HomeMy WebLinkAboutApplication and WC ��°���'�Q TOWN OF YARMOUTH BI�oe�f
0 -_ ._- '�, 1146 ROUTE 28, SOUTH YARMOUTH,MASSACHLJSETTS 02664-24 51 G3�G�fl�GD
�. �+r Ee`� • Telephone(508)398-2231,ext. 1241 e�
t�C ME Fax(508) 760-3472 Ut���'��4
HEALTH DEPT.
To: Yazmouth Business Establishxnents C.�r�Bc-2�Aµo �j-Q.enS -�22�Z
From: Bruce G. Murphy, Director "�
Yarmouth Health Department
Date: November 7, 2014
Subject: Increase in License/Pernut Fees
Please be awaze that the Yazmouth Boazd of Health, under the direction of the Yarmouth Boazd
of Selectmen, has raised a number of license and permit fees issued through the Yannouth
Health Department, effective January 1, 2015.
Attached is the Yarmouth 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 Yarmouth Health
Department with all required certifications 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 Swinuning Pools $ 80.00
Public WhirlpooUVapor Baths $ 80.00
Tobacco Sales $ 95.00 ,p p
Motels $ 55.00
Restaurants 0-100 Seats $ 85.00
Restaurants Over 100 Seats $160.00
Retail Food Service<25,000 sq. ft. $ 80.00 00.00
Retail Food Service>25,000 sq. ft. $225.00
Other fees owed but not listed above:
Total fees owed for your establishment: � 1�5-00
NOTE: To be entitled to pay the current 2014 rates listed above, your
business application, food and/or pool certifications, along with worker's
compensation information must be received, or mailed (postmarked) on or
prior to December 31, 2014. [Those establishments which open in the spring will be
allowed to provide food and/or pool certifications prior to opening, however, you must note
"Widl provide in the spring prior to opening" on the application.J
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� TOWN OF YARMOUTH BOARD OF HEALTH �����dCD
� � APPLICATION FOR LICENSE/PERMIT -2015�g: � �t� � 9 [O 14
`" * Please complete form and attach all necessary do�un�y l�Feeem er 15 2014.
Failure to do so will result in the return of your application pac et. HEALTH DEPT.
ESTABLISHMENT NAME• C�v�$a'R-� AtJ O Q-rn� 226�Z� TAX ID•
LOCATION ADDRESS: f30� �:E 2$ r.�.o,��� �'EL.#: - '�j���I
MAILING ADDRES ' P�Y. nEQ�: \o o CQuSS�tJ l',� • R�`V 0 f Q Aw..a�i(,�hYa+v� M F� O\�1�"L
E-MAILADDRESS: � SAt..�(� G�.� C� t� voncsE�� t�n/ O hP.�R-�nS . C c nn
OWNERNAME: C �%'^n�o.� a.� a�) c� �a_�S t n/ C.
CORPORATION NAME (IF APPLICART.F.1•
MANAGER'S NAME: .Y�A'�E� �-�S C�\JC E L�'� TEL.#: S�$' ��' � �13'1
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 form.
1. 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 wil(
not use past years' records. You must provide new copies and maintain a f►le at your place of business.
1. Z•
3. 4.
FOOD PROTECTION MANAGERS - CERTIFICATIONS:
All food service establishments are required to have at least one fu11-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 Heatth 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.
1. 2.
ALLERGEN CERTIFICATIONS:
All food service establishxnents 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.
1. 2.
3. 4.
RESTAURANT SEATING: TOTAL#
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# [,ICENSE REQUIRED FEE PERMIT#
B&B $55 CABIN $55 MOTEL $110
INN $55 CAMP $55 SWIMMING POOL$1 IOea.
