HomeMy WebLinkAboutApplication and WC c ,
o��Y'�R
��' -_ _ _ �c TOWN OF YARMOUTH Boardof
x�i�n
0 =. `j I 146 ROUTE 28, SOITI'H YARMOUTH,MASSACHUSETTS 02664-24451 -
�. �, e'� $ Telephone(508)398-2231, ext. 1241 Health
r���H6� Division
Fax(508) 760-3472
To: YarmouthBusinessEstablishments ED�B� f4tuzar-�c�eM�iS �
f�, L3G6C�OML�DD
From: Bruce G. Murphy, Director U
Yazmouth Health Department� UEI: 2 2 ZQ�¢
Date: November 7,2014 HEALTH DEPT.
Subject: Increase in License/Permit Fees
_ —_ - - - _ �
Please be awaze that the Yazrnouth Boazd of Health, under the direction of the Yarmouth Boazd
of Selectmen, has raised a number of license and pernut fees issued through the Yazmouth ,
Health Department, effective January 1, 2015. '
Attached is the Yazmouth 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 application after January l, 2015. '
However, if you fully complete the applica6on, and submit it to the Yarmouth Health ,
Depar[ment with all required certifications and worker's compensation coverage information
(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 Whirlpool/Vapor Baths $ 80.00
Tobacco Sa1es $ 95.00
Motels $ 55.00
Food Service 0-100 Seats $ 85.00 g .po '
_ __ _ _ �
Food�ervice Over 100 Seafs �160.60 -
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:
Total fees owed for your establishment: �85-�0
NOTE: To be enfitled 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 DeCembeT 31, 2014. [Those establishments which open in the spring will be
allowed to provide food andlor pool certifications prior to opening, however, you must note
"Will provide in the spring prior to opening" on the application.J
aGtwm�t
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r � TOWN OF YARMOUTH BOARD OF HEALT�3, � r ➢
� � APPLICATION FOR LICENSE/P�� �0{ ' ��� � �E(; 2 � ZQ�4
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` * Please complete form and attach a11 necess docu�eaat�tg+�ece $er 1 20 4
Failure to do so will result in the return�your application p ket. EPT.
ESTABLISHMENT NAME: �1��✓'�LL A2 2t�nl C�EwLF n1 t S TAX ID•
LOCATION ADDRESS: a 3 i.)ia� rE S A�TH TEL.#:,s-c�S 3SY�'/op
MAILING ADDRESS: PO cni �L ri '1D, ��?on rnFnJr d3 tvef/ /YlA O�? 5 3
E-MAIL ADDRESS: � r n�
OWNERNAME: �S-{e�� MC�E �e.rN�L _-
CORPORATION NAME (IF APPLICABLE): S�n S e �- Frui f � �,��
MANAGER'SNAME: � vz �1'lc C�2ru �I TEL.#: SoSr-�18�/-331'I
MAILING ADDRESS: PO l3cx 57v i�onu��ent /�.e�c.h, m�4 D�155 ''�
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 Cazdiopulmonary 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 wiR
not use past years' records. You must provide new copies and maintain a tile 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 I
Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000.
Please attach copies of certificaUon 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. Z•
PERSON IN CIIARGE:
Each food establishment must have at least one Person In Chazge (PIC) on site during hours of operation.
L �. Id � i� M�C�A�rt+ 2, ,
ALLERGEN CERTIFICATIONS: ;
All food service establishments are required to have at least one full-time employee who has Allergen certification, I
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 Cle at your establishment.
1. �'EJi� �V1 Cc A r�r�ta/] 2. !,
HEIMLICH CERTIFICATIONS: i�
All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich j
Maneuver on the premises at a11 times. Please list your employees trained in anti-chokmg procedures below and I
attach copies of employee certifications to this form. The Health Department will not use past years' records. I
You must provide new copies and maintain a Tile at your place of business. j
�. r� l� 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 CAB1N $55 MOTEL $110
INN $55 CAMP $55 SWIMMINGPOOL$110ea
_LODGE $55 _1RAILER PARK $l05 _WHIRLPOOL $110ea.
FOOD SERVICE: �.
LICENSE REQUIRED FEE P IT#,/ L[CENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# -
�0-100 SEATS $125 I��– jJ —CONTINENTAL $35 NON-PROFIT $30 '�..
>100 SEATS $200 COMMON VIC. $60 WHOLESALE $SO ��.
— — —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 VENDMG-FOOD $25 ��
_QS,OOOsq.ft. $150 —FROZENDESSERT $40 _TOBACCO $110 �'�,
NAME CHANGE: $15 AMOUNT DUE _ $ I ZS .O� �
"***"PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM**•** "'«-'`� � BS•OV '�.
� I�OO�� �Z�2i�f�
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ADMINIS'TRATION �
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Under Ghapter I 52,Section 25C,Subsection 6,the Tawn of Yazmoufh is naw required to hold issuance or renewal
af any license ar permit to operate a business if a person or company does nat have a Certificate af Worker's
Compensation Insurance. . THE ATTACHED STATE WORK�R'S COMPENSATION INSUI2ANCE
A..FFIDAVI'T MUST BE COMPLETED AND SIGNED, OR �
CF,RT. OF INSURANCE A'fTACHED
OR �WORKER'S CQMP. AFFIDAVIT SIGNED AND ATTACH�D
Town of Yarntouth taxes and liens must be paid prior to renewat ar issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID: /
YES V NO '
i
MOTELS AND ClTHER LODGiNG LSTABLISHMENTS i
TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotei use,Transient occupancy shatl be
limited ta the temparary and short term occupanoy,ardinarily and customarily assooiated with motei and hotei use. '
Transient occupants rnust have and be able to demonstrate that they maintain a principal place of residence !
elsewhere.Transient occupancy shall generaliy refer to continuous occupancy of not more than thirty(30)days,and �;
an aggregate of not mare than ninety{40)days within any six{6}monih period. Use of a guest unit as a residence or
dwelling unit shall not be considered transient. Occupancy that is subject to Yhe cc>llection af Room Occupancy
Bxcise, as defined in M.G.L. c. 64G or $30 CMK 64U, as amended, shall genaraIly be considered Tzansient.
