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Home My WebLink AboutApplication and WC O� �Y'9R �.� -� _ �`�[ TOWN OF YARMOUTH Boazdof Health ��=_ :�- ��, 1146 ROUTE 28, SOi.JTH YARMOUTH, MASSACHUSETTS 02664-24451 Health �, ,�'. Telephone(508)398-2231, ext. 1241 � �'"`"`E Fax(508)760-3472 Divisio G3GGr-C��'IC�D To: YannouthBusinessEstablishments $AGELS RUD 6�(ot�tD Ut� i � "[Ul4 From: Bruce G. Murphy, Director Yarmouth Health Department HEALTH DEPT. Date: November 7, 2014 Subject: Increase in License/Permit Fees -- —--- ---- - - — - Please be awaze that the Yannouth Boazd of Health, under the direction of the Yarmouth Boazd of Selechnen, has raised a number of license and permit fees issued through the Yannouth Health Department, effecrive Januazy 1, 2015. Attached is the Yannouth 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 application, and submit it to the Yarmouth Health Departrnent with a11 required certifications and worker's compensation coverage information (certificate of insurance OR completed affidavit) 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 BS.oO Restaurants Ov�r 100 Seats _ - _ $15Q00 __ __ _ __ . —--- 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.Ov �µno�.1�lC. Total fees owed for your establishment: �I�F5 ,� 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 certifications prior to opening, however, you must note "Will provide in the spring prior to opening" on the application.J ' BGM/maf , � , a . TOWN OF YARMOUTH BOARD OF HEALTH �� APPLICATION FOR LICENSE/PERMIT -2015 �t� •� � ��, * Please complete forxn and attach all necessary documents by De mber I S 2014. Failure to do so will result in the return of your application ac DEPT. ESTABLISHMENT NAME: TAX D• LOCATION ADDRESS L TEL.#: — MAILING ADDRESS: E-MAIL ADDRESS: l OWNER NAME: CORPORATION NAME IF,APP ABL MANAGER'S NAME. 1 f 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. _ _ I, 2. _ Pool operators must list a minimum 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 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 Tle at your place of business. 1. 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 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. � � 1 I C� 1 i KJ'��--C_4 1 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. �U 1 IC� � V i.�'� �JC.f 1 2. __ , ALLERGEN CERTIFICATIONS: All food service establishments are required to haue 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 applica6on. The Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment. 1.V U ��t 1 � IIJI � 2. HEIMLICH CERTIFICATIONS: All food service establiskunents 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 Deparhnent 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: '�� LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $1t0 � INN $55 CAMP $55 SWIMMING POOL$l l0ea � _LODGE $55 _TRAILERPARK $l05 _WHIRLPOOL $(l0ea � FOOD SERVICE: � LICENSE REQUIRED FEE P RMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# � �0-100 SEATS $125 /i-!!0 CONTINENTAL $35 NON-PROFIT $30 � >100 SEATS $200 �COMMON VIC. $60 �'],��(o _WHOLESALE $80 . —RESID.KITCHEN $80 . RETAIL SERVICE: � LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq.8. $50 >25,000 sq ft. $285 VENDING-FOOD $25 =<25,OOOsq.ft. $150 —FROZENDESSERT $40 _TOBACCO $ll0 NAMECHANGE: $15 AMOUNTDUE _ $� � X1� t/ �i ***•*PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** �-'�tK r l7'S vd �-(�I�IS �z�f�� , ADMINISTRATION Under Chapter 152,Section 25C,Subsection 6,the Town of Yarmauth is now required to hold issuance or renewal n£any license or permit'ta operate a business if a person or company does not haue a Certificate of Worker's Compensation Insurazzee. TFiE ATTACHED STATE WO12K�R'S COMk'ENSATION INSURPiNCE AFFIDAVIT MUST BE COIVIPLETED AND SIGNED, OR CERT. OF INSCTRANCE ATTACHED� OR WOR.KER'S COMP. AFFTDAVIT SIGNED AND ATTACHED Town of"Yarmouth taxes and liens must be paid prior to renewal or issuance of your perrnits. PLEt1SE CHECK APPROPRIATELY IF PATD: ` e YES Xi NO MOTELS AND OTHER LODGING ESTABLISFIMENTS TRAN5IENT OCCUPANCY: For purposes of the lamitations of Motel or Hotel use,Transient occupancp shall be lirnited to the temporary and short term occupancy,ordinarily and custornariTy associated with motel and hotel use. fizansient occupants must have and be able to demonstrate that they maintain a grincipal place of residence elsewhere.Transient occupancy shall generally refer to continuous occupancy of not more than thirty(30)c�ays,and an a�gregate of not moce than ninety(90)days within any six(6)manth period. Use of a guest unit as a residence or dwelling unit shall not be considered transient. Occupancy that is subject to the collectian af Raom Oocupancy �xcise, as defined in M.G.L. c. 64G or$34 CMR 64G, as amended, shall generally be considered Teansient. POdLS POOL OPEllTING:All swimming,wading