HomeMy WebLinkAboutApplication and WC �°��R�� TOWN OF YARMOUTH Boazdof
�. - -- � Health
� -: - ' `j 1146 ROUTE 28, SOUTH YARMOUTH, MASSACHLJSETTS 02664-24451 -
�. �� fo'� � Telephone(508)398-2231, ext. 1241 Divi i n
��L ME Fax(508) 760-3472
To: Yarmouth Business Establishments CAPE Co� CoN�����
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From: Bruce G. Murphy, Director
Yarmouth Health Department Ut(; �$ 2��4
Date: November 7, 2014 HEALTH DEPT.
Subject: Increase in License/Permit Fees
Please be awaze that the Yannouth 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
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 applicafion after Januazy 1, 2015.
However, if you fully complete the application, and submit it to the Yazmouth Health
Department witti all required certifications and worker's compensation coverage information
(certificate of insurance OR completed �davit) nrior 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 ,o�
Motels $ 55.00
Restaurants 0-100 Seats $ 85.00
Res4auran:s Over 100Seats — $150.E?0 _ __ __ __ __ , -
Retail Food Service <2,5,000 sq. ft. $ 80.00 ��O.00
Retail Food Service >25,000 sq. ft. $225.00
Other fees owed but not listed above:
Total fees owed for your establishment: l�5.00
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. [Those 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 spring prior to opening" on the application.J
BGM/maf
� TOWN OF YARMOUTH BOARD OF HEALTH G3[;C�C�p JC�oD
��� APPLICATION FOR LICENSE ERMI -20�5
c�i, a �� 1�,s.�--� UtC�1� ��14
* Please complete form and attach all ne ssa a aow9uep4's by:�e ember 1 0 .
Failure to do so will result in th�return'ofpour�pplication ac L7H DEPT.
ESTABLISHMENT NAME: � t •� •a�+ ��c TAX ID: �
LOCATION ADDRESS: .� 0 1.►�c +�./< <�� ,waf �' 1 �.�.r✓�1, y«� HA TEL.#: S� 8-2S 8-o�I��1
MAILING ADDRESS:S� 1�> Dr,,�c �w:9 :Ib� I...N. YSr,w��Y4 ,/''1d a L 6 6h
E-MAIL ADDRESS: c on�anri c �,l. .�.
OWNER NAME: o�.
CORPORATION NAME (IF APPLICABLE): N�Ma� �c�
MANAGER'S NAME: �1,,. l��t.,. TEL.#: S� P -2 Sd-CS 2 5
MAILINGADDRESS:�.r�.�uT�I..,f1 «n.�/Y�-- �,MA- ot6bq
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.
__ _ ._ ----- -- .__— __ _,� ---- _----�_ _
1. 2. - - -
Pool operators must list a minimum 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 establishxnents 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 far 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. Z•
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 Department will not use past years' records. You must
provide new copies and maintain a file at your establishment.
1. Z•
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.
l, 2.
3. 4.
RESTAURANT SEATING: TOTAL#
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQIDRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
B&B $55 CABIN $55 M01'EL $110
INN $55 CAMP $55 SWIMMINGPOOL$110ea
LODGE $55 TRAILERPARK $105 _WHIRLPOOL $IlOea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 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 PERMIT# LICENSE REQUIRED FEE PERMIT#
<50 sq.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25
�QS,OOOsq.ft. $150 _FROZENDESSERT $40 �TOBACCO $1l0
NAME CHANGE: $15 AMOUNT DUE _ $ 2�O.o 0
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***"* �"zC- � � �7���v
C�L`� (l(c5 /ZF c(� 1a�04��
ADMINISTRATION
CJnder Chapter 152, Section 25C, Subsection 6,the Town of Xarmouth is now required to hoid issuanee or renewal
of,any license or'permit ta aperate a business if a persan ar company daes not have a Cer[ificate of Warker's
Compensation Insurance. THE ATTACHED STATE W012KI:R'S COMPENSATION INSURANCE
AFFIDAVIT MUST I3E CONIPLETED AND SIGNED, CiR
C�RT. OF IN5TJRANCE ATTACHED
OR _ __
WORKER'S COMP_ AFFII)AVIT SIGNED AND ATTACHL�D
1'own of Yarrnouth taates and liens must be paid prior to renewal or issuance of your permits. PLEASE CHF.,CK
APPROPRIATELY IF PAID:
YES NO
MOTELS AND dTHER L4DGING ESTABLISAlYIENTS
TRANSIENT OCCUPANCY: For purposes of the limitations of MoteI or Hotel use,Transient occupancy shali be
limited ta the temparary and short term occupancy,ardinarily and customarily assaciated with motel and hatei use.
