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OF�Y'`�R
�{ -_ , _'�� TOWN OF YARMOUTH Ha�f
fl �, `j 1146 ROUTE 28, SOUTH YARMOUTH,MASSACHUSETTS 02664-24451 - �
�. ; � :� Tele hone 508 398-2231 e7ct. 1241 Health
•jr"OM��y P Fax(508) 760-3472 Division
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To: Yarmouth Business Establishments M iNl l�tFaerET �t� ► / [U 14
From: Bruce G. Murphy,Director � � HEAITH DEPT.
Yannouth Health Department�
Date: November 7,2014
Subject: Increase in License/Permit Fees
Please be awaze that the Yannouth Boazd of Health, under the direction of the Yarmouth Boazd ;
of Selectmen, has raised a number of license and permit fees issued through the Yarmouth
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 application after Januazy 1,2015.
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 afT'idavit) 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 �qS.bp . ,
Motels $ 55.00
Food Service 0-100 Seats $ 85.00
Faod 3ervice Dvei I00 Seats - -�I bU:�O - __ -__ ._ _-
RetaitFood Service <25,000 sq. ft. $ 80.00 ,� �3oTm.
Retail Food Service>25,000 sq. ft. $225.00
Other fees owed but not listed above:
Total fees owed for your establishment $1'15�00
NOTE: To be entitled 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 December 31, 2014. [77tose 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 springprior to opening" on the application.J
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�a TOWN OF YARMOUTH BOARD OF HEALTH
��� APPLICATION FOR LICENSE/P.��,1�'II'£�2Q� � - UtC � � jj�1f
* Please complete form and attach all necessaty doeua�te�i�s��; r c 'ber
Failure to do so will result in the return,of yotu ap�lie�tion
ESTABLISHMENT NAME: t a�� ID:
LOCATION ADDRESS: a'L�/ �- Ol1 ✓1 S �1 • YOu'�^'1QU _ TEL.#: SOB" �I S� 2��-�(p
MAILING ADDRESS: ��-( F - a�� S'� �,�,i. Varwipu � M q c] z� � ?i
E-MAIL ADDRESS:
OWNERNAME:�rahc-iSCo -�lo�'�S
CORPORATION NAME(IF APPLICABLE):
MANAGER'S NAME:�o�.�n C-i S LO dr� S TEL.#: 50£� 8)5 ��-1 LI )
MAILING ADDRESS:
POOL CERTIFICATIONS:
The pool supervisor must be certitied 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 operators must list a minimum of two employees currently certified in basic water safety, standazd 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 prov�de new copies and maintain a file 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
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 food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
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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 file at your estabGshment.
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 file at your place of business.
1. 2•
3. 4.
RESTAURANT SEATING: TOTAL#
OFFICE USE ONLY
LODGWG:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
B&B $55 CABIN $55 MOTEL $110 •
—INN $55 CAMP $55 SWIMMINGPOOL$110ea
LODGE $SS TRAILERPARK $]OS _WHIRLPOOL $ll0ea
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE RE UIRED FEE PERMIT#
0-100 SEATS $125 —CONT[NENTAL $35 NON-PRO�IT $30
>100 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.R $50 >25,000 sy.ft. $285 VENDING-FOOD $25
�QS,OOOsq.ft. $150 � —FROZENDESSERT $40 =TOBACCO $�IO �
NAME CHANGE: $15 AMOUNT DUE _ $—�—�o o•—c�O
*•***PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*"*** �.�'� `r I�'J•O�
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ADMINISTRATIQN
Under.G�;apter 1 S2,Section 25C,SubsecYion 6,the Town of Yarmouth is now required to hold issuanoe or renewal
of any license or j�ermit to operate a business if a persan or company does not have a Certificate of Worker's
Compensation Insurance. THE AT"I'ACHEI3 STATE WORKER'S Ct?MPENSATIQl�t INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR
CERT. OF INStJR1�NCE ATTACHED
OR �
WOR.KEI2'S COMP. AFFII7AVIT SIGNED AND ATTACHED
Town of I'annouth ta�ces and liens must be paid prior to renewal or issuance of your permiYs. PLEASE CHECK
APPROPRIATELY IF PAID:
YES N(3
MOTELS ANA UTHER LODGING ESTABLLSHMENTS
TRANSIENT OCCUPANCY: For purposes ofthe l9mitations ofMotel or Hotel use,TYansient occupancy shaTI be
lirnited to the temporary and short term occupancy,ordinarity and customarily associated with matel and hotel use.
Transient ocaupants must have and be able to demonstrate that they maintain a principal place af residence
elsewhere.Transient occupancy shall generally refer to continuous occupancy a£not more than tl�irty(30)days,and
an aggregate of not more than ninety(90)days within any six(6)manth period. Use of a guest unit as a residence or
dwetling unit shall not be considered transient. Occupancy that is subject to the collectian of Roam Oocupancy
Excise,as defned in M.G.L. c. 64G or 830 CMR 64G, as amended,shall generally be considered Transient.
