HomeMy WebLinkAboutApplication and WC E „ �
��°���'� TOWN OF YARMOUTH Bo�dof
� '�_`�� Health
� -:. �`" `'3 1146 ROUTE 28, SOUTH YARMOUTH,MASSACHLTSETTS 02664-24451 - �
�. +�, M �� � Telephone(508)398-2231 ext. 1241 Health
tT��NEb ' Division
F�(508)760-3472
G�3G(�CONIGD
To: Yarmouth Business Establishments -p�,y s �N� DEC p 1 '1014
From: Bruce G. Murphy, Director HEqLTH DEPT.
Yarmouth Health Department
Date: November 7, 2014
Subject: Increase in License/Permit Fees
Please be aware that the Yarmouth Board of Health, under the direction of the Yarmouth Board
of Selectmen, has raised a number of license and permit fees issued through the Yarrnouth
Health Department, effective January l, 2015.
Attached is the Yarmouth 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 l, 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) prior to December 31. 2014, you will be
allowed to pay the 2014 rates for the following licenses:
Current 2014 Fee
Public Swimming Podls $ 80.00 0.ao
Public WhirlpooUVapor Baths $ 80.00
Tobacco Sales $ 95.00
Motels $ 55.00 5S.
Restaurants 0-100 Seats $ 85.00
- _- _ Re���arant�flve� 1 OII��a�s _ _ ____ _ - ���00 _ - ___ _ ___—__ _ ___ _ _--- -
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: �39.0o ca�rnr►.ea.c��ts-� ;
Total fees owed for your establishment: �0 ,00
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
� � � TOWN OF YARMOUTH BOARD OF HEALTH ����0 °
= APPLICATION FOR LICENSE/P�l� ¢�015 ` ' � ',�
�, � ��`�-�2 ��? DEC a 1 2014
* Please complete form and attach all necessary';do� nts y Dece �er 1S 2014.
Failure to do so will result in the return c�£you�application p ketHEqLTH DEPT.
ESTABLISHMENT NAME: 1 S 'al TAX ID• 20 !� 6
LOCATION ADDRESS: G� Rc�C�� a,.� TEL.#: �-�G
MAILING ADDRESS: � - 2
E-MAILADDRESS:_�f�'�5��"i71�A ���� �Csh1Q►� , Ca `�
OWNER NAME: �-e�l�a� 5 �n i r 2..
,
CORPORATION NAME (IF APPLICABLE): 12 e�G N9 . Co�rl
MANAGER'S NAME: ��U G �5 1��l iT 2� TEL.#: '����-Ss(0-60 Z.
MAILING ADDRES S: 1 b 9 S Cti.c�o�c L2'l I��p b N n�%2� r� r�Z c o �
POOL CERTIFICATIONS: C��' � � P�'�v��� � d P� t IJC't�
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. �` �'� A v i i� l��� i�L;- 2. (:'/ _
Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid
and Community Cardiopulmonary Resuscita.tion (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 1N CHARGE:
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
1 __ _ -- -- - _ �_ �---- .__ ___-. -- - ----
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 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�le at your place of business.
1. 2•
3. 4•
RESTAUR.ANT SEATING: TOTAL#
._. . . .���� .��ww.���e��� ��e������� ,_ _.__
OFFICE U�E ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE P RMIT#
B&B $55 CABIN $55 �MOTEL $110 �bZ7
—INN $55 CAMP $55 �SWIMMING POOL$110ea.�ls-(1�
LODGE $55 TRAILER PARK $105 _WHIRLPOOL $110ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
0-100SEATS $125 �CONTINENTAL $35 �I� NON-PROFIT $30
>]00 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
—<25,000 sq.ft. $150 _FROZEN DESSERT $40 _TOBACCO $I 10
NAME CHANGE: $is AMOUNT DUE _ $ 2.SS _OC�
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM
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� The Commonwealth of Massachusetts
Department of Industrial Accidents
- Office of Investigations
' ' 1 Congress Street, Suite 100
Boston,MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legiblv
Business/Organization Name: ��� '� �l��l� �� C o�1� C't� A��'� '
Address: � � /Z O C��} 02�
City/State/Zip: C�o Q� �`Q C� (��"�c��� �'� Phone#: 5'�� � ��s '� Z3 3 Z
Are you an employer?Check the appropriate boz: Business Type(required):
1.❑ I am a employer with employees(full and/ 5. ❑ Retail
or part-time).* 6. ❑ Resta.urantBar/Eating Establishment
_ A_____ �__-. -- -
2. I am a sole propnetor or partners�iip and�have no �- �`-`-
- - - -_ _
, 7. ❑ Office and/or Sa1es(incl.real estate,auto,etc.)
