HomeMy WebLinkAboutApplication and WC o�'Y'`�R
��r --�`_ �c TOWN OF YARMOUTH Ha�f
� ; � "3 1146 ROUTE 28, SOUTH YARMOUTH,MASSACHiJSETTS 02664-24451 -
�. �,r ^eM �eE � Telephone(508)398-2231, ext. 1241 Health
r ` Fas(508)760-3472 Division
To: Yannouth Business Establishments P�e�zs (ZiV�12EsoR.-r
G,�, a�c��odQ�
From: Bruce G. Murphy, Director
Yarmouth Health Department� Utl: 1 6 20�4
Date: November 7, 2014 HEALTH DEPT.
Subject: Increase in License/Permit Fees
Please be awaze that the Yarmouth Boazd of Health, under the direction of the Yazmouth 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 Yatmouth 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 January 1, 2015.
However, if you fully complete the application, and submit it to the Yannouth 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 Pools $ 80.00 8 O:Op
Public W1urlpooUVapor Baths $ 80.00 � $0,00
Tobacco Sales $ 95.00
Motels $ 55.00 — 5�
Food Service 0-100 Seats $ 85.00
-- ----- _
- -Food Service Oaer 10� Seats $I6�:OG
--- — - -- -
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:
Total fees owed for your establishment: �ZI 5.00
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 andlor pool certifcations prfor to opening, however, you must note
"Will provide in the spring prior to opening"on the application.J
scNvm�t
� � b TOWN OF YARMOUTH BOARD OF HEALTH �
��� APPLICATION FOR LICENSEIP Utl: � 6 �U14
�,.,. ' '` �`���;
* Please complete form and attach all neces . ni� y D c ber I S 2019.
Failure to do so will result in the ret "'of ����a�iou�a ketH EPT.
ESTABLISHMENT NAME: 1 V 1� T D: rn
LOCATION ADDRESS: '-!�9 �R-'t `2.� S� �IAYZmdc 91'f� TEL.#: �J4S�q� ?1�3�D_
MAILING ADDRESS: � �C L1� � �iA-rYYlbL�r �YV� �2Jo`I~�
E-MAILADDRESS• cs ��CC' 'C`"c �- trG�ST• rJ�,
OWNER NAME: �m u� � � A
CORPORATION NAME IF APPLICABLE): LL.C—
MANAGER'SNAME: �tC��� �mul�('t� TEL.#: 7rO4i3G� 2�
MAILING ADDRESS:
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 fo -
1. ��� �UrtN�'�-� ��w1� rJCtrtl�� ���lCsl*LDadf�CS�i�t`rs�k-ii1�.�
Pool operators must list a minunum of two employees cturently 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 Tile at your place of business.
1. ��1 c.k-� �U- 'rr1`(-� 2.
3. \C,tk-�f-\ �v�f�-fC� 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.
---r
PERSON IN CHARGE:
Each food establishme�ny/t st 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 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 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 REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
B&B $55 CABIN $55 I MOTEL $110
INN $55 CAMP $55 I SWIMMINGPOOL$IlOea
� LODGE $55 TRA[LERPARK $105 i WHIRLPOOL $IlOea.
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
—RESID.KITCHEN $80
RETAIL SERVICE:
LICENSE REQUIRED FEE PERMIT/t I,ICENSE REQUIRED FEE PERM[T# LICENSE REQUIRED FEE PERMIT#
<50 sq.R. $50 >25,000 sq.ft. $285 VENDING-FOOD $25
=<25,000 sq.ft. $150 —FROZEN DESSERT $40 _TOBACCO $110
NAMECHANGE: $IS AMOUNTDUE _ $ 330.00
•***•PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** � � Z�6 � O�
a4L`� l`{(� ia-�I t�l�`{
ADMINISTRATION �
Under Chapter 152,Section 25C,Subsection 6,the Town of Yarmouth is now required ta 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. TBE ATTACHED S'CA`7'E W4ItKER'S COMPENSATION INSUIL4NCE
AFFIDAVIT MIIST SE COMPLETED AND SIGNETI, OR
cExT. o� �sz��rrc�aT�racxE� �� �s I�b'�;C� y�tW
ox tiu��l ovid� �� 1�a.�L...
WORKER'S COMP. AFFIDAVIT SIGNED ANU A'TTACH�D 1�
TowTt of Yarrnouth taxes and liens must be paid prior renewal ar issuance of youar permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES NO
MOTELS ANA O'CHFR LODGING ESTABLISHMENTS
TRAIVSIEIVT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be
limited to the temporary and shart term occupancy,ordinarily and customarily associated with matel and hotel use.
Transient occupants must have and be able ta demonstrate that they maintain a principal place of residence
elsewhere. Transient occupancy shall generally refer to continuous occupancy ofnot more than thirty{30)days,and
an ag�regate of nok more than ninety(90)days within any six(6)month period. Use of a guest unit as aresidence or
dwelling unit shalI not be consSdered transient. OccupaF�cy that is subjeet to the collection of Room Occupancy
Excise,as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient.
