HomeMy WebLinkAboutApplication and WC o�_Y'�k
�� � q _�a TOWN OF YARMOUTH Ha�f
� ,\\�`3 I 146 ROUTE 28, SOUTH YARMOUTH, MASSACH[ISETTS 02664-24451 -
�. ��� fb� � Telephone(508)398-2231, ext. 1241 Heal
rACME Fax(508) 760-3472 Division
To: YarmouthBusinessEstablishments $Ass'P�V�R-MoTEL Q[��,[�OM[sDD
From: Bruce G. Murphy, Director �tl. �:) LU14
Yarmouth Health Department `
HEALTH DEPT.
Date: November 7, 2014
Subject: Increase in License/Permit Fees
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Please be awaze that the Yannouth Board of�Iealth, under the�"irec�ion of the Yazmouth Board
of Selectrnen, has raised a number of license and permit fees issued through the Yattnouth
Health Department, 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 Januazy l, 2015.
However, if you fully complete the applica6on, and submit it to the Yarmouth Health
Department 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 SS-00
Restaurants 0-100 Seats $ 85.00
Restaurants Over 100 Seats $160.00
Retail Food�ervice<25;u0@ 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: S - 0
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 certif cations prfor to opening, however, you must note
"Will provide in the springprior to opening" on the application.J
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TOWN OF YARMOUTH BOARD OF HEALTH � �-
��� APPLICATION FOR LICElYS��Py��'�T'� Utl: .`•t 1 ZU14
" * Please complete form and attach all ne�es � docurrlent�by ec be PT
Failure to do so will result in the'refurn°of q�ur applica ion
ESTABLISHMENT NAME:�BASS �'-rvt'� �vt3 r��QR. 3�✓,9.�ns,��,;TAX ID:.��-
LOCATION ADDRESS:Sr9/ ,P r z � <h:�rN `f�+2�,od r�,����:�EL.#:.S�f/39Y- 2S�S-
MAILING ADDRESS: s4 w�-�
E-MAILADDRESS: -
OWNERNAME:�� o �t.=LJ� � cvtA-tt�il�r� 1�H�T'7`
CORPORATION NAME (IF APPLICABLE): --
MANAGER'S NAME: 1���-f�.ti-➢/� R L{!-1�97T TEL#• e2U �� 3 6y-Ssv p
MAILING ADDRESS: 5,�,..o l�+ N�9G ��fi- d y�-L i�77
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.
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Pool operatars 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 will
not use past years' records. You must provide new copies and maintain a file at your place of business.
1. z. 1
3. 4.—�
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FOOD PROTECTION MANAGERS - CERTIFICATIONS:
All food service establishxnents aze required to have at least one fixll-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.
I You must provide new copies and maintain a file at your establishment.
1. �t/a'( /�-l•'�'�-:�GNi31.� 2.�U'� t17�LI c�/�.
PERSON IN CHARGE:
' Each food establishment must have at least one Person In Chazge (PIC) on site during hours of operation.
.
_ _ 1, __ f Z• - / - ----- ---
ALLERGEN CERTIFICATIONS:
All food service establishments are required to have at least one full-time employee who has Allergen certification,
as defined in the State Sanitary Code far 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. /V7�
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 Deparhnent wilt not use past years' records.
You must provide new copies and maintain a file at your place of business.
l. 2. /
3. 4.
�
RESTAURANT SEATING: TOTAL#
OFFICE USE ONLY
LODGING:
. LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE P RMIT#
� _B&B $55 CABIN $55 �MOTEL $110 .b2-�v
INN $55 CAMP $55 SWIMMINGPOOL$IlOea.
_LODGE $55 TRAILER PARK $105 WHIRLPOOL $ll0ea
FOOD SERVICE:
LICENSE REQUIRED FEE PERM[T# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
0-]00 SEATS $125 _CONTINENTAL $35 NON-PROFIT $30
>I00 SEATS $200 _COMMON VIC. $60 WHOLESALE $80
—RESID.KITCHEN $80
RETAIL SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMTT#
<50 sq.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25
=<25,000 sq.ft. $150 _FROZEN DESSERT $40 TOBACCO $110
NAMECHANGE: $l5 AMOUNTDUE _ $ I�O. 00
" *****PLEASE�TURN OVER AND COMPLETE OTHER SIDE OF FORM***** �G � �J� -� �
c��a�� ia�ae/r�
. ADMIlVISTRATION
Under Chapter 152,Section 25C,Subsection 6,the Town of Yannauth is naw required to hold issuance or renewal
af any license or permit to operate a business if a person or company does not have a Certificate af Worker's
Compensation Insurance. TBE ATTACHED S"TATE WORKER'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR
CERT. OF INStTRt1.I�CE AT1'ACHF,D
pR
WQRKER'S CQMP. AFFIDAVIT SIGNED ANL7 A7"I`ACHED
Town of Yannouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PATD:
YES `y'� NO_,
MOTELS ANll OTHER LODGING ESTABLISHMENTS
1'i2AANSIENT OCCI7PANCY: For purposes ofthe limiYations ofMotel or Hotel usa,Transiet�t occup�ncy shall be
limited to the temporary and short terrn occupancy,ordinarily and customarily associated with motel and hotel use.
