HomeMy WebLinkAboutApplication and WC ��°����� TOWN OF YARMOUTH Ha�f
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fl � a- _ �`j ]146 ROUTE 28, SOUTH YARMOUTH,MASSACHLJSETTS 02664-24451 -
�. i,� f,� � Telephone(508)398-2231, ext. 1241 Health
r�c«E Fax(508) 760-3472 Division
To: YazmouthBusinessEstablishments 1-NuAti1 �oi �ESTAv�ac�t�
From: Bruce G. Murphy, Director � ������'/�DD
Yazmouth Health Department� Utl: �I 7 lUi�
Date: November 7, 2014 HEALTH DEPT.
Subject: Increase in License/Permit Fees
Please be awaze that the Yarmouth Boazd of Health, under ttte direction of the Yannouth Boazd
of Selectmen, has raised a number of license and pemut fees issued through the Yarmouth
Health Department, effective January 1, 2015.
Attached is the Yazmouth Business License/Permit Application for 2015. You will note that the
fees listed are the fees effective Januazy 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 Yazmouth Health
Department with all required certifications and worker's compensation coverage information
(certificate of insurance OR completed affidavit) arior 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 Whirlpool/Vapor Baths $ 80.00
Tobacco Sa1es $ 95.00
Motels $ 55.00
Food Service 0-100 Seats $ 85.00 �S-O
:--- -�ocs3�L.�:�� �:�r 109 Srats _ - �fS�J:fl61 _ —
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: 0.0o ca�noN vic.
Total fees owed for your establishment: �I�S.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
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 certif:carions prior to opening, however, you must note
"Will provide in the springprior to opening" on the application.J
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a TOWN OF YARMOUTH BOARD OF HEALTH
��� APPLICATION FOR LICENSE/PERMIT -2015 �t� i j ��14
�"'" * Please complete form and attach all necessary documents by Dece ber 1 S ZOl4.
Failure to do so will result in the return of your application p c eHEAI EPT.
ESTABLISHMENT NAME: `� • TAX ID• -
LOCATION ADDRESS: ' � 6 EL.#: .- 'L—
MAILING ADDRESS: e�-
E-MAIL ADDRESS: �
OWNER NAME:
CORPORATION NAME (IF APPLICABLE): `
MANAGER'S NAME: � 'I'EL.#: � �''
MAILING ADDRESS: �
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.-- -- -- -- -__ �
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 C►le at your place of business.
1. Z•
3. 4•
FOOD PROTECTION MANAGERS - CERTIFICATIONS:
All food service establishxnents 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.
�. �-r6� , 1���. 1�, 2.
T
PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
__ 1. �kti,�—�� �Ir;'�'\ �
ALLERGEN CERTIFICATIONS:
All food service establishxnents 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 Deparhnent will not use past years' records. You must
provide new copies and maintain a file at your establishment.
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.
1. 2.
3. 4.
RESTAURANT SEATING: TOTAL# �''�S
.� _ __ _ _
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 $55 SWIMMINGPOOL$ll0ea
LODGE $55 TRAILER PARK $105 WHIRLPOOL $110ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �
�0-I00 SEATS $125 CONTINENTAL $35 NON-PROFIT $30 �
>100 SEATS $200 �COMMON VIC. $60 WHOLESALE $80
—RESID.KITCHEN $80 �
RETAIL SERVICE:
LICENSE REQUIRED FEE PERMIT# UCENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_<50 sq ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25
_<ZS,OOOsq.ft. $I50 —FROZENDESSERT $40 _TOBACCO $110 �
NAME CHANGE: $15 AMOUNT DUE _ $ I S Jr�O(��/ '
�E.C-� tp �`C��Q
•****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** �.
� _ c� 103�0 ���'1`�
ADMINISTRATIQN
LJnder Chapter 152,Section 25C,Subsection 6,the Town af Yarmauth is now required to hold issuance or renewal
of any license or permit ta operate a business if a person or company daes not have a Certificate of Worker's
Compensation Insurance. THE A�'TAC�IED STATE WOT2KER'S CC}MPENSATION IPiSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, (?R
CERT. OF INStTRANCE ATTACHED
OR
WORKER'S COMP. AFF3DAVIT SIGNEI7 AND A'I'TACHED
'I'orvn of Yarmouth taxes and liens rnust be paid prior to renewal or issuance of your permi4s. PLEASE CHECK
APPROPRIATELY IF PAID:
YES_.� NO
MOTELS ANA OTHFR LODGING FSTABLISHMENTS
TRANSIENT OCCUPANCY: For purposes oT the iimitations ofivlutei or Hotel use,:ransicnt occupancy s�l be
limited to the temporary and short term occupancy,ordinariIy and custnmarily associated with motel and hotel use.
Transiant occupazits must have and be able to demonstrate that they maintain a prancipal place af residence
elsewhere.Transient occupancy shall generally refer ta continuous occupancy of not more than thirty(30)days,and !
an aggre�ate af not more than ninety(90)days within any six(6)month period. Use of a guest unit as a residence ar
dwel2ing unit shall not be consadered transient. Occupatzcy that is subject ta the collection of Room Oocupancy
Excise,as defined in M.G.L. c. 64G or$30 CMR 54G, as arnended,shall generally be considered Transient.
