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Home My WebLink AboutApplication and WC � . o�'�qR �� ==°` _ �� TOWN OF YARMOUTH Ha�f � —� { y 1146 ROUTE 28, SOUTH YARMOUTH,MASSACHiJSETTS 02664-24451 - �. t,, �.� :r Telephone(508)398-2231,ext. 1241 Health '"`"E Fas(508)760-3472 Division�� L'3C�Cr,C�OMGD To: Yarmouth Business Establishments Qu�ckMAR# r,�y� DE� 2 2 2014 From: Bnxce G. Murphy, Director �� Yarmouth Health Department� HEALTH DEPT. Date: November 7, 2014 Subject: Increase in License/Permit Fees Please be awaze that the Yannouth Board of Health, under the direction of the Yarmouth Boazd of Selectmen, has raised a number of license and pernut fees issued through the Yazmouth Health Deparnnent, 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 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 Swiinming Pools $ 80.00 Public WhirlpooUVapor Baths $ 80.00 TobaccoSales $ 95.00 $q ,r,.pp Motels $ 55.00 Food Service 0-100 Seats $ 85.00 Food SEroice f3��er i0fl Seats $YG6:00— _ ____ _____ _ _ ___ Retail Food Service<25,000 sq. ft. $ 80.00 $80.00 Retail Food Service>25,000 sq. ft. $225.00 Other fees owed but not listed above: Total fees owed for your establishxnent: I S. i NOTE: To be entitled to pay the current 2014 rates listed above, your business application, food and/or pool certifications, along with worker's compensation information must be received, or mailed (postmarked) on or prior to December 31, 2014. (Those establishments which open in the spring wild be allowed to provide food andlor pool certifications prior to opening however, you must note "Will provide in the springprfor to opening"on the application.J BGM/maf d TOWN OF YARMOUTH BOARD OF��EALTH �C�G� D�7C�D � � APPLICATION FOR LICENSE�'��2�1� � �- pE� 2 2 pOt4 * Please complete form and attach a11 necess�y doc�e�t�b,�'�ec ber IS 2014. Failure to do so will result in the returri of your appticahon ke�EqLTH DEPT. ESTABLISHMENT NAME•��r� i�c� �RbY � �1 r�K- r�� TAX ID• � LOCATIONADDRESS: 1$v � d�Y77o�� J��S�' l?-�� TEL.#:SoB-39 $ -/9(j MAILINGADDRESS: l�v L3 r7�h ew�l /ho,� �onr� � •ya2Mo�ti'- anPr bYX6� E-MAIL ADDRESS: OWNERNAME: A�1Jitr�,.Mo«'� �lG� CORPORATION NAME (IF APPLICABLE): MI S/3 A?3 /+�� MANAGER'S NAME: /n�N�,K»m Ac) A��.,� TEL.#:S"o,�,'�'h 4 r 3S'J� MAILINGADDRESS:� ,P� hA� �rnasart,D�1L7 �y- p�� POOL CERTIFICATIONS: The pool supervisor must be certi£ed 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 minimum of two employees currently certified in basic water safety, standard 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 provide new copies and maintain a Sle at your place of business. 1. Z• 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 at[ach 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 Chazge (PIC) on site during hours of operation. 1 2 - _ _ 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 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. l. 2• 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERM[T# B&B $55 CABIN $55 MOTEL $110 INN $55 CAMP $55 SWIMMINGPOOL$IlOea. LODGE $55 TRAILER PARK $l05 _WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE AEQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 _CONTINENTAL $35 NON-PROFIT $30 �>100 SEATS $200 COMMON VIC. $60 WHOLESALE $SO — — —RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# I.ICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 =<25,000 sq.ft. $150 � —FROZEN DESSERT $40 zTOBACCO $110 / � NAMECHANGE: $15 AMOUNTDUE _ $ Z.�o�, OC� **•**PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** ��`� ��S'OO c��ts I�Z�i� ADMINISTRATION iJnder Chapter 152,Section 25C,Subsection 6,the Towx of Yannauth is now required ta hold issuance or renewal nf any license or permit to operate a business if a person or cornpany dnes not have a Cartificate of Worker's Compensation Insurance. TAE ATTACHED STA7'E WOFtKER'S CC/MI'ENSATION IN9U12ANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. 4F INSURANCE A,TTACI-I�D OR WORKER'S COMP. AFFII)AVIT SIGNED ANI� ATTACHED Town of Yannouth taxes and liens must be paid pf r to renewal or issuance of your perrnits. PLEASE CHECK �PPROPRIATELY IF PAID: YES NO MOT.ELS AND OTHF.R LODGING ESTABLISHMENTS 'TRANSIENT OCCUPANCY: For purposes of the limitations oi Motel or Hotei use,Transient occupancy sha71 be limited to the temporary and short term occupancy,ordinarily and customarrly associated with motel and hotef use. Transient occupants must have and be able to dernonstrate that they maintain a principal place af residence elsewhere.Traasient occupancy shall generally refer ta continuous occupancy of not more than thirty 430)days,and an aggregate of not more than ninety(90)days within any six(6)month period. Use of a guest unit as a residence or dwelling unit shall not be