HomeMy WebLinkAboutApplication and WC �F.YAR� TOWN OF YARMOUTH Boazdof
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� �. ��- ��`y ll 46 ROUTE 28, SOUTH YARMOUTH, MASSACHL]SETTS 02664-24451 "
H <,� E9" � Telephone(508)398-2231, ext. 1241 Health
�A C ME Fax(508) 760-3472 Division
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To: Yannouth Business Establishments yaRN.o��f�t Ga2Dc-�N�o-toe (_ooc,t,
From: Bruce G. Murphy, Director � ��6��d��
Yarmouth Health Department�, �E� �9 2��4
Date: November 7, 2014 HEAITH DEPT.
Subject: Increase in License/Permit Fees
Please be awaze that the Yarmouth Board of Health, under the direction of the Yannouth Board
of Selectrnen, has raised a number of license and permit fees issued through the Yazmouth
Health Depamnent, effective January 1, 2015.
Attached is the Yarmouth 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 applicatio�, and submit it to the Yarmout�'� Health
Department with all required certifications and worker's compensation coverage information
(certificate 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
Public WhirlpooUVapor Baths $ 80.00
Tobacco Sales $ 95.00
Motels $ 55.00 5 S.o
Food Service 0-100 Seats $ 85.00
Fo�d Service Over 100 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: S.oo �NT1N.Pi�EAKFqS7'
Total fees owed for vour establishment $ 90 .00
NOTE: To be entitled to pay the current 2014 rates listed above, your
business application, food and/or pool certifications, along with worker's
Gompensation 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
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a � TOWN OF YARMOUTH BOARD OF HEALTH °
��� APPLICATION FOR LICENSE/PE T - 2ois DEC 0 g Zp�q
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* Please complete form and attach all neces�'8oeuments by DeCe ber IS 2014.
Failure to do so will result in the retqm of�our application�ia t. DEPT.
ESTABLISHMENT NAME: TAX ID:
LOCATION ADDRESS: �9 TEL.#: _
MAILING ADDRESS: �
E-MAILADDRESS: .0 �,/l��
OWNER NAME: �
CORPORATION NAME (I APPLICABLE): �"
MANAGER'S NAME: 2 TEL.#:,�" - �
MAILING ADDRESS: L�
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.
1. .d�k�// /'D �O � 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. �/� 0 /,D:� 2.
3.S.S���— �J P 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.
1. /✓�-�l 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.
l.l�/l`✓ 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 place of business.
l. /✓��f 2.
3� 4.
RESTAURANT SEATING: TOTAL#
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
B&B $SS CABIN $55 LMOTEL $110 $l S-n Z�-
INN $55 CAMP $55 SWIMMING POOL$110ea.
LODGE $55 TRAILERPARK $105 _WHIALPOOL $110ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# . LICENSE REQUIRED FEE P IT# LICENSE REQUIRED FEE PERMIT#
0-IOOSEATS $125 �._.CONTINENTAL $35 ��c�1 NON-PROFIT $30
>100 SEATS $200 COMMON VIC. $60 WHOLESALE $80
—RESID.KITCHEN $80
RETAIL SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED PEE PERMIT# LICENSE REQUIRED FEE PERMIT M
<50 sq.fr. $50 >25,000 sq ft. $285 VENDING-FOOD $25
<25,000 sq.ft. $150 —FROZEN DESSERT $40 _TOBACCO $110
NAME CHANGE: $15 AMOUNT DUE _ $ ���✓•C>O
� � � � 4
*'�***PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** �-� `��� �
Cl��IcS�7 /�oi/l�
ADMINISTRATION
LJnd�r Chapter 152, S�ctio�7 25C,Subsection 6,the Town of Yarmouth is naw required tn hold issuanr.e or renawal
of any Iicense or pennit to operate a business af a person or company does not have a Certiftcate of Worker's
Compensation Insuraxice. TFTE ATTACHEI) STATE WORKER'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OB
CERT. OF INSUREINCE ATTACHED
OR ^ /
WORKER'S COMP. AFFIf3AVIT SIGNED AND ATTACH�➢ ✓
7'owtl of Yannouth taxes and liens must be paid prior to renewal or issuance of yotur permits. PLEASE CHECK
APFROPRIATELY IF PAID:
YE5� NO
MOTELS AND OTHER I.ODGING ESTABLISHMENTS
TItANSIENT OCCUPANCY: For purposes of the]imitations of"Motel or Hotel use,Transient accupancy sna11 be
Irmited to the temporary and shart term occupancy, ordinarily and customarily associated with motel and hotel use.