_LODGE $55 1RAILER PARK $105 WHIRLPOOL $110ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
0-IOOSEATS $125 _CONT[NENTAL $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 1�� � g
T<25,OOOsq.ft. $150 / -QS�J —FROZENDESSERT $40 �TOBACCO $110 .�f-�1
� NAME CHANGE: $15 AMOUNT DUE _ $ 2�00. OO
*•***pLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*•*"* ��� � i 7�'�O
�� �55�os i�2�1'-�
ADMINISTRATION
Under Chapter 152, Section 25C, Subsection 6,the Tcrwn of Yarmouth is now required to hold issuance or renewal
of any license ar permit to operate a business if a person or company does not have a Certificate of Worker's
Compensatian Insurance. T�IE ATTACEIED STA1'E WOitKER'S COMPENSA7'ION INSUL2ANCE
AFFTDAVIT MUST SE COMPLETED A,ND SIGNEll, OI2
CFRT. QF iNSURANCE ATTACHLD
OR �
WdRKER'S COMP. AFFIDAVTT STGNEI}ANI3 ATTACHED�
'T'own of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPItOPKIATELY IF PAID:
YES NQ
A30TELS AND QTHER LODGING ESTABLISHMENTS
'TI2ANSTENI'OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be
limited to the temporary and short term accupancy,ordinarily and customarily assoeiated with motel and hptel use.
Trans3ent occupants must have and be able to demonstrate that they maintain a principai place of residence
elsewhere.Transient oocupancy shall generally refer to continuous occupancy oFnot more than thirty(30)days,and
an aggregate of not more than ninety(90)days within any six(6)month period. Use af a�,,uest unit as a residenee or
dwelling unit shall not be considerad transient. Occupancy that 3s subject ta the collectian of Room Occupancy
Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended,shail generally be cansidered Transient.
POOLS
POOL OPENXNG:All swimming,wading and whirlpaols wivch have been closed for the seasan must be inspected
by the Health Department prior to opening. Contact the Health Depazhnent to schedule the inspecHon three (3)
days prior ta apening. PLEASE NOTE: People are NOT allowad to sit in the poo] area until the paal has been
inspected and opened.
POOL WATER TESTING: The water must be tesCed for pseudomonas,total coliform and standard plate count
by a State certifed lab, and submitted to the Health Departmenf three (3) days prior to opening, and quarterly
thereafter.
PQOL CLOSING: Every outdaor in ground swamming poai must be drained or cavered within seven(7)days af
closing.
FOOD S�RVYCE
SEASONAL FOOD SERVICE OPENING:
AI2 food service establishments must be Snspected by the Health DeparCment prior to opening. Pleasa contact the
Health Department to achedule the znspection three (3) days prior to apening.
CATERIIVG POLICX:
Anyone who caters within the Town o£Yarmouth rnust notify the Yarmouth Health I7epartment by filing the
required Temparary Food Service Application form 72 haurs priar to the catered evani. These forms can be
obtained at the Health L7epartment,or from the Tawn's website at www,yarmouth.ma.us under Health Deparhnent,
Downloadable Forms.
FROZEN DESSERTS:
Frozen desserts must be tested by a State certified lab prior to apening and monthly thereafter,with sample results
submitted to the Healfh Department. FaiTure to do so will result an the suspension or revocation of your Fr�zen
Dessert Permit until the above terms have bc:en met.
OUTSIDE CAFFS:
Outside cafes(i.e.,outdoor seating with waiter/w�aitress service),must have prior approval frorn the Board of Health.
OUTDOOR COIJHING:
Outdoor 000king,prepazation,or display of any food product by a retail or food service establishment is prohibited.
NOTICE: Permits run annually from January i to December 31. IT IS YOUR KESPONSIBILIT'�r TO RETtJRN
THE COMPLETED RENEWAL APPLICATION{S}ANI}RBQIJIRI;I}FEE{S} BY DECBMBER 15, 26i4.
ALL RENOVATIONS TO ANY FOOD ESTABLISHMElVT, ]NIOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT,ETC.},MLTST BE ILEPORTED TQ AND APFROVED BY THE BOARD t)F HEALTH PI2IQR
TO COMMENCEMENT. RENOVATTONS MAY REQUIRE A SITE PL
t�aT�: i L� 1� � \�-t sSGNA�'uxE:
PRTI�3T NAME&TITLE: Ric 'ar Fournter
xev. ivaJna Ta anager v
� The Commarewealth afMassachusetts
Depart»tent of fndustriaX Accidents
O,�''ice of Invesligarions
X Congress Siree�Suite 100
Boston,MA 02774-2017
wwiumass.govt�fa
Worlcers'Compensation Insurance Affdavit:Generai Bnsinesses
ADP1�csnt IPfarma$on Flease Print Le¢iblv
BusinesslQrganizatian Name:�"���aod Farms.lnc.
