HomeMy WebLinkAboutApplication and WC : �
�'°���9�'�a TOWN OF YARMOUTH Boazdof �;
'� �, Health
�U� � `3 1146 ROUTE 28, SOUTH YARMOUTH,MASSACH[JSETTS 0266424451 "
L• �L��rACNf�O� �� Telephone(508)398-223i,ext. 1241 Div si n
Fa�c(508)760-3472
G3C�C�GOMI�D
To: YarmouthBusinessEstablishments TowN /-�vusE N�wS U�l: U ; (U14
From: Bruce G. Murphy, Director � HEALTH DEPT.
Yarmouth Health Department�
Date: November 7, 2014 , '
Subject: Increase in License/Permit Fees
Please be awaze that the Yarmouth Board of Health, under the direction of the Yannouth Boazd
of Selectmen, has raised a number of license and permit fees issued through the Yazmouth I
i
Health Department, effective January 1,2015. ;
Attached is the Yannouth 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 applicarion after January 1, 2015.
However, if you fully complete the application, and submit it to the Yannouth Health
Depattment 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 the 2014 rates for the following licenses:
Current 2014 Fee
Public Swimming Pools $ 80.00
Public W1urlpooUVapor Baths $ 80.00
Tobacco Sales $ 95.00 $9S.00
Motels $ 55.00
_ -- _ - __
Food Service 0-100 Seats $ 85.00
_-- -��erv'i�e-aver-i�d S'�au-- -- $rb�ee --___— -- -- _ _ _
Retail Food Service<25,000 sq. 8. $ 80.00 G.0
` Retail Food Service>25,000 sq. ft. $225.00
Other fees owed but not listed abov •
Total fees owed for your establishm t: �175-00
NOTE: To be entitled to pay the current 2014 rates isted above, our
business application, food and/or pool certi�cations, alo with rker's
compensation information must be received, or mailed (postmar ed) 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 applicarion.J
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I
a TOWN OF YARMOUTH BOAI;� ° �6��d��D
��� APPLICATION FOR LICENSF�FP =_ ��Sr��
` `�' !� Utl: 0 7 �U14
* Please complete form and attach all necessar� by�erem er IS 20I4.
Failure to do so will result in the return of your application pa et.HEALTH DEPT.
ESTABLISHMENT NAME: I{.�-0�1� AX ID: '
LocaTloNaDD�ss: 18' � olb�ow��std ��.?1 TEL.#: SQ 3q�-
MAILING ADDRESS: �a,.v�-
E-MAILADDRESS: I1 r25 kEL W ,
OWNER NAME:
CORPORATION NAME�IF APPLI LE): I1
MANAGER'S NAME: _ �5zi� �c�e( TEL.#: �'�'4- �I � I�6�
MAILING ADDRESS: �»�. W AS ��A-rmw�'� !1'1�- 02��3
POOL CERTIFICATIONS:
The pool supervisor must be ceMified 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.
--- --- -
- -..- ---
. - ---- -- __
_ _ — _
l. 2.
Pool operators must list a minimuxn of two employees currently certified in basic water safety, standazd 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 applicaUon. 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 Chazge (PIC) on site during hours of operation.
1. __ _ - -- --- - - - �: ----
ALLERGEN CERTIFICATIONS:
All food service establishments aze 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 Deparhnent will not use past years' records. You must
provide new copies and maintain a file 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 REQUIRER.�EE.,_PEItMIT# LICENSE REQUIRED FEE PERMIT#
B&B $55 CABIN $55 � MOTEL $110
INN $55 CAMP $55 SWIMMINGPOOL$110ea
LODGE $55 TRAILERPARK $105 WHIRLPOOL $ll0ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
0-100SEATS $125 _CONTINENTAL $35 NON-PROFIT $30
>100 SEATS $200 COMMON VIC. $60 WHOLESALE $80 �
—RES[D.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
L<25,000 sq.R. $150 =FROZEN DESSERT $40 TTOBACCO $110
NAME CHANGE: $15 AMOUNT DUE _ $ Z6 O. Op
*"***PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*"*** �t� �I��Q�/
��t��5 �o��S�
_ _ _ __. i
, .
- ;i:
ADMINiSTRATICIN
Under Chapter 152,Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal
o£any license br permit to operate a business if a person or cornpany does not haue a Certificate of Worker's
Compensation Inswance. TFiE ATTACAED STATE 1�'012KER'S COMPENSATTQN INSUI2ANCE
AFFTDAVIT MUST BE COMPLETED AND SIGNED, QR �
CERT. OF INSUR.ANCE ATTACHED I
OR C
WORKEK'S COMP. APFIDAVIT SIGNED ANI7 A'I"TA,CHED
Town of Yazmouth taxes and liens rnusY be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES � NO�
MOTELS AND OTHER LODGING ESTABLISHMENTS
TRANSTENT OCCUPANCY: For purposes of the limitarions of Motel or Hotel use,Transient oc:cupancy shall be
liznited to the temporary and short term occupancy,ordinarily and customarily associated with matel and hotel use.
Transient occupants mnst have and be able to demonstrate that they maintain a prancipal place of residence
elsewhere.Transient accupancy shall generally refer to continuous occupancy of not more than thirty{30)days,and
an aggregate af not more than ninety(90)days within any six(6)mpnth period. Use pf a�,�uest wvt as a residence or
dwelling unit shall not be considered transient. 4ccupancy that is subject ta the collectian af Room 4ecupancy
Excise,as defined in M.G.L. c. 64U or 830 CMR 64G,as amended, shall generally be considered Transient.