Transient oceupants must have and be able to demonstrate that they maintain a prineipal plaee af residance
elsewhere.Transient oocupancy shall genera!]y refer to wntinuaus occupancy of not rnore thart thix�ly(30)days,and
an aggregate of not rnore thr�n ninety(90)days within any six(6)month period. LJse of a guest unit as a residenae or
dwelling unit shall not be eonsidered transient. Occupancy that is subject to the coltection af Roam 4ecupancy
Excise,as defined in M.G.L. c. 64G or&30 CMR 64G,as amended, shall generally be considered Transient.
POOLS
POdL OPENING:All swimming,wading and whirlpaols cvhich have been ciosed for the season must be inspected
by the Health Dept�rtment prior to opening. Contact the I Iealth Department to schedule the inspection three (3)
days prior to opaning. PLEASE NOTT: Pcople are NOT allowed to sit in the poal area until the pool has been
inspected and opened.
POOL WATER 1'ESTING: The water must bc tested far pseudomonas,total coliform and standazd plate count
by a State certified lab, and submitted to the Health Department three (3) days prior to opening, and quarterly
therea$er.
Yt3�L CLOSI�YG: Every outdoar in ground swirnming paoi mnst be drained or covered wifhin seven(7}days of
clos'vng.
-- _ FOOD SERVICE
SEASONAL FOOD SERVICE OPENING:
AII food service establishments must be inspected by the Ilealth Department prior to opeaing. Please eontact the
Health Department to schedule the inspection three(3) days prior to opening.
CATERING POLICY:
Anyone who caters within the Town of Yazmouth must notify the Yarxnouth Health Department by filing the
reqairefl Temporary F'ood Service Applicatian form 72 hours priar to the catered event. These forms can be
obtained at the He la th Deparhnent,or frarn the Town's website at www.yazrnouth.ma.us under Health Department,
Downloadabie Forms.
FROZEN DESSEI2TS:
Prozen desserts must be tested by a State certified lab prior to apening and montkily thereafter,with sample results
submitted to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen
Llessert Permit until the abave terms have been met.
OUT3IDE CAF'ES:
Outside ca£es(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board o£Health.
OUTDOIJR COOHING:
Qutdaor cpoking,prepazatian,or dispIay of any food pxoduct by a retail or food service establishment is prohibited.
NOTICE.Permits run annuaIIy from January 1 to December 31. I'T IS YOUR KESPONSIBILITY Tt3 RE'I'tTRN
THE COMPLETEI}RENEWAL APPLICATION{S}AND REQUIREI}FBE(S}BY DECEMBBit 15,2414.
ALL RENOVATTONS TO ANY FOQD ESfiABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT,ETC.},MUST BE REPC?RTED TO AND AFPROVEI7 BY THE BOARD QP HEALTH PRIQR
TO COMMENCEMENT. RENOVATIQNS MAY REQUIRE A SITI;PLAN.
DATE: � — 1 "" -� �1� STGNATURE: . �-'�-a�`
PRINT NAiVIE& TITLE:���yV.�j�s (.Z , j3, H-"�`l"7`T� L�� __
Rev_11�3114
� � � The Commonwealth ofMassachusetts
Department oflndustria[Accidents
Office of Investigations
1 Congress Street, Suite 100
Boston, MA 02114-20U
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information M A Fl�-Iti-�� (Q - g� Please Print Legiblv
Business/OrganizationName:�R�S /2��/G� rAc�7�l-.. �� . Sw�'"s�'A� y.t"' Gu
Address: �y I (Z `T- 1.�
City/State/Zip: � � j �-� F�'f�-a`^�J7 Phone #:_�ff 3 !���— � '� �
Are you an employer? Check the appropriate bos: Business Type(required):
1.❑ I am a employer with employees(full and/ 5. ❑ Retail
or part-rime).* !L Lr ��+LU=j � 6. ❑ RestaurantlBaz/Eating Establishment
-Z� I am a soIe proprietor or partnership and�iave no
, -- — - - -- -- -- -
7. ❑ 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 10.❑ Manufacturing
no employees. [No workers' comp. insurance required]*
4.❑ We aze a non-profit organization, staffed by volunteers, 11.❑ Health Caze
with no employees. [No workers' comp. insurance req.] 12.� Other �u 0"T (i�
*Any applicant that checks box#I must also 511 out the section below showing their worke=s'compensation policy infotmation.
"If ihe corporate officers have exemp[ed themselves,but the corporatioa has other employees,a workers'covpensation policy is tequired and such an
organization should check box#1.
I am an employer that is providing wo�'compensation insurance for my employees. Below is the poldcy information.
Insurance Company Name:
Insurer's Address:
City/State/Zip:
Policy#or Self-ins. Lic.# Exp'vation Date:
Attach a copy of the workers' compensation policy declaration page(showing the poticy nnmber and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposirion of criminal penalries of a
fine up fo$T,500.60 ari�r one=year imprisonment,as wel�as civil penaTties inifie�rm of aSTOF WORK�RBER an�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 certify,under the pains and penalties of perjury that the information provided above is true and correct.
S�nature: 7VlaJ�zn� f�`P�-�..i_� Date• �� J- .?�l S�
Phone#: C�b� ., ' ��, �- � �� 7 L/L �'�- 3 6�— Ji �0 1
Official use only. Do not write in this area,to be completed by city or town officiaL
Ciry or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2. Building Department 3.City/Towu Clerk 4.Licensing Board 5. Selectmen's Office
6.Other
Contact Person: Phone#:
www.mass.gov/dia �