and whirlpools which have been clased far the seasom m�st be inspeeted by the Health Departrnent priar to opening. Contact the Health Department to schedule the inspection three(3) days prior to opaning. PLEASE NOT�:: People are NO"I'allowed ta sit in the pool area until the pool has been inspected and opened. POOL WATER TESTING: The waler must be tested for pseudomonas,tota!coliform and standard plate count by a State certified lab, and submitted to the Health Department three (3} days prior to opening, and quarterly thereafter. P40L CLOSING:Every outdaar in ground swiuuning pooi must be drained or covered within seven{7}days of closing. F(JOLI SERVdCE SEASONAL FOOD SEItVICE 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 Y�umouth rnust notify the Yarmouth Health Department by filing the required Temporary Food Service Application farm 72 haurs priar to the catarad event. These forms can be obtained at the Health I7epartment,or frorn the Tawn's website at www.yarmouth.ma.us under Health Deparhnent, Dawnloadable Forms. FROZEN DESSERTS: Frozen desserts must be tested by a State certified lab prior to opening and rnonthly thereafter;with sarnpla results submitted to the Health Departrnent. Pailure to do so will result in the suspension or revocation af your Frozen Dessert Permit untii the above terms have been met. OUTSIDE CATL+`S: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approvaJ from the Board of Health. OUTDOUR COOHING: Outdoor cooking,prepazation,or display of any food product by a retail or food service establishment is proLibited. iVOTICE; Permits run annually from January 1 to December 31. IT'IS YOUR RESPONSIBII.ITY TO RETURN THE COMPLETED REN�WAL APPLICATIQI�(S)ANI}REQI7IREI}FEE{S}BY DECEMBER I5, 2014. ALL RENOVATIONS TO ANY FOOD ESTABLISHMEI3T, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMEN'I',ETC.},MUST BE REPORTEI}TC}AND API'ROVED BY THE Bt}ARD OF HEALTH PRTOR TO COMIv1ENCEMENT. RENOVATTONS MAY k2EQUIRE A SITE PLAN. I7ATE .�d C�,.,_STGNATLTRE: PR1NT NAME&TITLE: . Rev. 11t03t74 ! � � The Commonwea[th ofMassachusetts Department of Industrial Accidents Off ce of Investigations ' I Congress Street, Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses AAAlicant Information Please Print Leeiblv Business/Organization Name:�P�� ,11 �✓1 �,I�IL,1 1.�► � Address:�� 1 � �r . City/State/Zip: , Qr �D� hone#:SO�—��—�� Are you an employer? Check the appropriate box: Business Type(required): 1�] I am a employer with�_employees(full and/ 5. ❑ Retail _ or part-6me)^*_ _ 6. � RestauranUBaz/Eating Establishment 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 aze a corporation and its officers have exercised 9. ❑ Entertairunent their right of exemption per c. 152, §1(4), and we have 10.❑ Manufacturing no empioyees. [No workers' comp. insurance required]* 4.❑ We aze a non-profit organization, staffed by volunteers, 11.0 Heaith Caze with no employees. [No workers' comp. insurance req.] 12.❑ Other *Any applican[that checks box#1 must also fill o�xt the section below showiag their workecs'compensation policy infolmation. **If the cocpomte officers have exempted themselves,but the corporatlon has other employees,a workers'compensation policy is reqnued and such an organiza[ion should check box#1. I am an employer that is providing workers'com nsation insurance for my em�.p./l'o,ye�es. Belnw ' the poli in ormarion. Inswance Company Name: � ► �.J�.1 1 Insurer's Addres . � 1� City/State/Zip: Policy#or Self-ins. Lic. #��,—��r��Expiration Date:f��_C./11J� Attach a copy of the workers' compensafion policy declarafion page(showing the policy number and expiration date). Failurein secuce coverage as required under Section 25A of MCiL�,_152 san lea�l to the itnpo�irion of criminal penalt��f a_ 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 verificafion. I do hereby certify,under thepains andpenalties ofperjury that the information provided above is true and corred. Si ahue. Date: � � ` Phone#: — '— Officia[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(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 a � NOTI�E TO ; � TO A EMPLOYEES �, �,� EMPLOYEES �. �. The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston, Massachusetts 02111 617-727-4900 As required by Massachusetts General Law, Chapter 152, Secdons 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 VWG100-6015935-2014A 07/30/2014-07l30/2075 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 Bageis&Beyond LLC 12-2 Whites Path So Yarmouth, MA 02664 EMPLOYER ADDRESS O6/27/2014 DATE MEDICAL TREATMENT The above named insurer is tequired 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 reqniring hospital attertrion, employees are hereby notified that the insurer has arranged for such attention at the NEAREST AND BEST MEDICAL FACILITY EMPLOYER ADDRESS T(1 RF Pl1CTF.iI RV F.MPT .(IVF.R