HomeMy WebLinkAboutApplication and WC �}o�'�R,�� TOWN OF YARMOUTH Boazdof
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� ; "'j 1146 ROUTE 28, SOUTH YARMOUTH,MASSACHiJSETTS 02664-24451 -
N a,T �e� � Telephone(508)398-2231,ext. 1241 Div sl n
'"°"` Fa�c(508)760-3472
To: YazmouthBusinessEstablishments SEYt24s S�Foo� t�NO �Da�'e`1 a
From: Bruce G. Murphy, Director � G3LC�L��'IGD
Yazmouth Health Department� DEC 1 1 2�14
Date: November 7, 2014 HEALTH DEPT.
Subject: Increase in License/Permit Fees
Please be awaze that the Yazmouth Boazd of Health, under the direction of the Yazmouth Boazd
of Selectmen, has raised a number of license and permit fees issued through the Yazrnouth
Health Department, effective January 1,2015.
Attached is the Yannouth Business License/Pemvt 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 l, 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 informa6on
(certificate of insurance OR completed affidavit) nrior 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
Food Service 0-100 Seats $ 85.00 S•00
- Faoci Servicc Over100 Seats e160.00
- - - -
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: �OO .oo CowtioN Vic.
Tota1 fees owed for your establishment: t�} .O
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 Decem6er 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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°` � TOWN 4F YARM{}UTH BOARI} 4F HEAL'I'H ����a���° !
�� APPLICATION FOR I.ICENSL+,lPERMIT -2Q1����{ DkG j`}�p(j1� I
* Please complete form and attach all necassary docum�y Decemb' XS 2014.
Failure to do so wiTl result in the return af your;application pack . NEAL7H DEPT.
BSTABLISHMENTNAME:_.SERRy'.`'� SFAF'(}p(� p,Nl� A1 `i/ TAXID• .�. '�--
�ocA�a�.arra�ss:�54 Rc�t}�� 2�S�CE� YARr�ouT H .Mfl TE�..�:5t78-'�`75-9752
MAILINGADDRE83:664 RUUTF �FrNffSi YH�MC7UTN Mk O (377s
E-MAII.ADDRESS: N �� j
OWNERNAME: �VA11CiE�rJS "T�f-I �ODG2C} i
CORPQRATION ItiTAMB(IF APPLICABLE}: tti;
MANAGER'S NAME: TEL.#: �(k�- 6 -9
Mai�;�•r�AD��ss: 9 � A oab
POOL CERTIFICATIONS:
The poal supervisar mast be certi�icd as a Paal Qperator,as required by State law. Please list the designated
Pool Operatar(s) and attach a copy of the certification to this form.
______ ,�____ ----- — �
- —
- -
2. _ -
Paol operators must list a minimum af twa emplayees currently ceriified in basic water safety, standard First Aid
and Community Cardiopulmonary Resuscitatron (CPR), having one certified employae on premises at all times.
Piease list the empiayees below and attach copies af their certifications to tl7is farm. The Heaith Department will
not use past years' records. You must provide new copies and maintain a file at your place of business.
i. z. ;
3. 4,
FOOD PROTECTION MANAGERS -CERTTFICATIC7NS;
All food servace establishxnents aze required to have at least one full-tirne emplayee wha is cert'rfied as a Food
Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 1d5 CMR 590.000.
Please attach capies of certification to this appiication. The Health Departmant will not use past years'records.
You must provide new copies and maintain a file at your establishment. --
1. EV/hNC�F_�,,Gs THE�[�G C,c� 2. MltRt,{'� ik-1 l [') ; C)( ,_
PERSON IN CHARGE:
Each food establishment rnust have at least one Person In Charge (PTC) on site during hours of operatian.
i: E��t�.I �� �� 3�=1Ec�.nc3�rn� z. M�i� °�'t��c �o�'Qt�
ALLERGEI�T CERTIFICA�TONS;
All faod service establishments are required to have at least ane 1'ull-time employee wha has Allergan certification,
as definad in the State Sanitary Code for Fnod Service Establishrnents, 165 CMR S90A09(G)(3)(a). Please attach
copies of certification to this application The Heaith Department wiii nat use past years' records. You must
provide new copies and maintain a�le Ht yonr establishment.
�. �.Y�NG �a,,oS �r�+ ax�e ,� z.
HEIMLICH CERTIFICATIONS:
All food service establishments with 25 seats or more rnust have at least one employee trained in the Heimlich
Maneuvar on the premises at all times. Please list your emplayees trained in anti-choking procedures below and
attach cppies of ernployee certifications to this form. The Health Depawtment will not use past years' reeords.
You must provide new eopias and maintain a file at your piaee of husincws.
�.�_V��r����r�s -�u�c�_nc-,�,p(��(� a. ma�n T�+E� nr�e�v
3. �(f1 � ( R[ i R �t-�FF(,�.[�C�E�LI 4.
