HomeMy WebLinkAboutApplication and WC ��°���`�Q TOWN OF YARMOUTH Boazdof
Health
0 -: � `3 1146 ROUTE 28, SOUTH YARMOUTH,MASSACHUSETTS 02664-24451 -
� 4� eW "r Telephone(508)398-2231,ext. 1241 Health
f��L Nff Division
Fax(508) 760-3472 �
To: Yannouth Business Establishments B�ck{t.�oo� Con»oMtNllf
G3C�C5�OM�D
From: Bruce G. Murphy,Director
Yarmouth Health Department utl: 3 0 "L014
Date: November 7, 2014 HEALTH DEPT.
Subject: Increase in License/Permit Fees
Please be awaze that the Yannouth Boazd of Health, under the direction of the Yazmouth Boazd
of Selectmen, has raised a number of license and permit fees issued through the Yazmouth
Health Deparkment, effective 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 application after January 1, 2015.
However, if you fully complete the application, and submit it to the Yannouth Health
Department with all 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 �O�OO
Public WhirlpooUVapor Baths $ 80.00
Tobacco Sales $ 95.00
Motels $ 55.00
Restaurants 0-100 Seats $ 85.00
R_estaurants Ovar 100 Seat�- -$1F�0.(1�
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: $80.E�
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 certifzcations prior to opening, however, you must note
"Will provide in the spring prior to opening" on the application.J
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� TOWN OF YARMOUTH BOARD•QF I�AL�I� � .
��� APPLICATION FOR LICENSE/PEIi11�IfIT -20�15 " " Utl; 3 U LU14
` * P l e as e c o mp l e t e f o r m an d a tt a c h a l l n e ce ssary d�e l�i-`b y D e c� b e PT
Failure to do so will result in the return of your applicat�on
ESTABLISHMENT N o a� (�� SSo ID:
� LOCATION ADDRESS: '�� a C�^'�0 TEL.#: �O-�`�1
MAILING ADDRESS:�e3 �.��n � S a
E-MAIL ADDRESS:
OWNER NAME:
CORPORATION NAM�IF A LICAB )•
MANAGER'S NAME: ��a�n � S TEL#• atD3-`�10,1
MAILING ADDRESS:
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated
, Pool O erator(s) and attach a copy of the certification to this form.
1. ��7i`J\ \,_ YJ� _ Z• :
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 provide new copies and maintain a file at your place of business.
1. �\� 2.
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 fo d establishxnent must have at least one Person In Charge (PIC) on site during hours of operation.
1 ��� Z,
�
ALLERGEN CERTIFICATIONS:
All food service establishments are required to have at least one fixll-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 applicafion. The Health Department will not use past years' records. You must
provi new copies and maintaiu a 61e 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 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# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
BBcB $55 CABIN $55 MOTEL $110
INN $55 CAMP $55 �S WIMMING POOL$1 l0ea��{'�
LODGE $55 TRAILERPARK $105 _WHIRLPOOL $110ea
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT 1! 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 PERM[T# LICENSE REQUIRED FEE PERMIT#
<50 sq.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25
=<25,OOOsq.ft. $I50 —FROZENDESSERT $40 _TOBACCO $1l0 �
NAMECHANGE: $15 AMOUNTDUE _ $ 110,0�
*•***PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*"*** �c� � �����J
�j�Ji'[X�GJW ����� 1
ADMINISTRATION
Under Chapter 152,Section 25C, Subsection 6,the Town of Yarmouth is naw required ta hold issuance or renewal
of any"license or perrrait ta opezate a business if a person or company does nat have a Certificate of Worker's
Compensafion Insurance. THE ATTACHED STATE WQItKER'S C4MPENSATI4N INSIIRANCE
AFFIDAVIT'MUST SE COMPLETED AND SI(:NED, OR
C�RT. OF INSURANCE ATTACHED " {�
OR T �-,,_
WORKER'S GOMP. AFFIDAVIT SIGNED AND ATTACHED i�I W
� .
Tawn of Yarrnouth taxes and liens rnust be paid prior to renewal or issuanoe of your permits. PLEASE CHECK
APPROPRIATELY IF PAID: /
YES / NO
MOTELS AND OTHFR LODGING ESTABLISHMENTS
TRANSIENT QCCUPANCY: For purposes of the limitations of Motei or Hotel use,Txansient occupancy s2�a11 be
limited to the temparazy and shart term occupancy,ordinarily and custamarily associated with motel and hotel use.
Transient occupants must have and be able to demonsYrate that they maintain a principal place qf residence
elsewhere.Transient occupancy shall generally refer to continuous occupancy oPnot more than thirry{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 residence or
dwelling unit shall not be considered frartsient. Occupancy that is subject to the collection of Roam Occnpancy
Excise, as defined in M.G.L. c. 64G or 834 CMR 64G,as amended, sizall generally be cansidered Transient.
