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�,e � _ '�� TOWN OF YARMOUTH B �vtt; Zg2014
� —_ - "3 1146 ROUTE 28,SOUTFI YARMOUTH,MASSACHUSE'I"I'S 0266424451 -
�: ., ,• CZ Telephone(508)39&2231,�. �za� `""°HEALTH DEPT.
'',<"`` Fas(508)760-3472 .
To: Yazmouth Busi�ss Establishments �
From: Bruce G.Murphy,Directar �
� Yaxmouth Aealth Department�
Date: November 7,2014
Subject: Increase in License/Permit Fees
please be aware thet the Yarmouth Board of Health,under the direc;tion of the Yarmoud�Board
of Selectmen, has raiud a nwiber of license and pexmit fces issued thmugh the Yarmouth
Health Depsrtment,effective 7anuary 1,2015.
Attached is the Yarmouth Buainess License/Permit Application for 2015.You will note that the
feea listed are the fees effecrive January 1, 2015. These fees will be due if you complete and
submit the application after Januaty 1,2015.
�However, if you fiilly complete the application, and submit it to ihe Yazmouth Health
Deparhnent wiTh all required certifications and worker's compeasation coverage information
(certificate of insurance OR completed affidaviQ prior to December 31. 2014. you will be
allowed to pay the 2014 rates for the following licenses:
C.lurent 2014 Fee
Public S'Nrimming ppp�s $ 80.00 �.R0.00
PublicWhirlpooWaporBatUs $ 80.00 �gp,Q�
Tobacco Sales $ 95.00
Motels $ 55.00
Food Service 0-100 Seats $ 85.00
Food Service Over 100 Seets $160.00 I60.00
Retail Food Service QS,000 sq.R. $ 80.00 � � AO,oA
Retail Food Service>25,000 sq.ft. $225.00
Other fees owed buT not listed above: �Co���+a� Nc.
Total fees owed for}rour establishment: ��FGp.00
NOTE: To be entitled to pay the current 2014 rates listed above, your
business application, food and/or pool certificetions, along with worker's
compensation informallon mast be received, or mailed (poatmarkedj on or
prior to December 31� 2014. [Those establishments which opert irs [he spring w!!1 be
allowed to provtde food m�d/or pool cerNfrcatiorxs�prior to�opening, however, yov.mast note
� � "�11 provide in the sprb+g prfor to opening"�on�the applicatianJ � � . �
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_ __ _ _ _ -- _ _ �:�-�'�a-
TOWN OF YARMOtJTH BOARD OF HEALTH � �
� ' APPLICATION FOR LICENSE(YERMIT-2fl15 u�.� Q � ?01+�
* Piease compiete form and attach all necessazy docwnents by Dec r IS 2Q 4.
Faiture ta do so will result in the return af your appiicat�aa p et{.{�q�.T'M DEPT.
ESTABLTSFiMENT NAME: - �
LOCATION ADDRESS:S' LtJ /L1 TEL.#: 8- �/O-O;tc>t,
MAILINGADDRESS: 5�3 �s'ucL' .�"s,(cw,,a k�.ec�/ !,t/�"cf �1r��1� O?�76s�
E-IYIAIL ADDRESS: 1�h�l�r s�i+�C oc,,,�r �a�
QWNER NAME: �
CORPQRATIdN NAME(tF PLICABLE :
MANAGER'S NAME: N TEL.#: Sca�-- 79C�-o Cx:>
MAILING AI)DRESS: 57 1 p -
POOL CERTIFICATIONS:
Tfie pool supervisor must be certitied as a Poo!Operatnr,as required by State law. Please iist the designated
Pool Operatur(s)and attach a copy of the certificatian ia this form.
1. t�;cha,L�. P�22�•�c7 z.
Pool operators must list a rninimum af two empto ces currentty certified in basic water safety,standard First Aid
and Community CardiopUtmonary Resnscitation�CFR�, having one certified employee on premises at all times.
Flease list t}te employees below and attach copies af their certificat�ons to tius form.The Health Departmeat will
not nse past y�rs' records. You muat provide new copies and maintain a file at your plaee of busineas.
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3. 4.
FOOD PROTECTIQN IviANAGERS-CEItTIFICAT[ONS:
All food service establislvnents are required to haue at least one full-time employee who is certified as a Faod
Proteciion Manager, as defined in the Stat�Sanita�y Code for Food Service Establishments, 105 CMR S9Q,Q00.
Please aitach copies of certification to this application. The Health Departmeat wil!nat ase past years'records.
You mast provide nesr cagies and maiataiu€�fite at your eatxblishment.