Addt'ess:100 Crossing Blvd
City/State/Zip:Framingham, MA Phane#:�08-270-1400
Are yon aa employer?Check the sppropriate boz: Bueiness 1�pe(requL�ed):
1.� I am a eaiptoyer with 7,232 �ptoyces(fuU and/ 5. �Retail
orpart-time}.� 6. ❑RestautanUBar/Eatipg Establixhment
2.❑ I am a sole proprietor or parmersbip and have no 7. ❑Office andtor Sates(inct.neal estate,auta,etc.}
employees working for me in any capacity.
(No workers' camp.insurance required] $• ❑Non-profit
3.❑ We are a carpomiion and its offioe�s hava exeroised 9. 0 En<orteimnept
their right of exemption per a 152,§i(4},and wc hsve 10.Q Manufactwing
no employees. [Na workers' comp.insruence requiredj'* i i �FTeaith Caze
4.❑ We aze a non-profit organization, staffed by volunteers,
with no employees. jNo workers' comp,insurance req.] 12•Q�ther
'My epplicent that chauks 6ox#1 musi atso fill oia the sedion betow showing ilieir workers'compensation po3iry infmmation.
""'If ths wtporats officsrs have exempted tbemselves,but the corporation has othtt employtes,a worktts'oompensation po)icy is requ'vtut and such en
agea'vstion shwld cl+eck box#1.
J am an emp/oy¢r lhot Isproviding workers'compensation insurance jor my employees. Below is thepoticq informat3on.
Insurance Company Name:ACE American lr�surance Compa�y
Insurer's ABdress:�3 Arch Streei,Suite 2900
CityJState/Zip: 8ostan, MA 42'110
Policy#or Self-ins. Lic. # SCF-C43120$S Expiration Date:��01/2095
Attacb a copy of the workers' compensation policy declaration pege{shawing tl�e palicy�arober and eYpiration ds�te).
Failvre to secure ooverage as required under Sec6on 2iA pf MGL c. 152 can lead to the imposition of crimina]pcna]acs of e
fine up to$1,SOO.QO and/ar one-year irnprieonmant, es well as crvil penalties in ttie foim of a STOP WORK QRDER and a fine
of up to$250.00 a day agsinst the violator. Be advised t1�t a copy of this stateuunt may be fo=a�arded ta tha dffice of
Invesdgationa ofthe DIA foxins�uanoe eoveasge verification.
I do kereb erti nder ' and pexa(Nes ofperjury Ihat the iaformatian provide� is aue and comct
i � : Z
#�: �� �-
O,(J`icurl use only. Do not write in this srea,to be campleted bp eity or toiwc oJfuiat.
City or Town: PermitlLicense#
Iasutng Aut6orPry(cirele one):
1.Basrd of Health 2.Building Department 3.+CityfTawn Clerk 4.Liaensing Board 5.Selectmen's Omce
b.OWer
Contsct Persoa: Phone f1:
www.mass.govldie
`1���,
/ •
Curr�be'�rland ��rf
Date of Incorporadon: September 14, l4$4
State of incorpora6on: Dclaware
Principal Address: ]00 Crossing Boulevard,Framingham,Ivip 01702
Office Telephone: 508-270-1400
Federal ID No:
P,_,, CI AL OF'FICERS:
Ari N, Haseotes President&Chief C}perating pf�cer
1$ Lovers Lane
Soufhboraugh, MA Oi7?2
Hawazd S. Rosenstein Treasurer
4 Hickory Road
Southborough, MA 01772
Mark G. Haward, Esq. g���ry
I S Greylock Road
Wellesley,MA 02481
Jahn T. Daly Assistant Treasurex
22 Thomas ltoad
Berkley, MA. d2779
Revised 10/1/13
Ctw6etland Gulf Gmup of Companiea
200 CrossingBoulevard,Fzaming}tam,Rf?.01702
508-270-1400