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��°F���c TOWN OF YARMOUTH Baazdof
Health
� —� a- ` "'3 1146 ROUTE 28, SOUTH YARMOUTH,MASSACHUSETTS 02664-24451 -
�. 4,� f�'� 'r Telephone(508) 398-2231, ext. 1241 Health
r�CNE Fa�c(508) 760-3472 Division
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GiGGrCSONIGD
To: Yannouth Business Establishments C��vDy Cor-�PAN`� UEI: 1 8' L014
From: Bruce G. Murphy, Director HEALTH DEPT.
Yazmouth Health Department
Date: November 7, 2014
Subject: Increase in License/Permit Fees
Please be awaze that the Yazmouth Boazd of Health, under the direction of the Yannouth Boazd
of Selectmen, has raised a number of license and permit fees issued through the Yartnouth
Health Department, effec6ve January 1, 2015.
Attached is the Yarmouth Business License/Permit Application for 2015. You will note that the
fees listed aze the fees effecrive 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
Department with all required certifications and worker's compensation coverage information
(certificate of insurance OR completed �davit) arior to December 31, 2014, you will be
allowed to pay t�e 2014 rates for the following licenses:
Current 2014 Fee
Public Swimmiug Pools $ 80.00
Public WhirlpooUVapor Baths $ 80.00
Tobacco Sales $ 95.00
Motels $ 55.00
Restaurants 0-100 Seats $ 85.00
Resta�ants Over 100 Seats �lf>�i:fif,
Retail Food Service<25,000 sq. ft. $ 80.00 80.U0
Retail Food Service>25,000 sq. ft. $225.00
Other fees owed but not listed above: �0•O
Total fees owed for your establishment:
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 certificatiorrs prior to opening, however, you must note
"Will provide in the springprior to opening" on the application.J
BGM/maf
'� TOWN OF YARMOUTH BOARp,� F HEALT �F o�����d��° I
� APPLICATION FOR LICENSE/P� '�� O
� �� � Utl: "I d'2014
* Please complete form and attach a11 necessary do s '' ec ' ber 15 2414.
Failure to do so will result in the return of your application p keiHEALTH DEPT.
ESTABLISHMENT NAME: T D•
LOCATION ADDRESS: �S - A/'►ti10U IYI TEL.#: SO (�IDBa
MAILING ADDRESS: 12(0 0• Q� 1�
E-MAIL ADDRESS:
OWNER NAME: OU7Ar 0(11��
CORPORATION NAME (IF APPLICABLE): a � n "
MANAGER'S NAME: Sq 1')'IQ� TEL.#:
MAILING ADDRESS:
POOL CERTIFICATIONS:
The pool supervisor must be certif►ed 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.
L2. - _ _ _ _ _
Pool operators must list a minimum of two employees currently certified in basic water safery, standard First Aid
and Community Cardiopulmonary Resuscitation (CPR), having one certified employee on premises at a11 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 file 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. 2:
PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
1. 2.
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 Department will not use past years' records. You must
provide new copies and maintain a�le 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 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#
OFFICE USE ONLY
LODGING: '��
LICENSE REQUIRED FEE PERMIT# L[CENSE REQIDRED 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: '�.
L[CENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �.�
0-100 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#! LICENSE REQUIRED FEE PERMIT# �
<50 sq.ft. $50 >25,000 sq ft. $285 VENDING-FOOD $25
=QS,OOOsq.ft. $150 �� _FROZENDESSERT $40 =TOBACCO $110
NAME CHANGE: $15 AMOUNT DUE _ $ I SO.OO
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM**•** �� � � 8O. Ov
e�i-�ll�3 I��BI�`�
ADMINISTRATIdN
L7nder Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal
o£any Iicense or permit to operate a business if a person or company daes not have a Cartificate of Worker's
Compensation Insurance. TFIE AT'CACI�EI} STATE WQItKER'S Cf1MPEN3ATlON INSURANCE
AFFIDAVIT MUST BE COMPLETED AND 5IGNEll, dI2
CERT. OF TNSURANCE ATTACHED
OR
WORKER'S COMP. APFIDAVIT SIGNED AND ATTACHED
1'own of Yazmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELX IF PAID: `
YES J Nd
MOTELS AND OTHER I.ODGING ESTABLTS$MENTS
TRANSIENT OCCUPANCY: For pusposes ofthe limitations of Motel 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 ta damonstrate that they maintain a principa] place of residence
elsewhere.Transient occupaney shall generally refer ta continuous accupancy of not more thau thirty(30)ciays,and
an aggregate of not more than ninety(90)days within any six(6)month period. Use of a guest unit as a residenae or
dwelling unit shall not be considerad transient. tJccupancy that is subject to the eolleetion af Room Occupancy
�xcise, as defined in M.G.L. c. 64G ar$30 CMlt 64G, as am�nded, shall generally be considered Transient.