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PERSdN IN CHA�RGE: �jPt����y t'��,�{'�
Each food establishment must have at least one Person In C2�arge(PIC)on site during hours of aperation. ��������
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ALLERGEN CERTIFICATIONS: � �
AII foad service establishments are required ta have at least one full-rime employee who has Allergen certificatian,
as defined in the State Senitazy Code far Foai Service Establishments, 105 CMIL 540.009(G}(3}(a}, Please attach
copies af certification to ihis application. The Health Dep�rkment wiU not use past yeara'records. You muat
provide aew copiea and maintain a file at your establishment.
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HEIMLICH CEItTIFICATIQNS:
All food service establislunents wiYh 25 seats or more must have at least one emplayee trained in the Heimlich
Maneuver on the premises at alt timas. Please list your employees trained in anti-choking procedures below and
attach copies of empioyee certifications ta Uus farm. The Heaith Department will not use past years' records.
Yan muxt providc new eopies and maintain a file at your piace of business. �
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RESTAURANT SEATTNG: TOTAL# 3S
ADMINISTRATIOiY • �
Under Chnpter 152,Section 25C,Suhscction 6,the Town afYmmouShia nowteqnireAiw hplgissuaacq p2 renewa�
of any license or permit to opernte s busine,ys;£a person or compeny dues not have a C ertif'irste of Vl+orker's
Compen�tion Iusuiaaace. THE ATTACHEB SfATE WORKER'S CdMPENSATION IN3TTRANCyr
AFFIDAVtT MTJST BE COMPLETED AND 3YGNFA,pIt
CERT.OF 1NStIRANCE A'1'TACHED_ f
OR r
WORKER'S COMP.A,FFIDAVIT SI()NED AND ATTACE�D i�
Town of Yarmouth tarzes and liena must be paid prior to reuewel or 7asuxnce of yovr parmitc. PLEASE CHECTC
APPROPRTATELY IE PAID: �
'YES NO
MOTELS AN:D O'I"HEEk LODGING ESTABLISHMENTS �
'I'RANSIENI'OCCUPANCY: For purposee ofthe limitatioas ofMotel or Hotet use,Tiansient occupaucy shati bc
limited to the tem.gorary aad short term acc�ancY,ardioarily and cuxtomazily essocieted with mote]end hotel use.
Trau,vient occupants must have nnd be able to demonshate that they znaintain a pxincipat ptace of residence
eLsew2�e.Ttansievt occupaucy shell gcnerslly refer to cantiauous occupency o£noi more tLm tivrty{3p)days,aoJ
anap,gregateofnoEmorethanninetq(9p)dayawithinanysix(6)monthperiod. Uaeofaguestunitesaresidenceor
dwalliag unit shell not be cansidexed truasient. Occupmcy that ia subj�t to tlze collection of 1Zoom Occupnncy
Excise,as defined in M,G.L.a 6RG or 830 CMR 64G,as amended.,shall genera(ly be considere�i Transient,
PO{YLS
POQL OPENIP7G:All swnuming,wadit�g affilwkarlaools ufiichl�ave beenclosed foxthe sexsan mustl�inspeeted.
by the Heehh Department�rIor to a� peuit�g. Conmct tlie Health Depaatment to schedute the inapection three�(3)
dsys prior W openfn�.PL�ASE�r[QZ'�;;:Peogle am NOT allawed to sit in the pool area ur�l tbe poal has beea
inspected and openad.
P�L WATER TES'I7I+TG; 1lte waYox mnst be trsted farpseudomonas,tatal califann aud staucSacd plate ruunt
by a Btate certi8ed lab,and submimed to tho Health Depazwent three(3)daya prior to openic�g,end cguuurly
iLeieaRer. �
POOL CI,OSWG:Every owdoor in ground swiuuning pool must be dtained or covered within seven('n days of
elosing. ..
, FOOD SER1'ICE �
SEASONAL FCIOD SERVICE OPENtNG: �
AII faod service esteblishments must be ivspated by tbe Fleatth Department prior to opening. Pleax cantecf'the
Healtlt Depertment to achedule the inspechon tliree(3)days Pt'ior w openmg.
CAT'ERING POT,ICX:
Anyohe who caters witliln the Towd of Yarmouth must notify the Yazm.outh Heatth Depw�tment the
reqnired T �ca�y Food 3esvice Appfication farm 72 hours prior to tlre catered evenG These f�be
obtained at the Fleslth Deparlment,or&om tha Town's website at w�w.varmouth.maus under Health I)epartinent,
Downiaadabie Foffis.