POOLS
POOL OPENI�tC:Ali swimmang,wading and whirlpools which have been closed for the season must be inspected
by the Health Department prior to opening. Contact the Health Departrnex�t to schedule the inspection three(3)
days prior to opening. PLEASE NOTE: People are NOT allowed to sit in the pool area until the pool has been
inspected and opened.
POQL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count
6y a State certified lab, and submitted Co the Health Department three (3} days prior to opening, and qnarterly
thereafter.
P44L CLOSING: Every outdoor in ground swimming paol must be drained or cavered within seven(7)days of
closing.
FCIOlI SERS'I�'E
SEA80NAL FOOD 3ERVICE OPEIVING:
All food service establishments must be inspected by the I Iealth Department prior k6 opening. Please contact the
Health Department to schedule the inspectian three{3) days prior to opening.
CATERING PQLICY:
Anyone who caters within the Town of Yarmouth rnust notify the Yarmouth Health Department by filing the
reqwred Temporarv Food Service Application form 72 haurs prior ta the catered event. These forms can be
obtained at the Hea�th Department,or from the Tawn's website at www,yannouth.ma.us under Health Department,
Downloadable Forms.
FROZEN DESSERTS:
Frozen desserts must be tested by a State certified lab prior to apening and monthly thereafter,with sample results
submitted Yo the Health Department. Failure to do so will result in the snspension or revooation of your Frozen
Dessert Permit untzl the abave terms have been met.
f3ITTSIDE CAFES:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval frorn the Board of Health.
OUTDOOR COOKING:
Outdoor cooking,prepazation,or display of any food product by a retail or food service establishment is prahibited.
NOTICE: Perrnits run annually from January I to December 31.. IT IS YOUR RESPONSIBILITY TO RGTLJRN
THE COMPLE'I`ED RENEWAL APPLICATIQN(S)ANA REQUIRF,D FEE(S} BY DECEMBER i S, 2014.
ALL RENOVATIQNS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING'r, NEW
�Qt3IPMENT, ETC.}, MUST BE REPORTEI}Td AND APPROVED BY THE BOARD OF HEALTH PRTiJR
T'O COMMENCEMENT. RENOVATIONS MAY UIRh SITE PLAN.
DATE: �Z-- 4l0 �' SIGNATU :
PRINT NANIB&TITLE: 1t,1C- t`��k-%'�'L�C t�U.»Il..�
ftev. 1 SN3ti4
� ' � The Commonwealth ofMassachusefts
Department oflndustrialAccidents
Office oflnvestigations
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: ��(LS �1LG`Q ��C,�'� �--
Address: `� -rjG �� ��
City/State/Zip: YYl pLJ'�� Phone#: ��� ��Q `�_Q�d
Are yo an employer? Check the appropriate box: Business Type(required):
1. I am a employer with�employees(full and/ 5. ❑ Retail
_ nr gart_ti�ne).* 6. ❑ Restaurant/Baz/Eating Establishment
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 requiredj $• ❑ Non-profit
3.❑ We are a corporarion and its officers have exercised 9. ❑ Entertainment
their right of exemption per c. I 52, §1(4), and we have 10.Q Manufacturing
no employees. [No workers' comp. insurance required]* 11.❑ Heakh Caze
4.❑ We are a non-profit organization, staffed by volunteers, ��L-
with no employees. [No workers' comp. insurance req.] 12.❑ Other
•Any applicant t6at checks box#I must also fill out the section below showing their workers'compensatio¢policy information.
**If the corporate officeis have exemp[ed themselves,but the corporation has other employees,a workers'compensation policy is tequired and such an
organization should check box#1.
I am an emp[oyer that is providing worker 'compensation insurance or my emp[oyees. Be[ow is the po[icy information.
Insurance Company Name: ��'��oc k- �i �`c�� 1�'"� —�w�ro'v�c9.� �ti A��
Insurer's Address: 22 Z /��E S �T:
CiTy/State/Zip: ��=� l-Nkl�1 � M A 0 ��2(,�
Policy#or Self-ins.Lic. # UI ��� 4i 3�✓ �c Expiration Date: 05�18�719l�=j
Attach a copy of the workers' compensation policy declaration page(showing the policy number and ezpira� tion date).
Failurela.secu=e�overage as requir��under$ection 25A of_MGL c. 152 can lead to the imposi6on 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 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 insurance coverage verification.
I do hereby ce ,under the p ' a enalties of perjury that the information provided above is true and correct.
Signahve•��lJ-�Yv`� � Date• `2--�] C, 1 � `t�
��
Phone#: �i'� t-�'`-1'`�� �23C1
Official use only. Do not write in this area,to be completed by city or town official
City or Town: PermitlLicense#
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