employees working for me in any capacrty.
[No workers' comp.insurance required] 8• ❑Non-profit
3.❑ We are a corporation and its o�cers have exercised 9. ❑ Entertainment
their right of exemption per c. 152, §1(4), and we have 10.0 Manufacturing
no employees. [No workers' comp. insurance required]* 11.0 Health Care
4.❑ We are a non-profit organization,staffed by volunteers,
with no employees. [No workers' comp. insurance req.] 12.❑ Other /?'r�,j^ �
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
**If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensarion policy is required and such an
organization should check box#1.
I am an employer that is providing workers'compensation insurance for rrty 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' compensation policy declaration page(showing the policy number and ezpiration date).
Failure 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-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Of�ice of
Investigations of the DIA for insurance coverage verification.
I do hereby certify,under the pains and penalties of perjury that the information provided above is true and correct.
Si�nature: � � ��f'v Date: /Z� l- Z�CI'J
Phone#: /a Z
Official use only. Do not write in this area,to be completed by city or town offacial
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2. Building Department 3.City/Town Clerk 4.Licensing Board 5. Selectmen's Office
6.Other
Contact Person: Phone#:
www.mass.gov/dia
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N�TICE - NOfiI�E '
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EMPL����� T �K �I��IFLC}YEE� �
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Th� �o�r���.onvc�ealth of l��Iassachus�tts �
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DEPARTMENT t�F Il`+TDUSTRIAL ACCIDENTS �
� ;
I Congress Street, Suite 10�, Boston, Massachusetts 02114-2Q 17 r
C 17-72�-491�U - http://www.state.�na.usidia
As required by Massachusetts General Law, Chapter 152, Sectians 21, 22 & 30, this will give you notice '
that I(we) have provided far payment to our injured employees u�der the above-mentioned chapter by
insuring with:
I
� NorGUARD Tnsurance Company
� �� � NA.ME OF INSURANCE C4MPANY �
P.O. Box A-H, 16 S. River Skreet, Wilkes-Barre, PA 18703-Q020
ADDRESS OF 1NStJTtANCE CQMPANY
PAWC556715 0$/11/2014 08/lij2QI5 �
PQLICY NUMBER 973 Iyannaugh Road P,o. Box 1990 EFFECTIVE DATES �
DOWLING & O'NEI� INS AGY Nyannis, MA Q2601 508-775-162(} ,
NAME QF INSURANCE AGENT ADDRESS PHONE #
PARI DEVANG CORP. 69 Main Street West Yarmouth, MA 02673
EMPLOYER � ADDR��SS � � , i
o�ji�/2oi4
EMPLCI�R'S VVC}RI{ERS' COMPENSATION O�FIC-ER(IF AN�) � DATE �
i
MEDICAL T'REATMENT
The above named insurer is required in cases af persanal injuries arisin� out af and in the caurse of '
emplayment ta furnish adequate and reasonabie haspital and medical services in accordance with the t
provisions of the Workers' Compensatian Act. A copy of the First Repart of Injury must be�iven ta the i
injured employee, The employee may select his or her own physician. The reasonable cast of the ser- `
vices provided by the treating physician will be paid by the insurer, if the treatment is necessary and ;
reasonably connected ta the work reIated injury. In cases rec�uirin�hospital attention, emplayees are ;
hereby notified that the insurer has arranged far such attention at the
NAME OF HOSPITAL ADDRE�S
TO BE POSTED BY EMPLC?YER �
;