The URL can be used to link to this page

Home My WebLink AboutApplication and WC . I ��°�_�'��`�� T O W N O F Y A R M O U T H Board of �,a Health �'— ' � "3 1146 ROUTE 28, SOUTH YARMOUTH, MASSACHLISETTS 02664-24451 - �.14.�,1 E6�/� Telephone(508)398-2231, ext. 1241 Div si n "c"f Fas(508)760-3472 � To: Yarmouth Business Establishments 3A��5 AND �`(cuJ9 �P�S From: Bruce G. Murphy, Director G3C6L�NIC�D Yannouth Health Department UtL 'i � ?U14 Date: November 7, 2014 HEALTH DEPT. Subject: Increase in License/Permit Fees Please be aware that the Yarmouth Boazd of Health, under the direction of the Yarmouth Boazd of Selectmen, has raised a number of license and permit fees issued through the Yarmouth Health Department, effecfive January 1, 2015. Attached is the Yarmouth 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 applicarion after January 1,2015. However, if you fully complete the application, and submit it to the Yarmouth Health Department with all required certifications and worker's compensation coverage information (certificate of insurance OR completed �davit) nrior to December 31, 2014, you will be allowed to pay the 2014 rates for the foilowing 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 35.00 R�staurants Over 100 Seats $i 6fl.00 _ _- - - - , Retail Food Service Q5,000 sq. ft. $ 80.00 Retail Food Service>25,000 sq. ft. $225.00 Other fees owed but not listed above: Tota1 fees owed for your establishment: �85.0C� 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 certifcations prior to opening, however, you must note "Will provide in the springprior to opening" on the application.J ' BGM/maf , , . 6Ac,�s +-6 0 � d TOWN OF YARMOUTH BOARD OF HEALTH G3[2C'c,[�OMC�DD �� APPLICATION FOR LIC� �t,R� MIT-2015 ` * Please complete form and attach all nec��Pi•�locuments by Dec beULll� �6j�O 14 Failure to do so will result in the r�tur�`of your application c e�t��TM DEPT. ESTABLISHMENT NAME TAX ID: _ � LOCATION ADDRESS:Io� - TEL.#: - MAILING ADDRESS: a- E-MAIL ADDRESS: { OWNER NAME. CORPORATION NAME IF PPLI BLE). � MANAGER'S NAME. 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. - 2: _ _ Pool operators must list a minunum of two employees cunently 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 empioyees 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 Sle at your place of business. l. 2• 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 Establistunents, 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. i. � �PP I�(�CS�� a. �1��,I� 1 � � (— PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. ��'z�� l�l�:� 3. U �tl� 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.��U�� 0�I-�Cx,l ) 2. V 1 � ��;� �� 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. I, 1. 2. ' 3. 4. RESTAURANT SEATING: TOTAL# 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 TRAILERPARK $105 WHIRLPOOL $110ea. �� FOOD SERVICE: LICENSE REQUIRED FEE PE IT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �0-100 SEATS $125 �10� CONT[NENTAL $35 NON-PROFIT $30 '. _>]00 SEATS $200 �COMMON VIC. $60 WHOLESALE $80 �. —RESID.KITCHEN $80 . RETAIL SERVICE: �. LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMiT# �� <50 sy.ft. $50 >25,000 sq ft. $285 VENDING-FOOD $25 _QS,OOOsq.ft. $150 _FROZENDESSERT $40 _TOBACCO $110 �. NAME CHANGE: $15 AMOUNT DUE _ $�- � ****'PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*•**• �G� � ��QO � �8�z ��1�� ADMINISTRATION Under Chapter 152,Section 25C, Subseotion 6,the Town of Yarmauth is naw required to hold issuance or renewal a£any iicense or permit to operate a business if a person or company does not haue a Certificate of Worker's Compensation Insur�ce. THE ATTAC�IED STATE WORKER'S COMPENSATION INSUItA1tiCE ' AFFIDAVIT MUST BE COMPLETED AND SIGNED, CIR CER1'. OI' iNSURANCE ATTACHED� OR WORKER'S CdMP. AFFIDAVIT SIGI3ED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal or isstaance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES� NO — MOT�LS AND OTHER I.ODGING FSTABLISHMENTS TRAN3YENT OCCUPANCY: Far purposes of the limitations ofMotel or Hotel use,Translent accupancy shall be limited ta the temparary and short term nccupancy,ordinarily and customarily associated with motel and I�otel use. Transient occupants must have and be able to demonstrate that they maintain a principal place of residence elsewhere.Transient occupancy sha11 generally refer ta continuous occupancy ofnot more than thirry(30)days,and an a�gregate of not more than ninety(90)days within any six(6)month period. Use of a guest un'rt as a residence or dwalling unit shall not be considered transient. lJecupancy that is subject to the collection of Roam Occugancy ! Bxcise, as detrned in M.G.L. c. 64G or 830 CMR 64G, as amended,shall generally be considered Transient. i P40LS � POOL OPENING:AEI swimming,wading and whirlpools which have been closed for the season must be inspeoted by the Health Department prior to opening. Contact the Health Department to schedule the inspection three(3) days prior to opening. PLEASE NOTE: People are NdT allowed to sit zn the paol area until the paal has been inspeeted and apened. POOL WATEIt TESTING: The water must be tested for pseudamonas,total coliform and standard plate count by a State certified Tab, and submitted to the HeaIth Department three (3) days prior to opening, and