HomeMy WebLinkAboutApplication and WC ���°��\','�a TOWN OF YARMOUTH Boazdof
Health
� :_ :�- ' "'3 1146 ROUTE 28, SOUTH YARMOUTH, MASSACHiJSETTS 02664-24451 -
� ��� �LNE�,`�'� Telephone(508)398-2231, ext. 1241 Div si n
Fa�c(508) 760-3472
To: Yarmouth Business Establishments S�� S�p���� �7692
From: Bruce G. Murphy, Director � ��`'��b�D
Yazmouth Health Department� �t� � 5 2��4
Date: November 7, 2014 HEqLTH DEp7;
Subject: Increase in License/Permit Fees
Please be awaze that the Yazmouth Boazd of Health, under the direction of the Yannouth Boazd
of Selectmen, has raised a number of license and permit fees issued through the Yarmouth
Health Deparhnent, effective January 1,2015.
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 1, 2015.
However, if you fully complete the application, and submit it to the Yarmouth Health
Department with all required certificarions 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 $ q5.00
Motels $ 55.00
Food Service 0-100 Seats $ 85.00
rood Service 3ver 100 Seats $16C.00 - --
Retail Food Service<25,000 sq. ft. $ 80.00
Retail Food Service>25,000 sq. ft. $225.00 Z2S•oo
Other fees owed but not listed above:
Total fees owed for your establishxnent: �'�Z 0 Ua
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
pCior to Decembel' 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 springprior to opening" on the application.J
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� TOWN OF YARMOUTH BOARD OF HE�ILTH +,� "'�
��� APPLICATION FOR LICENSE/PE T-20�1�5�� � �uc� �t 5 2U 14
`" * Please complete form and attach a11 necessa�y do ,�'b�Dece ber
Failure to do so will result in the retur�f your application p EPT.
� ESTABLISHMENT NAME:��t�vv'" �'u cv y vn�v i� � �I�� 2 TAX ID:
� LOCATIONADDRESS: �\�R 12DUte "L� JGu11, yu'�l7�ou.ihi YYl/k 0?b��-�-TEL.#: �,-�7�'. :`�`� . C`�`1'�
MAILINGADDRESS: �.�. ��ok ZL Lzc�r �Oif2� P,c�i,�, ID 8�`!'`io
E-MAIL ADDRESS: �i Ge 2 a 8 ��
0 WNER NAME: S Y Y71a v fis Ca-n �,u. �Y`�� .
CORPORATION NAME (IF APPLICABLE):�``�,'U v 11'lu v ice fs C�r�x}pG v��a � f v�t� .
MANAGER'S NAME: TEL.#: �V k . ��)�I- . D 99':
MAILING ADDRESS: � i� 3��x � � I�cr�t "1�'-�2� I%'��i�=e�.J il 3'�2-G,
POOL CERTIFICATIONS: +1�q.
The pool supervisor must be c rtified 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, standard 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 £►le at your place of business.
1. 2•
3. 4.
FOOD PROTECTION MANAGERS - CERTIFICATIONS:
All food service establishxnents 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. S� �.A� 2.
PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
1. ��1��"r,i � !� � � _
�. 1,�� m y'1 �_C �. � —
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 file at your establishment.
1. SF.E ATT/�CH1E� 2.
HEIMLICH CERTIFICATIONS: �1'a
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
LODGING:
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 $55 _TRAILER PARK $l05 _WHIRLPOOL $110ea.
FOOD SERVICE: �
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
0-t00SEATS $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 AEQUIRED FEE PERMIT#
<50 sq.ft. $50 l >25,000 sq.ft. $285 VENDING-FOOD $25
<25,OOOsq.ft. $I50 =FROZENDESSERT $40 �TOBACCO $110
NnMECHnrrcE: $ts AMOUNTDUE _ $ 3`�5-O
"****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** �L"` '�0`�d
��'G�tf l��ur�e O l�(�`I
ADMINISI`RATIf)N � r
Under Chapter 152,Section 25C, Subsection 6,tlze Tawn of Yarmouth is now required to hold issuance or renewal
of any license or permit to operate a business if a person or company does not have a Certificate of Worker's
Campensation Insurance. THE ATTACHED S'TATE WdRK�R'S COlYIPENSATIt}N INSUI2ANCE
AFFTDAVIT MUST SE COI�PLETED AND SIGNED, OR
CLRT. QFINSURANCEATTACHLD �
OR �
WORKER'S COMP. AFFIDAVIT SIGNED ANI7 ATTACHEI7 �
Town of Yarmouth taaces and liens rnust be paid prior to renewal or issuance of your permits, PLEASE CHECK
APPROPRIATELY IF PAID:
YES � NQi_^
MOTF.LS ANA OTHER LODGING ESTABLISHME�TTS
TRANSIEN'1'OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy sha1l be
limited to the temporary and short term occupancy,ordinarily and customarily associated with motel and hotel use.