POOLS
P40L OPENING:All swimming,wading and whirlpoals which have been cIosed far the seasan must be inspected
by the Health Department prior to opening. Contact the Health Department to schedule the inspection three(3) '
days priar to opening. PLEASE NOTE: Feople are NOT allowed to sit in the paal area until the paal has been
inspected and opened.
POOL WAT'ER TESTING: The water mast be tested for pseudomonas,tota!coliform and startdard plate count
by a State certified lab, and submitted to the Health Departrnent three (3) days prior to opening, and quarterly
thereafter.
POOL CL08ING:Every outdoar in ground swimming paal must be drained or covered within seven(7)days af
closing.
__. _ FOOD SERVIC�
_._ _ _ _.__
SEASONAL FOC1D SERVICE OPENING:
A71 food service establishments must be inspected by the Health Department prior ta opening. Please contact the
13e21th Department to schedule the inspection three(3) days prior to apening.
CATERING POLICY:
Anyone who catezs within the Town of Yaamouth must notify the Yarmouth Health Department by filing the
required Temparary Foad Service Application form 72 haurs prior ta the catered event. These forms can be
obtained at the Health Department,or fram the Town's website at www.yarrnouth.ma.us under Health Department,
I7awnloadable Forrns.
FROZEN DESSEi2TS:
Frozen desserts must be tested by a State certified 1ab prior to opening and monthly Chereafter,with sample results
submitted to the Health Department. Failure to do so wilt result in tt�e snspension or revocation of your Frozen
I7essert Permit until the above terms have been met.
OUTSIDE CAF�`S:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval frorn the Board of Health.
OUTDOQR COOKING: I
Outdoor cook'rng,prepazation,or display of any food product by a retail or food service esCablishment is prohibited. ,
NOTICE;Perrnits run annually from January 1 to December 3 I. IT IS XOUR RESPONSIBII.ITY Td R�1`tJRN
THE COMPLETBD RENEWAL A]'PLICATION(S}AND REQUIREI}FEE{8}BY D�CEMBER 15,2414.
ALL I2ENOVATIONS T4 ANY POOD ESTABLI5HMENT, MOTEL OR POOL (i.e., PAINTING, NF,W
EQUZPIv1ENT,ETC.),MI3ST BE REPORTED Td AND APPRO VEI7 BY T1IE BtJARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATTONS MAY FLEQUIRE A SIT, PLAN.
DAT�: c� S�__SIGNATURE: ...��--.
PRINT NAME& TITLE: �
� Rev.Iif03t14
' � The Commonwealth ofMassachusetts
Department of Industrial Accidents
Office of Investigatdons
' I Congress Street, Suite 100
Boston,MA 02114-20U
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legiblv
Business/Organization Name: ��j������� ��j/�� � Iri �cn �,��G) ,1�i��
Address: /�Ob MaFn — S� � Zc�
City/State/Zip: !t d ` hone#: Jr�' 3/ - �.S �
Are you an employer? Check the appropriate box: Business Type(required):
1.� I am a employer with��employees(full and/ 5. ❑ Retail
or art-time .* __ 6. RestaurantlBazBating Establishment _ _ _
2. I am a sole proprietor or partnership and have no �, � Office and/or Sa1es (incl. real estate,auto,etc.)
employees working for me in any capacity.
[No workers' comp. insurance required] 8� ❑Non-profit
3.❑ We aze a corporarion 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.❑ 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 musf also fill out the section below showing their workers'compensation policy infotmation.
*'If the corporate office=s have exempted themselves,but the co:porabon has other employees,a workecs'compensation policy is required md such an ��.
organization should check box#L ,
I am an employer that isproviding workers'compensation insurance for my emp[oyees. Be[ow is the policy information.
Insurance Company Name:�� � 1
Insurer's Address: � /7 r/
City/State/Zip: � Z"�
Policy#or Self-ins. Lic. # �� �0/��i C �O l/, �� Expiration Date: � 0 �
Attach a copy of the workers' compensa6on policy declaration page(showing the policy number and eapiration 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 $1,500.00 and/or one-yeaz imprisonment,a�well as civil penalties in the form of a STOP WORK ORDER and a fine
of np to$250.00 a day against the violator. Be advised that a copy of this statement may be forwazded to ttte Office of
Investigations of the DIA for insurance coverage verificarion.
Ido hereby cenify,under thepains andpenalties ofperjury that the information p�ovided above is true and correM.
Sienature: L.-� � ✓��----_ Date: IOZ �!/� f �Lj
Phone�o^� s�J��! �—�—
Official use on[y. Do not write in this area,to be comp[eted by city or town officiaL
City or Town: Permit/License#
Issuing Authority(cirde one):
1.Board of Hea1tL 2. Building Department 3. City/'I'own Clerk 4.Licensing Board 5. Selectmen's OfSce
6. Other
Contact Persou: Phone#:
www.mass.gov/dia .
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