quarterly thereafrer. P40L CLOSING: Every autdaor in ground swimming paai must be drained or covered within seven(7)days af closing. , FOOI) SET2VICE SEASONAL FOOD SERVICE OPENING: All food service establishments must be ans�sected by the Health Department prior ta opening. Please eontact the Health Departrnent to schedule the inspectian three (3) days prior to opening. CATERING PQLICY: Anyone who caters within the Town af Yarmauth must notify the Yarmouth Health Department by filing the required Temparary k'ood Service Applicatian form 72 hours priar to the catered event. These forms can be abtained at the Health Department,ar from the Town's wabsite at www�.yarrnonth.ma.us under Health Department, Downloadable Forms. �120ZEN DESSEI2TS: Frozen desserts must be tested by a State certified 1ab prior to operling and monthly thereafter,rvith sample results submitted to the I-Iealth Departrnent. Failure to do so will result in the suspension or revocation of yonr Frozen Dessert Permit until the above terms have been met. t}UTSIDE CAF�S: Outside cafes(i.e.,outdoor seaYing with waiter/waitress service),must have prior approval frorn the Board of Health. OUTDOOR COOHING: i Outdoor cooking,prepazation,or display of any food product by a retail or food service establishment is prohibited. NOTICE:Pernuts run annually from January 1 to December 3 I. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETEI3 RENEWAL APPLICATIC?N{S}AND REQUIREI}FEE(S}BY DECEMBER I5, 2414. ALL RENOVATIONS TO ANY F04D ESTABLISHMENT, MO'I'EL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),iV1UST BE REFORTED TO AND APPRQVED BY TFIE BC?Al2D OF HEAT,TH PRIQR TO COMMENCEMENT. RENOVATIONS MAY RE U RE A SITF PLAN. � DAT��• (��jl�( SIGN.ATURE. � � PRINT NANTE& TITLE. ' � Rev. l1f43114 " � � The Commonwealth ofMassachusens Department of Industrial Accidents Office oflnvestigations I Congress Street, Suite l00 Boston,MA 02I14-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Le�iblv Business/Organization Nam 1 1,� � 1�--� Address: � �. Q � City/State/Zip: Phone#��Q�-�� (� Are you an employer? Check t6e appropriate box: Business Type(required): 1.� I am a employer with�_employees(ful]and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant7Baz/Eating Establishment ' _ _ - 2. I am a sole proprietor or pazmership andhave no - -- - ; Z ❑ 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.❑ We aze a non-profit organization, staffed by volunteers, with no employees. (No workers' comp. insurance req.] 12.❑ Other *My applicant thaz checks box#1 must also fill out the section below showing their workers'compensation policy information. � *'If the coipomte office:s have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organizaTion should check box#I. I am an employer that is providing workMers'compensa' t`ioln'in'nsurance for employe^es.nBelow is e policy,/i�nifo�rm/a�tion. Insurance Company Name� � . 1 � � . rnI�T�A�I ��u�]`I Il'Q ��l �.1,1 1� Insurer's Addres� .� . � �� City/State/Zip:� r��I I� a TV I 1 1 � � 1� 1 �I � —�� Policy#or Self-ins. Lic. # ��.1�'� -�f��"'l� [�� Expiration Date: I �� T�� Attach a copy of the workers' compensation policy declara6on page(showing the policy number and exp�ration date). Failure to secure coverage as required under Secrion 25A of MGL a 152 can lead to the imposition of criminal penalries of a - - fine up to $1,500.00 and/or one-yeaz imprisonment,as welras civil penaltiesin the�orm ofa ST��VORK("1ADER and a�"ine ' of up to $250.00 a day against the violator. Be advised that a copy of this statement may be fonvazded to the Office of ' Investigations of the DIA for insurance coverage verification. I do hereby certify,under the pains and penalties of perjury that the information provided above is bue and correct. Si ature: Date: • �� 1 Phone#: -' � � � Officta[use only. Do not write in this area,to be completed by city or town offacial City or Town: Permit/License# 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 �� NOTICE . �- NOTICE . TO = � TO a EMPLOYEES �.� ,� EMPLOYEES �,,, ,� The Communwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston, Massachusetts 02111 617-727-4900 As required by Massachusetts General Law, Chapter 152, Sections 21, 22, & 30, this will give you notice that I (we)have provided payment to our injured employees under the above mentioned chapter by insuring with: A.I.M. Mutual Insura�ce Company NAME OF INSURANCE COMPANY P.O. Box 4070 Burlington, MA 01803-0970 ADDRESS OF INSURANCE COMPANY VWC-100-6015935-2014A 07/30/2014-07/30/2015 POLICY NUMBER EFFECTIVE DATES P O Box 836 Marshall K Lovelette Ins Agcy West Yartnouth, MA 02673 (508)775-4559 NAME OF INSURANCE AGENT ADDRESS PHONE Bagels&Beyond LLC 311 Main St West Yarmouth, MA 02673 EMPLOYER ADDRESS O6/27/2014 DATE MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers Compensation Act. A copy of the First Report of Injury must be given to the . injured employee. The employee may select his or her own physician. The reasonable cost of the services provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably connected to the work related injury. In cases requiring hospital attention, employees are hereby notiFed that the insurer has arranged for such attention at the NEAREST AND BEST MEDICAL FACILITY EMPLOYER ADDRESS mn u� vncm�n Rv FMPT .(1VF.R