Transient occupants must have and be able to demonstrate that they maintain a principa] place of residence
elsewhere.Transient occupancy sha11 generally refer to continuous occupancy of not more than thiriy(30)days,and
an aggregate of not mrne than ninety{90}days within any s3x{6}month period. Usa af a gues2 unit as a residence ar
dwelling unit sha11 not be considered transient. Occupaucy that is subject to the callection of Room Occupancy
Excise, as defined in M.G.I�. c. 64G or 830 CMR 64G, as amended, shall genarally be considered Transient.
POOLS
POOL OPENING:All swimming,wading and whirlpools which laave been closed for the season must be inspected
by the HeaEth Aeparhnent prior to opening. Contact the Iiealth Department ta schedule the inspection three(3)
days prior ta opening. PLEASE NOTE: People are NOT allowed ta sit in the poal area uz�til the pool has been
inspected and opened.
POOL WATER TESTING: The water must be tested for pseudomanas,Cotal coliform and standard plate cnunt
by a State certified lab, and submitted to the Heaith Department three {3} days prior ta opening, and quarterly
thereafter.
POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of
closing.
F(3aD SERVICE
SEASONAL FOOD SERVICE OPENING:
Ail food service establishments must be inspected by the T3ealkh Department prior to opening. Please contact the
Health Departrnent to schedule the inspection three (3} days prior to opening.
CATERIIVG POLICY:
Anyone who caters within the Toum of Yarmauth must noTify the Yarniouth Health Department by filing the
required Temporary Food Service Application form 72 hours prior ta the catered event. These forms can be
obtained at the Health Department,oz from the Town's tivebsite at www.yannouth.ma.us under Hea]th Department,
llownloadable Forms.
k'ROZEN DESSERTS:
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 da so wiil result in the suspension or revocatian af yaur Frozen
Dessert Permit until the abave terms have been met.
OUTSIDE CAF�S:
Outside cafes(i.e.,outdoor seating with waitezlwaitress sezvice),must have priar agprnval from the Board of Health.
OUTDOOR C04KING:
Outdaar cooking,preparatian,ar display of any faod prodnct by a retail ar food service establishment is prohibited.
N01'ICE:Permits run annuaily frorn January i to L}ecember 31. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 15, 2014.
ALL RENOVATIQNS TO ANY FQOD �STABL[SHMENT, M4TEL 4R POOL (i.e., PAINTING, NEW
EQUIPMENT, ETC.), MiJST BE REPORT�D 'TO AND APPROVED BY THE BQARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE FLAN.
DATE: i l�pIf y SIGNATj1RE: �¢��.�-_�
PRINT NAME & TITLE:�A-S� �'�,.,,, �(�c��'r,It„ a-
xe�. wosna
. .
t� The Commonwealth ofMassachusetts
Department oflndustria[Accidents
' Office of Investigations
I Congress Street, Suite 100
Boston,MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Analicant Information Please Print Legiblv
Business/Organization Name: N,,,N•�•• ��� D�� : ��t f ,� ` W K�,-t. e �
Address: So � ��,•� 1'�,•�.. ,,�.,,f.aa1
City/State/Zip: .fo..�. ycr.�....�.�M� � a z 6 l�1 Phone#: Jr� d ' 2 s� - �Y 6 y
Are you an employer? Check the appropriate box: Business Type(required):
1.❑ I am a employer with employees (full and/ 5. 0 Retail
__ _ or art-time * _ 6. RestaurantlBaz/Eating Establishment,�,
2. I am a sole proprietor or par[nership 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 aze a corporarion and its officers have exercised 9. ❑ Entertainment
their right of exemprion per c. 152, §1(4), and we have 10.❑ Manufacturing
no employees. [No workers' comp. insurance required)*
4.❑ We are a non-profit organization, staffed by volunteers, 11.❑ Health Care
with no employees. [No workers' comp. insurance req.] 12.❑ Other
*Any applicant that checks box#I must also fill out the sectioa below showing their workecs'compensation policy i¢formatiou.
**If the cocpomte officers have exempted themselves,but the cotporalion has other employees,a workers'wmpensatioa policy is requ'ved and such aa
organization should check box#1.
I am an employer[hat is providing workers'compensatian insurance for my 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 poticy number and expiration date).
_____ ail e t�secure cQYeraee as reanired under,R,,_ection 25A of MG.�,,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 fne
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
Invesrigations of the DIA for insurance coverage verification.
I do hereby certify,under the pains and penalties ofperjury thal the information provided above is true and correct.
Si ature: ��Y� ����--- Date: ��I �'�w
Phone#: $ o g- 2 g� -6 5 z y
Official use on[y. Do not write in this area,to be completed by city or town offzciaL
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 O�ce
6. Other
Contact Person: Phone#:
www.mass.gov/dia