Transient occupanfs must have atzd be able to demonstrate that they maintain a principal place of residence
elsewhere.Transient occupancy shall generaUy refer to continuous occupancy of not more than thiriy(30)days,and
an aggregate of not more tt�an ninety(90)days within any eix(6)month period. Use of a guest unit as a residence or
dwelling unit shall not be eonsidered transient. Occupaney that is subjeet to the eallection of Room Oeeupancy
�xcise,as defined in M.G.L. c. 64Ci or 830 CMI2 64G, as amended, shall generally be considered TransienT.
xao�,s
POOL OPENING:All swsmming,wading and whirlpaols which have been clased tar the season must be inspeeted
by the Health Depattment prior to opening. Contact the Health Departrnent to schedule the inspection three (3)
days priar to apening. PZ,EASB N4TE: People are NdT al]owed to sit zn the poal area nntil the pool has been
inspected and opened.
POOL WATER TESTING: The water must be Yested i'or pseudomonas,total coliform and standard plate eouat
by a State certified iab, and submitted to the Health Departrnent three (3} days prior to opening, and quarferIy
thereafter.
POOL CT.OSING: Every autdoar in ground swimming paoi must be draiz�ed or covered within seve:n(7)days of
closing.
FOQD SERVICE
SEASONAL FOOD SERVICE OPENING:
.�1II food service esCabfishments must be inspected by the I Iealth Department przor to opening. I'lease ca,ntaet the
I Iealth Department to schedule the inspection three (3) d;�ys prior to opening.
CATERING PCILIC S':
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by fiiing the
requFred Temporary Food Service Application form 72 hours priar to the catered event. These forms can be
obta�ned at the Health Departrnent,or from the Town's website at www.yarmouth.ma.us under Health Depaztn�ent,
Downloadable Forms.
I�`ROZEIV DESSERTS:
Frozen desserts m:ust be tested by a Statc certified lab prior to opening and monthly thereafter,wi:th sample results
submitted to the Health Department. Faiture to do so will result in ti�e suspension ar revocafion of your Frazen
Dessert Permit until the above terms have been met.
OU1'SIDE CAFFS:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),nlust have prior approval frorn the Board af Health,
(JUTDOdR COCIKING:
Outd�or cooking,preparation,or display of any food product by a retail or food service establasIunent is prohibited.
NOTICE: Permits run annually from January 1 ta December 31. TT IS YOUR I2ESPONSIBILITY TO RE"I`LiRN
THE CQMPLETED RENEWAL APPI,ICATION{S}:1ND REQIJIR�D FEE{S} BY DECEMBER 15, 2014.
ALL RENOVATTdNS TO ANY FOOD ESTABLISHVIENT, MOTEL OR POOL (i.o., PAINTING, NEW
PQUIPMENT',ETC.}, MUST I3E REPt3RTED TO AND APPROVED BY THE BOARD C?F HEALTH PRIdR
TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PI,AN.
D=�TE: SIGNATURE:
PRINT NAME & TI'TLE:
Rev.3 VC13t 14
'� ' � The Commonwealth ofMassachusetts
Department of Industrial Accidents
Office of Investigations
1 Congress Street, Suite 100
Boston, MA 02I14-2017
www.mass.gov/dia
Workers' Compensation Insurance Af�idavit: General Businesses
Auplicant Information Please Print Legiblv
Business/Organization Name: � ,� �a,PGl,e,� ��u,P ���
Address:�9� �ic ��
City/State/Zip: Phone #: , ��//��79/ �
Are yo employer? Check the appropriate box: Business Type(required):
1. I am a employer with�employees (full and/ 5. ❑ Retail
or part-rime).* 6. ❑ Restaurant7Baz/Eating Establistunent
2.❑ I am a sole proprietor or partnership 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 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]* 11.❑ Health Caze
4.Q We aze a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp. insurance req.] 12.�8"ffier o
*My applicant that checks box#1 must also filI out the sec[ion below showing their workers'compeasation policy infotmation.
**If the cosporate officers have exempted themselves,but the wrporation has other employees,a workers'compeasation policy is requ_ired and such an
organization should check box#I. �
I am an employer that is providi workers'co nsation insur e for my emp[o�ye�es. Be[ow is the policy information.
InsuranceCompanyName•�P P�S ,���/ ,�//0��� C_e- /�.5��/�l_
Insurer's Address:�//-G�- oX �����
City/State/Zip: �/'��/�,/�_�"'� 3��/v�7—C�/J;/�
Policy#or Self-ins. Lic. # ����/`�-.32�/9�0� –�/S� Expuation Date: �
Attach a copy of the workers' compensation policy declaration page(showing the policy numbe an ezpiration date).
Failure to secwe coverage 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
Invesrigations of the DIA for insurance coverage verification.
I do hereby certify, under thepains a dpenaltie o perjury that the information provided above is true and correct.
Sienatur � � /,�./A��— Date: /� –����
Phone#: �
Official use only. Do not write in this area,to be completed by city or town officiaL
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmeds Office
6. Other
Contact Person: Phone#:
www.mass.gov/dia