Transient occupants must have and be able to demanstrate that they ma3ntain a principai ptace of residence
elsewhere.Transient oc;cupancy sha11 generally refer to continuous occupancy of'not more than thirty(30)days,and
an aggregate of not more than nrnety(90)days within any six(6)month period. L7se of a guest unit as a residence or
dwelling unit shall not be considered transient. Occupancy that is subject to the collectian af Room 4ecupancy
Excise,as defined in M.G.L. c. 64G ar $30 CMR 64G, as amended, shall generally be considered Transient.
POOLS
PO4L OPENING:All swimming,wading and whirlpools which have been ciosed for the season rnust be inspected
by the Health l�epartment prior to opening. Contact the Health Depaztment to schedule the inspection three(3)
days priar to apening. PLEASE N4TE: People are NOT allowed to sit in the pool area until the pool has been
inspected and opened.
POOL WATER TESTING: 'The water must be tested f'ar pseudamonas,total coliform and standard plate count
by a State certified lab, and snbmitted to the Health Bepartrnent three (3} days prior ta opening, and quarterly
thereafter.
P40L CLOSING: Every outdoar in graund swimming pool rnust be drained or cavered within seven{7)days of
closing.
�'QOI? SERVICE _ __
SEASONAL FOOD SERVICE OPENING:
All food service establishments rnust be inspectad by the Health Deparkrnent prior to opening. Please contact the
Health Department to schedule the inspectian three(3) days prior to opening.
CATERING POLICI':
Anyone who caters witfun the Town of Yarmouth must notify the Yazmouth Health Deparhnent by filing the
required Temparary Foad Service Appizcation form 72 haurs prior to tbe catered event. These forms can be
obtained at the Health Departmettt,ar from the Town's website at www.varmouth.ma.us under Health 17epartment,
Dawnlaadable Forms.
FROZEN 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 do so will result in the suspension or revocation of your Frozen
llessert Pcrmit until the abave terms have been met.
dUTSIDE CAFES:
Outside cafes(z.e.,outdoor seating with waiter/waitress sezvice),must have prior approval from the Board of Health.
C)UTDOOR COOKING:
,___ Outdoor eookin�, repazation,or dispIay of any food product by a retail or faod service establishment is prahibited.
NOTICE:Permits run annually from 7anuary 1 to December 3 I. IT IS YdUR RESYONSIBILITY TO RETURN
THE COMPLET�D RENEWAL APPLICATIt};�I{S}AND REQUIR�D FEE(S}BY DECEMBER 15, 2014.
ALL RENOVATIONS TO ANY FOOB ESTABLISHMENT, MOTEL dR PdOL (i.e., PAINTING, NBW
EQUIPMENT,ETC.}, MUST BE REPORTED 'I"Q AND APYROVEI7 BX THE BOARD OF HEAI,TH PRIOR
TO COMMENCEMENT. RENOVATIQNS MAY REQUIRE A SITE PLAN.
DAT�,: DEC p B 2014 s1�tvATU1tE: �".=��,�"f�`i�t,=-�t�G�j�v� �
PRINT NAME& TITLE:_��V;{'-�}.�T1�xlLicense Associate __
ftev. 11f03114 � �
� The Commonwealth ofMassachusetts �'""���� '
Department oflndustrialAccidents
Ojfice 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 Le¢ibly
Business/Organization Name: Shaw's Supermarket#7692
Address: �108 Route 28
City/State/Zip: South Yarmouth, MA 02664 Phone #:508.394.0995
Are you an employer? Check the appropriate boa: Business Type(required):
1.❑� I am a employer with"'110 employees(full and/ � 5. ❑✓ Retail
or part-time).* 6. ❑ RestaurantBaz/Eating Establishment
2.❑ I am a sole proprietor or parinership 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 corporation and its officers have exercised 9. ❑ Enter[ainment
their right of exemption per c. 152, §1(4), and we have 10.❑ Manufacturing
no employees. [No workers' comp. insurance required]* 11.❑ Health Caze
4.❑ We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp. insurance req.] 12.❑ O[her
*My applicant that checks box#1 must also filt out the section below showing their workers'compensation policy information.
**If the corpora[e of£icers have exempted themselves,but[he corporation has other employees,a workers'compensation policy is required and such an
organization should check box#1.
I am an employer that is providing workers'compensation insurance for my employees. Belaw is the policy information.
Insurance Company Name: ACE American Insurance Co
Insurer's Address:
City/State/Zip:
Policy#or Self-ins.Lic. # �-RC4788763A AOS Expiration Date: 03/31/2015
Attach a copy of the workers' compensaHon policy declaration page(showing the policy number and expiraHon 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-yeaz imprisonment,as well as civil penalUes 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
Investigations of the DIA for inswance coverage verification.
I do hereby certify,under the pains and penalties ofperjury that the information pravided above is true and correct.
Si ature: " �� Date:
12/08/2014
Phone#: z08. 5.6022
Offtcial use only. Do not write in this area,to be comp[eted by city or town o�cial
City or Town: PermitlLicense#
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3. CitylTown Clerk 4.Licensing Board 5. Selectmen's O�ce
6. Other �
Contact Person: Phone#:
www.mass.gov/dia
i
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