F&02EN DESSERTS:
Fmzen desserts must be tested by a State certified lab prior ta apening and monthly thereafter,with sample msv2ts
submitted to the HealW Depa�ent. Fail�u�e to do so will result in the auspeneion or mvacation of yqta Frozen
I}esseit Permit twtil the above tecros have beea met.
QU1`BIDE CAD'k`S: �
Qutside cafes(i.e,outdoor seating with wa'sterlmaitress service},must Iffive prior appmvai fromdreBa9zc1 offleatth
� OUTDOOR COQ�NG: .
Outdoor coqldng,prepnmtion,or display of any food produci by aretail or food sezvice esteblIshwent is prohibited.
NO'ITCE:Paarits nm aunuaiiyfmm Jan�ry i w I?a�mC�er31. TT IS YQUR ItESPONSIHII.IT'Y TO RET'{JRN
THE COMPLE'1'ED RENEWAL APPLICATION(S)AND REQUIRED F'EE(S)BY DECF?MBBIt 15,2014.
ALS. RENQVATION$ TO ANY FOQD ESTAHI.ISFIMENf,�M4TB POOL (i.e., PAINTING, NEW
EQUIl'MEN1',ETC.),trfU9T BE RAPflRTED TO AND APPROVED BOARD qF Hf3ALTH PRiOIt
TO C4MMENCBMEPIT. }tfiNpVATIONS MAY REQ(7IRE A S �
DATE: I� � L 3TGNATURE:��� otret I�lot� f.�.�;C4C
PRINf NAME�TTPf.,E: y/
�.�im�aa .=i�5 �•� N r �
' � � The Commonwedih ofMassachustus - .
Depmbnex[oflndustrial Accidents �
O,�ce ojlmesUgations �
l Congress Stred,Suite 100
Boston,MA 02II4-Z017.
www.mass.gov/d3a
Workers'Compensation Insurance Affidavir General Bnsinesses .
Anolicant Information Please Print Le¢iblv
$USIIICSS/�Ig8IIIZ2hOi1N8D1C;Maplewood at Mayflower Place ALF LLC �
A��, 579 Buck Island Road �
Ciry/StatelZip: West xarmouth ru oz6�s phpae#:
Are you an employv?Check tLe aPProPriste hox Bosinms Type(TWnired): .
t.❑ I em a empluYa wit6 �Ployeas Cfiill andl 5. Q R�ail .
orpart-time)•" . 6. �RamwanVBWEatingFatablishment
2.� I eai a sok proprietor or pertnas6ip and have no �. �p�ee mdlor Sda(incL rml ostate,auto,em.)
employm vro�k3ng for ma in any upeciry. 8. �Non•p¢o5t .
[No wotkas'comp.;*n,•�re�equ'va!] .
3.❑ We are a coryontion end its officros have exeicised 9. Q Bntatainmmt
thair right of ezanption per c.152,§1(4�and we have 10.0 Mmufacn¢mg
no amptoyea.[No workas'comp.insurance required]•
4.� We aze a no¢profit orgeniration,s�8'ed by voluamas. 1].�Heehh Care
witL no�pioyxs.(No workas'comp.insurma ceq.] 12.0 Other
•Any appllmt thrt ehab bwt sl mu�[dao hll om tha eatiao belowalwwWg hm woel�sa'empmeWm P�tiry Into�m'ew.
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mgemvriw�oWd eLad box RI.
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Ia9iuenceCompanyNeme:wesco Ineurance Companv
��,SAd�: 800 Superior Avenue East 21st Floor
Cleveland OH 44119
CiTyBtnidZip:
PolicyMorSelf-ias.LiaM �'C3092965 _��y��: 6-1-15 �
Attee6 a copy otNe workera'oompensad poH deelantlon paga(ahawiog the poliey namber and aipintbn date}
Fai7un to secura cova+ga as raquired�mdu ecdon A of MGL a I52 ean leed m the�posiHon of crimiml pmetGn of a
5ne up to$I,500.00 nndlor ono-year' � en well ea civi]penalties in t6e form of a STOP WORK ORDER md a 6ne
of up to$250.00 e day against 1Le vio tl�at a copy of this stazemeut mty be forwarded m the 06m ot
Invesripflone of rLe DIA for ins�asnca ' ce6aa
I do pps�e�, a IQ�2¢ ry!T�tk�ji�ort provideda6ave fs bue axd eorrert
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Of/fclal ure only. Do nol wrNe tn th to bt compldtd by eky or towa olj'utaL
City or Towu• . � Permitli.iceou# . .
Iauing Aathority(drek one): �- �
L Board of Health 2 Ba'Id(ng Dopartment 3.Cky/forvn Clerk 0.Llcensfag Board 5.Saloehaeo's OtGm
6.OWer
CoumMPermn: - Phone#:
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