considered transient. Occupancy that is subject to the collection of Room Oceupancy Excise, as defined in M.G.L. c. 64G or 834 CMR 64G, as amended, shall generally be cansidered Transient. POOLS POf1L OPENING:Ail swimming,wading and whirlpaols which have been closed for the season must be inspected by the Health T)epartment prior to opening. Contact the Health Department to schedule the inspection three(3) days priar to opaning. PLEASE NQTE: Peop€e are NdT allowed to sit in the poaI area until the poal has been inspected and opened. POdY.WATER TESTING: The water must be tested ibr pseudomonas,total col'rform and standard plate count by a State certified lab, and submitted to the Health Departrnent three (3) days prior to opening, and quarterly thereafter. P40L CLflSING: Every outdaor in ground swirnming pool must be drained or covered within seven{7}days of closing. FOOI) SERVICE 3EASONAL FOCID SERVICE OPENING: AIT food service establishments must be inspected by the I-Ieahh Department prior to opening. Please contact the Health Department ta schedule the inspection three{3)days prior to opening. CATERING POLICY: Anyone who caters within the Town of�Yarmouth rnust notify the Yarmouth Health Department by filing the required Temporary Faod Service Application farm 72 haurs priar to the caterad event. These forms can be obtained at the Health Department,or frorn the Town's website at www.varmouth.ma.us under Health Department, Dow►ilaadable Forms. FROZEN DESSEI2TS: Prozen desserts must be tested by a State certified lab prior to ppening and monthly thereafter, with sample restilts submitted to the Health Department. Failure to do sa will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,autdoor seating with waiter/waitress service),must have prior approval frorn the Board of Health. OU'l'D04R COOHIIVG: Qutdoor cookrng,preparation,or dispIay ofany faod prodixct by a retail or food service establishment is prohibited. NOTICE: Permits run annually from January I to December 31. IT IS YOUR RESPONSIBILITY TO RE'I`URN TIIE COMPLE'TED RENEWAL APPLICATI{?N{S)AND REQUIREI7 FEE(S}BY DECEMBER I5, 2414. ALL RENOVATTONS TO ANY FOOD ESTABLISHMENT, MO'PEL OR POOL (i.e., PAINTING, NEW BQUIFMENT,ETC.},MUST BE REPORTED TO AND APPROVED BY THB BOARD OF FIEALTH PRI{}R TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: )Y ��! tf SIGNATUI2E: (►q,,,,4-�� • --� I ' -- PRINT NAME& TITLE: tYl�}7�rc�,n+� }3� �-��- Rev.1 if03t74 , f � � The Commonwealth ofMassachusetts Department of Industrial Accidents � Office of Investigalions ' 1 Congress Street, Suite 100 Boston, MA 02114-20U www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Aualicant Information Please Priut Legiblv Business/Organization Name: l�)�/�Q(/.� /r� <- J11�¢a Q J I�K �� Address: I� L �3 bL>> i o w�J f�-a a�F ce�v� City/State/Zip:�oi� yAzw,w�+- nn� ov66� Phone#: ��8 � �SB ' /�6� Are you an employer? Check the appropriate bos: Business Type(required): 1.❑ I am a employer with employees(full and/ 5. [�Retail or part-time).*__ _� _ 6. ❑ RestauranUBaz/Eating Establishment 2.❑ I am a sole proprietor or paRnership and have no �, � Office and/or Sales (inc1.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 iu 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 aze a non-profit organization, staffed by volunteers, 1 I.� Health Caze with no employees. [No workers' comp. insurance req.] 12.❑ Other *Any applicant that checks box#I must also 5ll out the section below showing their workers'compensation policy infocmation. •*If the corpomte officers t�ave exempted tLemselves,bu[the corporatlon has otha employees,a workers'compensation policy is required and such mm organization should check box#I. I am an employer thal is providing workers'compensation insurance for my emp[oyees. Below is the policy information. Insurance Company Name: /�/�� /Y)J TU� y/l2� /4`Lt 11 X-'�tT Cf3M f(aTl�� Insurer's Address: �� '� ' �7i�� /�� 0 City/State/Zip: ��1�'� f"�,�' O,� R Y) '`%� S � Policy#or Self-ins.Lic. # �G 2 � �/� '.3� g 3�.6 ^ �� Expiration Date:�� Attach a copy of the workers' compensafion policy declaration page(showing the poticy number and expiration date). Failure to secure_Goverage as required under_Section 2�A 4f Iv�GL�52 can le�d SQ the imoosition Qf criminal�enalti��Qf 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 forwazded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify,under thepains andpenalties ofperjury that the information provided above is due and corred Si ature: /�'�`�`""� o`� 1� - Date: 1�/I/ � I� � �� Phone#: �� 3 `��' � �(� � Official use only. Do not write in this area,to be comp[eted by city or town officiaL City or Town: Permit/License# Issuing Authority(cirde 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.macs.gov/dia