POClLS
POOL QPENING:A11 swimming,wading and whiripools which hava been closed f'ar the se�.son must be inspected
bq the Health Deparhnent prior to opening. Contact the Tiealth Department to schedule the inspection three(3)
days prior to opening. PLEASE NOTE: People are NOT allowed to sit in the poal area unrii the pool has been
inspected and opened.
POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count
by a State certified lab, and submitted to che Health Departrnent three (3) days prior to opening, and quarterly
thereafter.
PQOL CLOSING:Every autdoar in graund swimming pool must be drained or covered within seven{7}days of
closing.
FOOD SF.AVICE _ . _ _ _
SEASONAL FOOD SERVICE OPENING:
AII food service establishments must be inspected by the Iiealth Department prior to opening. Please contact tfie
Health Department to schedule the znspection three(3)days prior to opening.
CATERING POLICY:
Anyone who caters within the Town of Yarmouth rnust notify the Yazmouth Health Department by filing the
requirad Tempa Foad Service Application form 72 haurs prior to the catered event. These forms can be
obtained at the H�th Department,or from the Town's website at www.yarrnouth.ma.us under Health Department, �
Doumioadable Forms. t
FROZEN DESSERTS:
Frozen desserts must be tested by a State certified lab prior to opening and rnonthly thereafter,with sample results
submitted fo the Health Depaztment. Failure to do so will result in the suspension or revooation of your Frozen
Dessert Pernvt untii the above terms have been met.
OUTSIDE CAF�S:
Outside cafes(i.e.,outdoor seating with waiter/waitrass service),must have prior approval frorn the Board of Health.
QUTDOOR COOKING:
Outdoor cooking,prepazation,or display of any faod product by a retail or food service establishment is prohibited.
NOTICE.Permits run annuaIly from 7anuary 1 to December 31. IT IS YOUR RESPONSIBTLII'I'TO RETt.iRN
THE C4MFLETEI}R.ENEWAI,AI'PLICATIdN{S)AIVD REQLTIRED FEE(S)BY I}ECEMBEIZ S 5,2014.
ALL RENOVATIONS TO ANY FOQD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINT3Nf.i, NEW
EQUIPMENT,ETC.},MUST BE REPt7RTED TO AND APPROVED BY TfiE BC}t1Ri}OF HEALTH PRI4R
TQ COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
77ATB:_�����j�.�,��_SIGNATCTRE:x�'��f/�1,S�C3 F`�C.�"+�t�
PRINT NAME&TI'I"LE:.-�f`av�t�i S cc) .���r c S
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' ` � The Commonwealth of Massachusetts ;
, Department of Industrial Accidents �
Office of Investigations
' I Congress Street, Suite I00
Boston, MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Le¢iblv
Business/Organization Name: 1`1� n 1 �Wr t�--e„�
Address: `�� � Mo�1 v� S� ����i���aesa�vn���5� � a 33 - D ss 3
City/State/Zip: UJ• c.lrwlbU`M M 0 Phone#:�So 8'� 9'S�- _ 2� � �o
Are you an employer? Check the appropriate boa: Business Type(required):
i.❑ I am a employer with employees(ful]and/ 5. ❑ Retail
--- -- or part-timel* —,-- ___ _ 6. ❑ RestaurantlBaz/Eating Establishment
2.� I am a sole proprietor or partnership and have no � � � I
employees working for me in any capacity. �• Office and/or Sales inci.real estate,auto,etc.
[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]*
4.❑ We aze a non-profit organization,staffed by volunteers, 11.0 Health Caze
with no employees. [No workers' comp. insurance req.] 12.�Other ��S Se.t-� GS S�r'2
*Any applicant thaz chedcs box#1 must aLso fill ou[the section below showing their workers'compensation policy information.
*•If the corpoxate officeis have exempted[hemselves,b�rt the corporation has other employees,a workers'compensation policy is required and such an
organi�ation should check box#I. � � �
I am an employer that isproviding workers'compensation insurance for my employees. Below is thepolicy information.
Insurance Company Name:
Insurer's Address:
CiTy/State/Zip:
Policy#or Self-ins. Lic. 1� Expiration Date:
AttacL a copy of the workers' compensation policy declaration page(showing the policy number and eapiration datc).
- - Failure to seeur�coueFage assequued under_Seotion25�ofM�'iI-c,_152 can lead to the imposition of criminal penakies of a
-- -- —
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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
Investigations of the DIA for insurance coverage verification.
I do hereby certify,under the pains and penaUies of perjury that ihe informafion provided above is true and corred
Sienature:'� ��ticrsco �l o�'�s Date: l Z.��1 1 y
Phone#:�So� 1 qS�- — 2�� `o S��'C �So`6� $) S -3�1�1 1 �W�'\Q 1�
Offacial use only. Do not write in this area,to be completed by city or town offaciaL
City or Town: Permit/License#
Lssuing 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