RESTAURANT SEATING: TOTAL# �9
OFFICE USE ONLY
L4DGdNG:
L[CENSE REQUIREI) FEE PERMiT# LICINSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
. B&B $55 CABIN $55 MOTEL $L10
=[NN $54 (;AMP $53 . yS�VIMMING POOL$f IOea -
`LdDGF. $55 �� �'I'RAIL,ER PARK $IOS _ _WHIRLPOOL $f10ea.,,
FOOD SERVICE:
LICENSE I2EQUIRED FEE P RMIT# LICENSE REQUIRED FEE I�ERMIT# LICENSE RE UIRED FEE PERMIT#
�0-100 SEATS $S25 �� —CONTSNENTAL $35 NON-PRO�ST $30
>l00 SEATS $200 �COMMON VIC. $60 �''�'�j —'WHpLESALE $SO
..— -..RESCD.KI7'CHEN $80 ��--
RETAIL 9ERVICE:
LICENSE REQUIRED FEI; PCRMIT# LICENSB REQUIRED FEE PERMIT# LICENSE REQUIRF.D FEE PERMIT#
e50sq.R. $50 >25,006sq.ft. $285 VENI�INfi-FOOD $25
—<25,000 sq.ft. $150 =FROZ6N DESSERT $40 ��" TOBACCO $I 10
NAMECHANGE: $15 AMOiJNTDUE _ $ �B�. OIJ
*****PLEA9E TTJRN OVERANU COMPLETE OTHER SIpE OF FORM***** �G.,tOI Y'jT���
C�e�� j,�-rli �[+�
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ADMINISTRATION '
Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal
of any license or permit to operate a business if a person or company does not have a Certificate of Worker's
Compensation Insurance. THE ATTACHED STATE WORK�R'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR
CERT. OF INSURANCE ATTACHED '
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
� YES�� NO
MOTELS AND OTHER LODGING ESTABLISHMENTS
TRANSIENT OCCUPANCY: For purposes of the limitations ofMotel or Hotel use,Transient occupancy shall be
limited to the temporary and short term occupancy,ordinarily and customarily associated with motel and hotel use.
Transient occupants must have and be able to demonstrate that they maintain a principal place of residence
elsewhere.Transient occupancy shall generally refer to continuous occupancy of not more than thirty(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 residence ar
dwelling unit shall not be considered transient. Occupancy that is subject to the collection of Room Occupancy
Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient.
POOLS
POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected
by the Health Department prior to opening. Contact the Health Department to schedule the inspection three (3)
days prior to opening. PLEASE NOTE: People aze NOT allowed to sit in the pool azea until the pool has been
inspected and opened.
POOL WATER TESTING: The water must be tested for pseudomonas,total wliform and standard plate count
by a State certified lab, and submitted to the Health Department three (3) days prior to opening, and quarterly
thereafter.
POOL CLOSING: Every outdoar in ground swimming pool must be drained or covered within seven(7)days of I
closing. '
FOOD SERVIGE
SEASONAL FOOD SERVICE OPENING: ,
All food service establishments 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 POLICY:
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the
required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be
obtained at the Health Department,or from the Town's website at www.yarmouth.ma.us under Health Department,
Downloadable Forms.
FROZEN DESSERTS:
Frozen desserts must be tested by a State certified lab prior to opening and monthly thereafter,with sample results
submitted to the Health Department. Failure to do so will result in the suspension or 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 Boazd of Health.
OUTDOOR COOHING: '
Outdoor cooking,prepazation,or display of any food product by a retail or food service establishment is prohibited.
NOTICE: Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 15, 2014.
ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT, ETC.), MCTST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. '
DATE: I� — j� �y SIGNATURE: �dd�q'�/� ����o�p���/
� .�— �—
PRINT NAME&TITLE: E"dRI�G E1.SJS T H EO Da�71�. O V�f N E
Rev. 11/03/14 �
. .
� The Commonwealth ofMassachusetts
Department of Industrial Accidents
Office of Investigations
' I Congress Street, Suite 1 DO
Boston,MA 021I4-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Aualicant Information Please Print Le¢iblv
Business/Organization Name: J E���S c,�F�F C�Cjp f� N O �f�l '�.�y
Address: (� 5�} ROUT E 28�
Ciry/State/Zip: V�IF�ST YlkRMOUTN� M/� 02613Phone#: 5 C6 - �l r15�9752
Are you an employer? Check t6e appropriate box: Business Type(required):
1.❑ I am a employer with employees(full and/ 5. ❑ Retail
__- -
orpart-rime).* 6.�RestaurantBar/Eating Establishment
— — ---
2. I am a sole proprietor or partnership and haee no �, � Office and/or Sales(incl.real estate,auto, etc.)
employees working for me in any capacity.
[No workers' comp.insurance required] $• ❑Non-profit
3.❑ VJe 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]*
4.❑ We are a non-profit organization, staffed by volunteers, 11.❑ Health Care
with no employees. [No workers' comp. insurance req.] 12.� Other
'Any applicant tk�t checks box#I mus[also 51l out the seclion below showing[he'v workers'compensation policy information. �
*�If the coxpomte officers have exempted themselves,bu[the corporatioa has other employees,a workecs'compensafion policy is required and such an
organization should check box#1.
I am an employer that is providing workers'compessation insurance for my employees. Below is the policy injormation.
Inswance 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 eapiration date).
_ _ Failpre�2securecoverageasre�uizedunderSe�rion?St�ioflvlGIi�..1�2canleadto_theimp�siLion9f�rinainaln nali�of�_-__
fine up to $1,500.00 and/or one-yeaz 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 forwazded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby cenify,under the pains andpe alties ofperjury that the tnformation provided above is true and correct.
Si ature: �'t.G'�Ci� � I �—'-i7���- Date: /2 — �O � l y
Phone#: J�O�- 77J'—��7JrmC.
Official use only. Do not write in this area,to be comp[eted by city or town offuiaL
City or Town: PermitlLicense#
Issuing Authority(circle one):
1.Board of Health 2. Building Department 3. City/Town Clerk 4.Licensing Board 5. Selectmen's Office
6.Other
Contact Person: Phone#:
www.mass.gov/dia