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Home My WebLink AboutApplication and WC � , .��-�, O��Y`qR �� --�` _`fa TOWN OF YARMOUTH H��f 0 -:. .�- � `y 1146 ROUTE 28, SOUTH YARMOUTH, MASSACHUSETTS 02664-24451 Health Y. �, � ,'� � Telephone(508)398-2231, ext. 1241 T�"`"`� Fax(508) 760-3472 Division � To: Yarmouth Business Establishments C�pE T�p E W i N t�S GtF�S From: Bruce G. Murphy, Director L'3GGrL�-OMGDD Yarmouth Health Department Utl: '1 6 1014 Date: November 7, 2014 HEALTH DEPT. Subject: Increase in License/Permit Fees Please be aware that the Yannouth Board of Health, under the direction of the Yarmouth Boazd of Selechnen, has raised a number of license and pernut fees issued through the Yannouth Health Deparhnent, 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 l, 2015. However, if you fully complete the application, and submit it to the Yarmouth Health Departrnent 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 Restaurants 0-100 Seats $ 85.00 -------__ __---- RestauranYsOver 1.QD_Seats-__-____ -- - --$150.451 ------ - - ______ Retail Food Service 45,000 sq. ft. $ 80.00 $ �0 .O� Retail Food Service>25,000 sq. ft. $225.00 Other fees owed but not listed above: � Tota1 fees owed for your establishm t: O,O� � NOTE: To be entitled to pay the current 2014 rates listed above, your� business application, food and/or pool certi�cations, 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 certifications prior to opening, however, you must note / "Will provide in the spring prior to opening" on the application.J �,.�y�(f� CJ"" y/�/� BGM/maf /'^ ,,/ V'�� . �� a�c��ad�� '`�DS^ �� TOWN OF YARMOUTH BOARD OF HEALTH �� APPLICATION FOR LICENSEER 3� -2ff1 Utl: 1 6 (O14 ��2°85� �g . * Please complete form and attach all neces� ents I�y De ` ber IS 2014. Failure to do so will result in the ret�n;of}�nr-�p t�cation ac L T H P T. ESTABLISI-IMENT NAME: � .t/ TAX ID: LOCATION ADDRESS: 2 1`I TEL.#:S - -��fit MAILING ADDRESS. D E-MAIL ADDRESS: OWNER NAME: /! A�'%� Tfll/1 • i!//c CORPORATION NAM�APPLICABLE): MANAGER'S NAME:—�q�7'/��"��L, TEL.#: 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 __ --- 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 prov►de new copies and maintain a file at your place of business. 1. Z• 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. 1. 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. _ __ 1 _ __ __ _ _ - -- - � -__ - -- ----- -- ---- ALLERGEN CERTIFICATIONS: All food service establishments aze 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. 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 a11 times. Please list your employees trained in anti-chokmg procedures below and attach copies of employee certifications to this form. The Aealth 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. RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LODGING: L[CENSE REQUIRED FEE PERMIT# . LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $l10 INN $55 CAMP $55 SWIMMINGPOOL$110ea LODGE $55 TRAILERPARK $105 _WHIRLPOOL $110ea. FOOD SERVICE: � �I LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# � 0-t00 SEATS $125 —CONTINENTAL $35 NON-PROFIT $30 '� >100 SEATS $200 COMMON VIC. $60 WHOLESALE $80 � — — —RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# L[CENSE REQUIRED FEE PERMIT k <50 sq.ft. $50 >25,000 sq ft. $285 VENDING-FOOD $25 . �<25,000 sq.ft. $150 �-0 —FROZEN DESSERT $40 _TOBACCO $ll0 � NAME CHANGE: $15 AMOUNT DUE _ $ 15 0_pp ***•*PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*•*** �.0�� ' O� ��zas� ��{�bj�a � � . _ � .. � a�►Mnvis•ruaTiorr Under Chapter 152,Section 25C,Subsection 6,the Town of Yarmauth is now required ta hold issuance or renewal af any license or permit to operata a business if a person or cocnpany does not have a Certificate of Workers Campensation Insurance. TFIE ATTACHED STATE WOItKE;R'S C0IYIPENSATION INSUILAI�CE AFFIAAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF iNSURANCE ATTACHED OR WORKER'S COMP. AFFII3AVIT SIGNED ANI3 ATTACHED Town of Yarmouth taaces and liens rnust be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NQ _ MOTELS AND OTH�R LODGING ESTABLISHMENTS TItANSIENT OCCUPANCY: For purposes of the limitations of Motel ar Hotel use,Transient accupancy sha11 be limited to the temporary and short term accupancy,ordinarily and custamarily associated with motel and hotel use. Transient occupants must have and be able to demonstrate that they maintain a principal place of xesidence elsewherc.Transient occupancy shall generally refer to cantinuous 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 reszdence or dwelling unit shall not be considered transient. Occupancy that is subject to the eollec;tion of Raom Occupancy Excise, as defined in ivI.G.L. c. 64C, or 834 CMI2 64G,as amended, shall generallp be considered Transient. POOLS P4QL{}PENING:All swimming,wading and whirlpaols which have been closed for the season must be inspeeted by the Health Department prior to opening. Contact the Health Departrnent to schedule the inspecHon three(3) days prior to opening. PLEASE NOTB: People are NOT allowed to sit in the paal area until the poal has been inspected and apened. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate caunt by a State certified lab, and submitted to the Health Departrnent three (3) days prior to opening, and quarterly thereafter. P40L CLOSIIV(s: Every outdoor in ground swimming paoi must be drained or covered witi�in seven{7}days of closing. FOOD SF,RVIC� SEASONAL FOOD SERVICE OPENING: All food service establishments must be inspected by the Health Department prior to opening. Please contact the I3ealth Department to schedula the inspection tYiree (3)days prior to opening. CATERING P4LICY; Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temparary Faod Service Apglicatian farm 72 hours priar ta the catered event. These forms can be obtained at the Health Deparhnent,ar from the Town's website at www.varrnouth.ma.us under Health Deparhnent, I�owtiloadabte Forms. FROZEN DESSERTS: Frozen desserts must be tested by a State certified lab prior to apening and rnonthly thereafter,with sample results submitted to the Health Departrnent. Failure to do so w911 result in fhe suspension or revocation of your Fr�zen Dessert Permit until the abave terms have been met. OUTSIDE CA�'�S: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. QUTDOCIR COOKIIVG: Outdaor cooking,prepazation,or display of any faod product by a retail or food service establishment is prohibited. NOTICE:Permits run annually frorn January 1 to December 31. IT IS YOUR RESPONSIBILI'TY TO RETURN Z`HE C4MPLETED RENGWAL APPLtCATION(S)AN13 REQUIREI}FEE{S}BY DBCEMBER 15, 2014. ALL RENOVATIONS Td ANY FOOD T:STABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NBW EQI3IPMENT,ETC.}, MUST BE REPORTEI}`I'4 AND AFPROVED BY TF-IE B{7ARD C?F HEALTH PRItJR TO COMMENCEMENT. RENOVATIONS MAY RE UIKG A SITE PLAN. DATE. SIGNATURE: �� ! PRINT NAME& TITLE: �j�_j�� J,� Rev. iif031]4 '�� The Commonwealth ofMassachusetts Department of Indust�ial Accidents Off ee ef InvestigrtEinns l Congress Street, Suite I00 Boston,MA 02114-2017. www.mass.gov/dia Workers' Compensation Insurance Affidavit: Genera{Businesses Applicant Informat'ron Please Print Le�blv Business/Organization Name: �%�/ � ��,2��/%/'l�.�S �j��//V C Address: '��y�� City/StatelZip:pl� ��j�DUT� /`/lT Phone #y .SC�p � 3 ��d ��) Are you an employer?Z7t�ck t)re appropriate boz: -- - -Business Tygg(t�uired�;_ - - — - --_ i.❑ I am a employer wi emplo ees (full and/ 3• �e�� or part-time).* � R (5�� 6. ❑ RestaurantlBazBating Establishment 2.❑ I am a sole propnetor or partne ip and have no �, �Office ancUor Sales (incl. real estate, auto,etc.) employees working for me in any capacity. [No workers' comp. insurance required] 8• ❑ Non-profit 3.❑ We ue a corpomrion and its o�cers have exercised 9. ❑Entertairunent their right of exemption per a 152, §1(4), and we have 10.❑ Manufacturing no employees. [No workers' comp. insarance required]* I LQ Health Caze 4.❑ We are a non-profit organization,staffed by volunteers, with no emptoyees. [�to workers' comp. insurance req.j 12.❑ Other •My applicant that checks box N7 must also fill out the section below showing the'u workers'compensation policy information. •'If the coipo:ate officers have exempted themseives,but the corporaRon has other employees,a workers'compensation policy is required and such an organization should check box#i. I am an employer that is providing wor 'campensation insurance for my employees. Below ' the po ' ueformalion. Insur�ce�qmp�rry N�ne: 0 (�i � � Insurer's Address: � � G� C � � City/State/Zip: +Q��,,,/�� l9��"'J - --- -- f-_-- - -- - _ -- _ - - - _ -- -- __ - __ _ Policy#or Self-ins. Lic. # Expiration Date: Attach a copy ofthe workers' compensation policy declaration page(showing the policy number and eapiration date). Failwe to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalries of a fine up to $1,500.00 and/or one-yeaz imprisonment,as well as civil penalties in the form of a STOP WORIC ORDER apd�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 InvesGgations of the DIA for insurance coverage verification. , /da hereby cen�under t e palns andpenalHes ofperjuty that the information pravided above is irue and corred. Si e: � � Dat : /- , <` 9 Phbne� �- — Ojficia[use only. Do not write in this area,to be completed by eity or tawn offigj�� City or Town: Permit/License# Issuias Aathority(circle oue): 1.Board of Health 2.Buildin¢Denartment 3. Citv/Town Clrrk 4. T.iran¢ina Rnord a ao�o..r.,,o..+�nra..e