POOLS
Pt}OL OPElYING:AIl swimming,wading aud whirlpoots which have been ciosed for the season must he inspected
by the Health llepartment prior to opening. Contact the Health Department to schedule the inspection three(3)
days prior to opening. PLEASE NOTE: Peaple are NO'I'allowed to sit izz the poal area until the pool has been
inspected and opened.
POOL WATER TESTING: The water must be tested for pseudomonas,total coli£orm and standard plate count
by a State certified lab, and submitted to the Health Department three (3) days prior to opening, and quarterly
thereafter. '
Pt3dL CLOSTNG: Every autdoor in graund swimming paoi must be dzained or covered witlun sev�n{7)days of j
closing. ;
FOOD SERVICE
SEASONAL FOOD SERVICE OPENING:
All food service estabtashments must be inspected by the Fiealth Department priar to apening. Please contaat the i
Healtli Department to schedule the inspection three (3) days prior to opening.
CATERING POLICY: �
Anyone who caters within the Town of Yarmauth must notify the Yarmouth Health llepartment by filing the '
required Temparary Foad Service ApplicaTian iorm 72 hours prior ta the catered event. These forms can be
abtained at the Health Department,ar from the Town's website at www.yarmouthnaa.us under Health Department,
Downlaadable Forms.
FROZEN DESSERTS:
Prozen desserts must be tested by a State certified lab prior to apening and monthly thereafter,with sample results
submitted to the Heaith Department. FaiTure to do so wi11 result in the suspension 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 from the Boazd of Health.
OUTDOOR COOHING:
_ Qutdoor cooking,preparation�oz dis�lay of any food product by a retail or food service establishment is prohibited.
NOTICE:Pernuts run annually from 7anuary I to December 31. IT IS YOIIR RESPONSIBILITY Td I2�Tt.TRN '
'ZHE C4MPLETED REN�,WAL APPLICATION{S}AND REQUIR�D FEE(S}BY DBCEMBER 15, 201�4.
ALL RENOVATIONS TO ANY FOOD �STABLISHMENT, MQTEL dR POOL (i.e., PAINTING, NEW
EQUIPMENI',ETC.}, MLJST BE ItEP{7RTED'CO APPROVED BY THE BQARD OF HEAI,TH PRIOR
T'O COMME C MENT. RENOVATIONS MAY UIRE A SITE PLAN.
DATE: � STGNATURE:
p�rT�r�� T�z�,E: l��u�a�� CA Q�.e�
Rev. ll703114
� � The Commonwealth ofMassachusetts
Department of Industrial Accidents
" Office ojlnvestigations
1 Congress Street, Suite I00
Boston,MA 02I14-20U
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Annlicant Information Please Print Leeiblv
Business/Organization Name: �DIY1,Q, 1.9.�h l:� • _
Address: -I� �u�� ��
Ciry/State/Zip: �� Qr Phone#: �� 3g8 88��
Ar�e y an employer?Check the appropriate bos: Busin Type(required):
1.pd I am a employer with �� employees(full and/ 5. [�Retail
_ orpart-time).*. ___ __ 6._ORestauranUBar/EatingEstablishment _
2.❑ I am a sole proprietor or parmership 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.❑ VJe are 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]*
4.❑ We aze a non-profit organization,staffed by volunteers, I 1.❑ Health Caze
with no employees. [No workers' comp. insurance req.] 12.� Other
*Any applicant that checks box#1 must also fill out the section below showing their workecs'compensation policy informatioa. .
'*If the coiporate officers 6ave exempted ihemselves,but the corporation has other employees,a workers'compensation policy is iequired md such an �
organi�ation should check box#I.
I am an emp[oyer that is pro�id�g�orkeyr�,s,'Uc�q�m'p"e�esation insurance for my emp[oyees. Below is the policy information.
Insurance Company Name: L� /1 b 7 K.�v`
Insurer's Address: ��I{(`3� ��N
City/State/Zip:
Policy#or Self-ins. Lic. #__�►�( �, q� ��y/ 0 Expiration Date: '� �S c��I S
Attach a copy of the workers' compensafion policy declaration page(showing the policy nnmber and eapiration date).
FailuFe to-sec�ire covgrage as rcn»�undeL_Section 25A ofMGL c.152_�an leadso the imposition of criminal��nalti�s 9f 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 verification.
I do hereby c ' ,under the pains and penalfiu of perjury that the tnformation provided abav is irue and correcL
Si ature: Date: �Z �
Phone#: J�p ��- �b�
Offacia[use on[y. Do not write in this area,ta be completed 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. Liceasing Board 5. Selectmen's Office
6.Other
Contact Person: Phone#:
www.mass.gov/dia �