POOLS
POOL OPENING:All swimming,wading and whirlpools which have been closed for the season rnusk be inspected '
by the Health Department prior ta opening. Contact the Health Department to sekedule tha inspection threQ(3}
days peior to opening. PLEAS$NOTE: People are NOT allawed to sit in the pool area until the pool has been
inspected and opened.
POOL WATER TESTING: The water must be tested for pseudomanas,total coliform and standard plate count
bg a State cezCified lab, and submitted fo the Health Deparimenf three (3) days prior to opening, and qnarterly
thereafrer.
�
POOL CLOSING: Every outdoor in ground swimming pool musi be drained or covered within seven(7)days of C
closing.
�f3f}ll SF:RVICE '
SEASONAL FQOD SERVICE OPEIVING: �
All food service establishments must be inspected by the Health Department prior ta opening. Please contact the !
Health Depariment to schedule the inspection three (3) days prior to opening.
CATERING POLICY:
Anyone wha caters within the Town of Yarmouth must natify the Yarmouth Health Department by filing tha
required Temporary Faod Service Application form 72 hours prior ko the catered event. These Forms can be
ahtained at the Haalth Department,or fram the Town's website at www.yarmoulh.ma.us under Health I}epartment,
Downloadable Forms. �
FROZEN DESSERTS: �
Frozen desserts must be tested by a State certified Iab prior to opening and monthly thereafter,with sample results
submitted ta the Health Depar(snent. Failure to do sa will result in the suspension or revocatian of your Frpzen
Dessert Permit until the above terms have been met.
OUTSIDE CAFES:
Outside cafes{i.e.,outdoor seating with waiteriwaitress sen>ice},must have prior approval fram the Board of Health. E
OITTDOOR COCYKING: �
____ Outdoor eooki�reparation,Ur display of any food product by a retail or food service establishment is prohibited. �'
__ ._ — _---_____ _
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NOTICE:Pernuts run annually fram January 1 to December 31. IT IS YOLJIi RESPONSIBILITY TQ ItET'[)RN
THE COMPLETED RENF,WAL APPLICATION(S) AND REQLJIRED FEE(S) BY DECEMBER I5, 2014.
ALL REI�TOVATIONS TO ANY FOOD ESTABLiSHMENT, MOTEL OR POOL (i.e., PAIN'1"ING, NEW
EQUIPMENT, ETC.), MUST BE REPQRTED "1'O AND APPROVED BY THE BOAR.D OF HEALTH PRIOR
Td COMIvfENCEMENT. RENOVATIONS IvLA��,K�Ctt,,'IR�A SITE P t
� � �
DATE: / Z ~ S - / � STGNATUItE: „_
PR1NT NAME & TI1'LE: .S7'-fi�.�, /"i��C 7``N`� �',�.r,f
Rev. 11/03/14 �
�
• ' t� The Commonwealth ofMassachusetts
Department of Industrial Accidents
O�ce of Investigations
' 1 Congress Street, Suite I00 '
Boston,MA 02II4-20U
www.mass.gov/dia
Workers' CompensaHon Insurance AfSdavit: General Businesses
Applicant Information Please Print Legiblv
Business/Organization Name: �U��1����An;f�G u�(r�a�! t�
Address: �v� i.0 N� 7F_ C �''A T�
City/State/Zip: Phone#: �6�c' � �9 y'�3 i D� ,
�
Are ou an employer? CLeck the appropriate box: Busin s Type(required): ',
1.� I am a employer with�employees(full and/ 5. �Retail i
or part-timeZ* _ 6. ❑ RestaurantBaz/Eating Establishment '
-- -
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.❑ We 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]* 11.❑ Health Caze
4.❑ We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp. insurance req.] 12.❑ Other
*Any applicant ihat checks box#1 must also fill out the sec[ion below showing their workexs'compensation policy informatioa.
••If the coipornte office=s have exempted themselves,but ihe cotporation has other employees,a workers'compensation policy is reqnired and such an ,
organization should check box#I. .
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy inforination.
1
InsuranceCompanyName: �HE f�K( 2T�=c:�c.�J _ l ,vSJ��r1�;LE �
Insurer's Address: C7nl -L �A�iJ-- PL/1C� , �300 J. �rn,rF �7 �]'`�'FL � S�1RAcL5=, , ,v �/ /3:�2
CiTy/State/Zip: GU < . 0 a"
Policy#or Self-ins.Lic. # �g W k C. �-F D�3�- Expiration Date: S � .S
Attach a copy of the workers' compensation policy declaration page(showing the policy number and ezpiration date).
F_ailure to secure co_verage as required under Section 25A o#�MGL c. 152_can lead t_o the imposition_of criminal penalties of 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 forwarded to the Office of
Investigafions of the DIA for insurance coverage verification.
I do hereby certify,under the pains and penaUies o ery'ury that the information provided above is true and correct.
Si atur • a Date: � ' Sl' �7
Phone#: a - � �3
Official use only. Do not write in this area,to 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.Licensing Board 5. Selectmen's O�ce
6.Other '
Contact Person: Phone#:
i
www.mass.gov/aia