P{}OLS
P40L OPEh�ING:All swimming,wading and whirlpools which have been closed for the season must be ii�spected
by the Health 17eparhnent prior to opening. Contact the Health Department to schedule the inspection three(3)
days prior to opening. PLEASB NOTE: Peopie are NOT allowed to sit in the pool area until the pooi has been
inspected and opetted.
PQOL WATER'i'ESTING; The water must be tested far pseudomonas,total 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.
POOL CL4SING:Every oatdaar in ground swimmSng paal must be drained ar covered wiThin seven{7}days of
closing.
FO011 SERVICE
3EASONAL FOOD SERVICE OPENING:
AII food service establishxnents must be inspected by the I-Iealth Department prior to opening. Please contact the
Health Departrnent to schedule the inspection three{3)days prior to opening.
CATERING POLICY:
Anyone who caters within the Town of Yarmouth rnust notify the Yarmoutl� Health Department by filing the
required Temparary Food Service Application farm 72 haurs prior to the catered event. These forms can be
obtained at the Health Department,or from the Town's website at www.varrnouth.ma.us under Health Deparhnent,
Downloadable Forms.
FROZEN DESSEBTS:
Frozen desserts must be tested by a State certified lab prior to opening and monthly thereafter,with sample results
submitted to the Health Department. Failure to do so will result in the suspension ar revooation of your Frozen
L7essert Fermit untii the above terms have been met.
OUTSIDE CA.FES:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health.
OUTDOOR COQHING:
Outdoor cooking, repazation,ar display of any faod product by a retail or food service eslablishment is prohibited.
NOTLCE:Petmits run annually frorn January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETLJRN
TFIE COMPLETED IZENEWAL APPLICATION(S)AND REQUTRED FEE(5}BX DECEMBER I5,2014.
ALL RENOVATTONS TO ANY F04D ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NBW
EQUIPMENT,ETC.},MIUST BE REPORTPD 1'O AND APPRdVEi�BY THE� ARI3 C7F HEALTH PRIC}R
TO COMMENCEMENT. RENOVATTQNS MAY REQUIRE A SI PLA .
DATE: 1� �2- 1 SIGNATURE:
PRINT NAME&TITLE:
Rev. �if03114
� � The Commonwea[th ofMassachusetts
Department oflndustria[Accidents
O�ce of Investigations
' I Congress Street, Suite 100
Boston, MA 02114-2017
www.mass.gov/dia
' Workers' Compensation Insurance Affidavit: Gener$1 Businesses
Applicant Information Please Print Le�iblv
Business/Organization Name\ C��,t� �,�WO(`�\'(1\V1� �S�OGVJ,�
Address: �� �-�
' City/State/Zip: S � �'��1�Phone #: �'� �
Are you an employer? Check the appropriate box: Business Type(required):
1.❑ I am a employer with employees (full and/ 5. ❑ Retail
o�art-rime�*_ 6. ❑ Restaurant/Baz/Eating Establishment
_ -- -- _
2.❑ I am a sole proprietor or partnership and have no �, � Office and/or Sales(incl.real estate,auto;etc.)
employees working for me in any capacity.
[No workers' comp. insurance required� g• ❑ 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 �0.❑ Manufacturing
no employees. [No workers' comp. insurance required]*
4.� We aze a non-profit organizarion,staffed by volunteers, 11.❑ Health aze r� ,
with no employees. [No workers' comp. insurance req.] 12.❑ Other�\�('�� V��mL�'1\
*Any applicant that checks box#1 must also fill out the section below showing the'v worke=s'compensation policy infoimation.
*•If the coipomte officers have exempted themselves,but the cotporadon has other employees,a workers'compensation policy is required and su an
organization should check box#I. �
I am an employer that is providing workers'compensation insurance for employees. Below is the policy information.
Insurance Company Name: �
Insurer's Address:
City/State/Zip:
Policy#or Self-ins.Lic.# Expiration Date:
Attach a copy of the workers' compe sation policy declaration page(showing the policy number and ezpiration date).
Failwe to secure coverage as required under Section 25A of MGL c. 152 can lead to 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 forwazded to the Office of
Invesrigations of the DIA for insurance cov ge verification.
I do hereby certify,under th ains a[ties ofperjury that the information provided bove is true and correcd.
Si ature: Date: � �
Phone#: � '
O�cia!use only. Do not write in this area,to be comp[eted by city or town offciaL
City or Town: PermiULicense#
Issuing Authority(circle one):
1.Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmeds Office
6.Other
Contact Person: Phone#:
www.mass.gov/dia �