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Home My WebLink AboutApplication and WC �°� ��o TOWN OF YARMOUTH Boazdof �; - - = C, Health �{�—_. ' `j 1146 ROUTE 28, SOUTH YARMOUTH, MASSACHLJSETTS 02664-24451 - L 4�r�ACNE�`6� � � � Telephone(508)398-2231, ext. 1241 Divis n Fax(508) 760-3472 To: Yazmouth Business Establishments �,,�B��N� �� #��8 From: Bruce G. Murphy, Director G3�C�ls�Mf�[°� Yannouth Health Department = Ut� 2 9 20?d Date: November 7, 2014 HEALTH DEPT, Subject: Increase in License/Permit Fees Please be awaze that the Yannouth Boazd of Health, under the direction of the Yannouth Board of Selechnen, has raised a number of license and pernrit 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 l, 2015. However, if you fully complete the application, and submit it to the Yarmouth Health Departrnent 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 Public WhirlpooUVapor Baths $ 80.00 Tobacco Sales $ 95.00 �,4S.0o Motels $ 55.00 Restaurants 0-100 Seats $ 85.00 Restaurants Over 100 Seats $160.00 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: Tota1 fees owed for your establishment: (? .p 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 "Will provide in the springprior to opening" on the application.J BGM/maf r ` C � � � TOWN OF YARMOUTH BOARD OF HEALTH �� APPLICATION FOR LICENSE/PERM��T�-}.2015 �3 ,, UtC 2 9 ZO14 ` * Please complete form and attach a11 necessazy documen3s by4becembe IS 2014. Failure to do so will result in the return ofyouY app�icahon paC e . HEALTH DEPT. ESTABLISHMENT NAME: 'M E �-�1 +v�S #c � bg TAX ID: ��" LOCATION ADDRESS: 6 2 b rv�(�� tJ �� .E . `(�.�,�.,.o��t'� nn o. TEL.#: S�B�� I 1- �\�3 MAILING ADDRESS.`Te�X O EQT• \06 GQaSL�+�� glvv t ca.�n�nl(;.tih�n M�R � \1ro�L E-MAILADDRESS: l- S{��.v�ii�CC:.9;�6Et=-�-�NO �rAtLrnS . C�^'+ OWNERNAME: (^ �.^��E'Q-�-�� P C PQ-rv�S � N C. CORPORATION NAME (IF APPLICABLEI: MANAGER'S NAME: '�� A '(`^_�T�� '�'Z_ TEL.#: S��'-1`71- �c 1`�� MAILING ADDRESS: 6� r^�R�w V S� w y fl�,ti.o�� 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 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. 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 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. T'�-�^� A M t��-"` �7tv� �'Z._ 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 fixll-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-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 REQIDRED FEE PERMIT# LICENSE REQUIR$D FEE PERMIT# B&B $55 CABIN $55 MOTEL $110 INN $55 CAMP $55 SWIMMINGPOOL.$IlOea LODGE $55 TRAILERPARK $105 WHIRLPOOL $IIOea � FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQOIRED FEE PERMIT# LICENSE REQU[RED 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 =<25,OOOsq.ft. $150 _FROZENDESSERT $40 +TOBACCO $110 NAME CHANGE: $15 � AMOUNT DUE _ $ Z.C-�O -00 •****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM**•'* �L"` �t��-� ��#36�.a8 �z(z5`�� ADMINISTRATION Under Chapter 152,Section 25C,Subsection 6,the Town pf 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 Compensation Insurance. THE A.TTACHEL/ STATE WORKER'S CQMPENSATI4N INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNEI), OR C�RT. OF INSURANCE A"I"I'ACHI;D OR � WORKER'S COMP. AFFIDAVIT SIGIVED ANI7 ATTACHED� Tawn of Yarmouth taxes and liens rnust be paid prior to renewal or issuance of your permits. FLEASE CHECK APPROPRIATELY IF PAID: YES ItiTO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSILNT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be lirnited to the temporary and shart term occupancy,ordinarily and customarily associated with motel and hotel use. Transient accupanis must have and be able to demonstrate that they maintain a principal place of residence elsewhere.Transient oocupancy shall generally refer to continuous occupancy of not rnore than thirty(30)days,and an aggregate of not more than ninety(90)days within any six(6)month period. iJse af a guest unit as a residence or dwelling uni# shall not be considered transient. Occupaney that is subject to the coliection of Room 4ecupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64CT, as amended, shall generally be considered Transient. PQOLS POOL 4PENIt�G:AII swimming,wading and whirIpoals which have been ciosed for the season inast be inspected by the Health Department prior to apening. Contact the Health Departrnent to schedule the inspection three(3) days prior to openin�. PLBASE 1`TOTE;: People are NdT allowed to sit in the pool area until tha pool has baen inspected and opened. POOL WATER TES'�'ING: The water must be tested for pseudomonas,total coliform 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 CI,OSING; Every outdoar in ground swirnming poal must be drained ar cavered within seven{7)days of closing. I�dOD S�RVICE SEASONAL FOOD SERVICE