliform and standard plate caunt
by a State certified lab, and submitted to tl7e Health Departznent three {3) days prior to opening, and quarterly
thereafter.
POOL CLOSIN(>: Every outdoor in ground swimming pool musY be drained ar covered wrthin seven(7)days of
closing.
��aoa s�;xvzcr
SEASdNAL FOOD SERVICE dPENING:
All food service establislunent,�;must be inspected by the Health Department prior to opening. Please contact the
Health Department to schedule the inspection three (3} days prior to opening.
CATERING POLIC'Y:
Anyone who catez•s within the Town of Yarmouth must natify the Yarmauth Heakh Aepartment by filing the
requ�red '1'emporary Food Service Application form 72 hours prior to the catered event. These forms can be
obtained at the Health Depat-tment,ar from the Tpwn's website at zucvw.varmouth.ma.us under Health Departmant,
Downloadable Forms.
FROZEN DESSERTS:
Frozen desserts must be tested by a State certified lab priar to opening and monxhly thereafter,with sample results
submitted to the Heahh Department. Failure to do sa will result in the suspensian or revocation of your Frozen
Dessert Permit untiI the above terms have been met.
OUTSIDE CAFES:
Uutside eafes{i=e.,autdoor seating wiCh waiterlwaitress sarvice�},mast hace prior approvaI from tiie Baard of Health,
OUTI}OOR C4CfKING.
Outdoar cooking,preparation,c�r display of any food�roduct by a retail ar food service establishment is prahibi#ed.
NOTICE:Permits run annually frorn January 1 to December 31. I'I'IS YOUR RESPONSIBILITY TO RET�JRN
THE COMPLETED RGNEWAL APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBrR 15, 2014.
ALL RENOVATIONS TO ANY FOOD F,STABL[SHMENT, MOTEL ,OK POQL {i.e., PAINTINU, NEW
F,QUIPMEN7”, ETC.), MUST BE I2EPORTED TO AND APPROVED BY THE BOARD OF HEAi,TH PRIOR
Td CdMN1ENCEMENT. RENdVATT4NS M�Y REQiJIRE A SIT13 PLAN.
DAT'F: SIGNATL)RE:
PRINT NAME & TIT'LE:
Rev. 11/03/14 '
'� ' � The Commonwealth ofMassachusetts
Department of Industrial Accidents
- Office of Investigations
I Congress Street, Suite 100
Boston, MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
AAplicant Information Please Print Legiblv
Business/OrganizationName: `-l{,. (�,,�� w �s����n.:._ I��
Address: 18 1c.a�w,,�. ���.a..l' (l.�-
City/State/Zip: �„�,�.,..o„rh o� N✓� vw Phone #: �� 3b2 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 parEnership 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.�We are a corporarion and its officers have exercised 9. ❑ Entertainment
their right of exemprion per c. 152, §1(4), and we have 10.0 Manufacturing
no employees. [No workers' comp. insurance required]* �I.0 Health Care
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#1 must also fill out the section below showing their workers'compensation policy information.
*•If the coxpornte officers have exempted themselves,but the wrporation has other employees,a workers'compensation policy is required and such an
orga�vzation should check box#1.
I am an empinyer that is providing workers'compensation insurance for my employees. Be[ow is ihe policy information.
Insurance Company Name:
Insurer's Address:
City/State/Zip:
Policy# or Self-ins.Lic. # Expuation Date:
Attach a copy of the workers' compe¢sation policy declaration page(showing the policy number and ezpiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $],500.00 and/or one-yeaz imprisonment,as well as civil penalties in fhe 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 Office of
Investigations of the DIA for insurance coverage verificarion.
I do hereby certify,unde the pains and penalties ofperjury that the informatinn provided above is true and correct.
Si ature: zo� Date: 2 2. I
Phone#: Sn B 3b z 2'I��
Official use on1y. Do not write in this area,to be comp[eted by city or town officiaL
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2. Buildiug Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's O�ce
6. Other
Contact Person: Phone#:
www.mass.gov/dia