PQOLS
P40L OPENING:AIl swimming,wading and wl�irlpaols which have beezz ciased forthe season must be inspected
by the Health Aepartrnent prior to apening. Contact 1he Health Department to achedule the inspection three(3)
days prior to apening. PLBASE NOT'E: Feople are NOT allawed to sit in the pool area until the paol has been
inspected and opened.
POOL WATER TESTING: The water must be tested for pseudomonas,total co1`tform and standard plate caunt
by a State certified iab, and submitted to the Health Departrnent three (3} cfays prior to opening, and quarterly
theraafter.
PQOL CLOSING:Every outdoor in graund swimming paoi must tte drained or covered within seven{7)days of
closing.
FO011SF.RVICE -_ ___.____-----..__ ____
SEASONAL FOOD SERVICE OPENING:
All food service establishments must ba inspected by the Hea�th I3epartment priar to opening. Please contact the
Health Deparhnent to schedule the inspectian three(3)days prior to opening.
C'ATERiNG PQLICYc
Anyone who caters within the Town of Yaamouth must notify the Xazmouth Health Department by filing the
reqwred Tempa Faod 3ervice Applicatian farm 72 haurs priar to the catered event. T'hese farms can be
obtained at the H�th Department,or from the Town's website at www.varmouth.ma.us under Health Department, �
Aowtzloadable Forms.
FROZEN DESSERTS:
Frozen desserts must be tested by a State certified lab prior to opening and rnont�ly thereafter,with sampla results
submitted to the Health Departrnent. Failure to do so wilI result in the suspension or revoeafion of your Frozen
I7essert Pernut until the above terms have been met.
OUTSIDE CA�'�S:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must haue prior approval frotn the Boazd of Health.
OUTDOOR COCIHING:
Outdoor cooking,preparation,or dispIay of any food product by a retait or food service establishment is prahibited.
NOTICE;Permits run annually from January 1 to Decembc;r 31. IT IS YOUR RESPONSIBILITY TO RETLJIZN
THE COMPLETED RENEWAL APPLICATIC7N(S}AND REQt31RED FEE(S}BY DECEMBBR 15, 2Qi4.
� ALL RENOVATION3 TO ANY FOQD ESTABLISHMENT, MOTEL OR POOL (i.e., PAIlV`T'ING, NEW
BQUIPMENT,ETC.},MIIST BE REPC7RTEI}TO AND APPRflVED BY THE B(?ARI}OF HEALTH PRlQR
TO COMMENCBMENT. REIVOVATIONS MAY REQiJIRE A SITE PLAN.
DATE: �(-� C� -�� SIGNATURE: � . .
PRINT NAME&TITLE:��'�S�'t �t�{ � �,S t t�n�'�
. Rev. 11t43114
' ` � The Commonwealih ofMassachusetts �
Department oflndustrialAccidents
O�ce oflnvestigations
' 1 Congress Street, Suite 100 I
Boston, MA 02114-2017 I
www.mass.gov/dia l
Workers' Compensation Insurance Affidavit: General Businesses i
Analicant Information Please Print Le¢iblv
Business/Organization Name: �G S�t��ia-b� C�] ��)I�} �Uy[�lU���u�
Address: � � � � �C� �OC�vt�-{.C�� (fisq
tY P'��CJ+-i9r`-��'�'YI�oU��"pz�Phone#: es0!��9 c��
Ci /State/Zi . r
Are you an employer? Check the appropriate boa: Business Type(required):
i.❑ I am a employer with�_employees(full and/ 5. �Retail
_ _ orp_art-rime�____ _ _6. ❑ RestaurantBaz/EatingEstablishment
2.❑ I am a sole proprietor or partnership 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 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]* I 1.❑ Health Care
4.❑ We aze a non-profit organization,staffed by volunteers,
with no employees. [No workers' comp. insurance req.] 12.❑ Other
•Any applicant that checks box#1 must also&ll out the sec[ion below showing their workers'compensatioa policy infoimation.
**If the coipoxate officecs have exempted themselves,but the corporation has otha employees,a wocke=s'compensation policy is required and such an
organization should check box#1.
I am an employer that is providing workers�' �ensation insurance for my employees. Be[ow is ihe poldcy infornwtion.
Insurance Company Name:�t�. � ; 1/l�,/Y N
Insurer's Address:� �� G�I Y� eYJlT�
City/State/Zip: ZI�Q'd�� �(3q�_��'
Policy#or Self-ins.Lic. # O����S6 ��� �� t`'I Expiration Date:��'� � '�O I�
Attach a copy of the workers' compensation policy declaration page(showing the policy number and espiration date).
__Failure tn_s�cute cov�r�_�r��ui�ed under Section 25A of MGL c. 152 can lead to the imposition of criminal�nalties of a __
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalfies 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
Inves6gations of the DIA for insurance coverage verificafion.
I do hereby certify,under the pains and penalties of perjury that the information provided above is true and correct
Si�nature: P- �^ �SL� Date• � �' �l'� " � �
Phone#: SC3�'3q �-7 �o
O�cial use on[y. 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 OfSce
6.Other
Contact Persou: Phone#: �
www.mass.gov/dia