OPENING: All foad service establishments must be inspected by the Ilealth Departsneni prior to opening. Please contact the Health Department to schedule the inspection three(3) days prior to opening. CAT"ERIIYG POLICY: Anyane who caters within the Town of Yarmouth must notify the Yannouth Health Department by filing the required Temporary Faod Service Applicataon form 72 haurs prior to the catered event. These forms can be obtained at the Health Dep�rhnent,or fram the Tawn's website at www.y_umouth.ma.us under Health Deparhnent, Downloadable Forms. FROZEN DESSERTS: Prazen desserts must be tested by a State certified lab priar to opening and rnonthly thereafter,with sarnple results submitted to the Health DeparGment. Failura to do so will result in the suspension or revocation of your Frozen Dessert Permit untii the above terms have been met. OUTSIDE Ct1FES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval frorn the Board of Health. OUTDOOR COOHING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prphibited. NOTICE:Permits run annually from January 1 to December 31. IT IS YOTJR 12ESPONSIBILITY TO RETLIRN TAE COMPLET`ED RENI;WAL APPLICATIQN{S}AND REQLTIRED FEE{S}BY DECEMBER 15, 2414. t1LL RENOVATIONS TO ANY FOdD LSTABI.ISHMENT, MOTEL OR POOL (i.e., Pt1INTING, NEW EQiJIPMENT,ETC.}, MITST l3E REPC?RTED TO AND APPRQVEL}BY THE B4A OF HEALTH PRT4R TO COMIvIENCEMENT. RENOVATTONS MAY REQUIRE A SITE PL N. L?ATE: �,!1��i$ri�'C SIGNATURE: _ PRTNT NAME& TITLE: Rich2�rd Fou¢�nie —Tax Rev. ]it03tf4 � T/ee Colnmen�uealth vf Marssachuseus Deparbnent oflndustriaCAccidenis (l,,(�ic�oflnvestigations 1 Congress Street,Suite I00 Baston,MA 02114-201� www m¢s�gav/dia Workers'Campeasation Iasarance Af6davih General Bnsiaesses Aapifcant Informatioa P2ease Print Lt;�iblv Bttsiness(t?rganizaLion NBme:Cumberland Farms, tnc. Address:loo Crossing Bnrd City/3tatelZip:Framingham,MA Phone#:508-270-1400 Are yon an employer?Check tLe appropriate boz; Business Type(required): 2.� I am a empJoyer with 7,232 c,mpioyees(full andj 5. �Ttetail orpart-time)•• 6. ❑RestaucanUBar/Eating Establishment 2.❑ J am a so2a progrietor or paitnership and have� 7. ❑Office ancUor Sales(incl.real estate,auto,etc.) employees working for me�any capacity. [No warkers' comp.irrsurance requiredj $� ❑Noa-profit 3.❑ We are a cp7garetion end its officeis have exezcised 4. ❑F.ntsrtainmenz their right of exemption per a 1 S2, §1(4),and we have 10.0 Maaufacttuing no employecs. [No workers' camp.insurance required)*' 4.� We ere a non-pro&t organization, stsffed by volunteers, 11.�Healttt Care with no employees. [No workers' comp.insurance req.j 72,�Clther "Any applicantthat checks bmt#1 must also 51k out ihs section below showing their woxkers'cAmpensation policy eifmmetia�, *'If the corpqrate afficers have enempied thcroselves,buf the coryomtvon has other employees,a workers'compensation policy is required and such an organization st�ould cbeck box#1. 1 am an emp/oyer lhat is providing wnrkers'con�pensatlnn rr�suratrce for my employees Belnw}s thepoticy urformatio�u Insurance Company Name:ACE American Insurance Company Insurer's Address:38 Arch Street, Suite 2900 City/State/Zip: �oston, MA 02110 Policy#or Self-ins. lCaa� SCF-C4312088 p,MP�u��:04/D1l2015 Attacb a copy af t6c workers' compensation poticy declaraHon page(showing the pulicy number and ezpiration date). Failure to seeure cave5age as raquired under Scctian 25A af MGL a I 52 cen 2ead W the imposition of criminal penaities of a fine up to$1,500.00 wd/ox one-year imprisonment, as well as civil penalties in the fo:m of a STOP�T✓QRK ORDElt and a fi� of up to$250.00 a day against the via2ator. Be advised tY�at a copy of tbis statement may be forward�l to the 08ice of Investigations of the DIA far iasvrance coverage verification. I do here er[i nder ' and pexaJd'e,s ofperJury that the infor�eafion prm$ded }�� S' ture: ' Da : � , � Pb �� S�" Ojj'Jcia!use on[y. Da xat wriXe in tkis ateq w 6e coletpleted Lp city or tonm afJ'tclet. City or Tawn: PermitlLicense tF Isswtng Autkority{circle onej: 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Licepsing Board 5.Selectmen's Oifice �.oca� Contact Person: Phone#: www.mass.gavktia Cur��lat�i ��r� Date of Incorpomtion: September T4, 1984 State of Iucorporation: I}elawaze Principal Address: 100 Crossing Boulevard,Framingham,MA 017Q2 Office TaJephone: 508-270-1400 Federal ID No: PRINCIPAL OFFICERS: Ani N. Haseates President& Chief Operating Officer 1$ L,overs Lane Southborough, MA 01772 Howard S. ltosenstein Treasurer 9 Hickory Road Souihboraugh, MA Ol?72 Mark G. Howard, Esq. Secretary 15 Greylock Road Wellesley, MA 02481 John T. Daly Assistant Treasurer 22 Thomas Road Berkley,MA 02779 Revlsed Il1/IlI3 Camberland Gul£Gmnp of Companies 100 Crossing Boulevazd,Framingham,hL�.017Q2 50$-276-74