HomeMy WebLinkAboutApplication and WC O��Y'9!R
�� -�" _: �`�� TOWN OF YARMOUTH Ha�f
� —._ ` �`j ll 46 ROUTE 28, SOUTH YARMOUTH,MASSACHLJSETTS 02664-24451 '
� �,rr tEa`�� 'r Telephone(508)398-2231, ext. 1241 Div s�n
"`" Fas(508) 760-3472
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To: Yarmouth Business Establishments -�rE Ki NGs I N N�
� Utt; 3 0 Y014
From: Bruce G. Murphy, Director
Yazmouth Health Department� HEA�TH OEPT.
Date: November 7, 2014
Subject: Increase in License/Permit Fees
Please be aware that the Yarmouth Boazd of Health, under the d'uection of the Yannouth Boazd
of Selectmen, has raised a number of license and pernut fees issued through the Yarmouth
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 Yannouth Health
Department with all required certifications and worker's compensation coverage information
(certificate of insurance OR compieted �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
Motels $ 55.00
Food Service 0-100 Seats $ 85.00 SS.00
Food Ser�•ice Over 1�0 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: � t lS.ao 6+-e;ar�Koni v�c.
Tota1 fees owed for your establishment: �200.00
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
priol' to DeCember 31, 2014. [Those establishments which open in the spring will be
allowed to provide food and/or pool certif:cations prior to opening, however, you must note
"Will provide in the springprior to opening" on the application.J
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a TOWN OF YARMOUTH BOARD OF HEALTH
k� APPLICATIONFORLICE�IS�' I'I"�„Z,�'1�. Utl: ��Q 1��4
" * Please complete form and attach ali ngcess����Yn�ts by-De mber 15 20I4PT.
Failure to do so will result in the return ofyo�r application c
ESTABLISHMENT NAME: Ti-� �- K�,.�c s i.,��� TAX ID: �
LOCATION ADDRESS: 1 i 2 2ou�r � a TEL.#: S v 8 ?7�`7! o%
MAILING ADDRESS: Y a�v.�—c�+ ��0 2� c5 2��S
E-MAIL ADDIZESS: �� �c�� � ,�,�r—r�nc- c��� � A o �� • c_o� .
OWNERNAME: i'�.,�� n� �o c�,a.�r1 t��;,.��-s
CORPORATION NAME (IF APPLICABLE):
MANAGER'S NAME: .c�,s �30�t= - TEL.#: _
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, standazd 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. NIA • 2.
3. 4.
FOOD PROTECTION MANAGERS - CERTIFICATIONS:
All food service establishments aze 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 �le at your establishment.
1. ��ui,- �.t w�S 2.
PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
L Z• .
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 �le 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-chokmg procedwes below and
attach copies of employee certifications to this form. The Health Deparhnent 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�! LICENSE REQUIRED FEE PERMIT#
I B&B $55 I - O(o CABIN $55 MOTEL $110
INN $55 CAMP $55 SWIMMINGPOOL$110ea
LODGE $55 _"CRAILERPARK $105 _WHIRLPOOL $110ea
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# L(CENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
�0-100 SEATS $125 l5� �f:� CONTINENTAL $35 NON-PROFIT $30
>100 SEATS $200 �COMMON VIC. $60 i �D _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.R. $I50 —FROZENDESSERT $40 _TOBACCO $110
NAME CHANGE: $15 AMOUNT DUE _ $ Z4p .00
*"*"*PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** I�C � � Z��' �d
c,1��3�tz ��a 8��`�
ADMINISTRA.TION *
Undex Chapter 152,Sectior�25C, Subsection 6,the Town of Xarmouth is now required to hold issraance or renewal
oP any license or permit to operate a business if a person or company does npt have a Certificate of Worker's
Compensation Insurance. THE ATTACHED STATE W4RKER'S COMPENSATION 3NSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, C1I2
CERT. OF INS[TRANCE ATTACHED
OR
WORKER'S COMP. AFFII)AVtT SIGNED ANT) ATTACHED
Town of Yannouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
�1PPROP.RIATEI,Y IF PAID:
YES v'� NO
MOTELS ANA OTHGR LODGING FSTABLISFIMENTS
TI2ANSIENT OCCITPANCY: For putposes ofthe limitations of Motel or Hotel use,Transient occuparicy shall be
lirnited to the temporary and short term accupancy,ordinarily and customarily associated with motel and hqtel�ise.
Transient oceupants must have and be abie to demonstrate that they maintain a principal place of residence
elsewhere.Transient occupancy shall generally refer to continuous occupancy of not more than thirty(30)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
dweIling unit shall not be considered transient. Occupancy that is subject ta the collectian af Room dccupancy
Excise, as defined in M.G.L. c. 64G or$30 CMIL 64G, as amended, shall generally be conszdered Transient.
P40LS
Pd{}L 4PENING:All swimming,wading and whirlpools which have been closed far the season must be insgected
by the Health Department prior to opening. Contact the Healtb DepaztmenC to schedule the inspection three(3)
days prior to opening. PLEASE NOTE: People are NC3T allowed to sit in the pool area untit the pool has been
inspected and opened.
POOL WATER TESTING: The water must be tested for pseudamonas,total coliform and standard plate count
by a State certified lab, and submitted to the Health Department three (3) days prior to opening, and quarterly
therea$er.
P(}C1L CLQSING: Every outdoor in ground swimming paol must be dzained ar couered within seven{7)days of
closing.
FO011 SF.RVICE
SEASONAL FOC1D SERVICE OPENING:
All faod service establishments must be inspected by the Health Department prior ta opening. PleaSe contact the
Health Department to schedule the inspection three{3) days priar to apening.
GATERING k'OLICX;
Anyone who caters within the Town of Yarmouth rnust notify the Yarmoufh Health Department by filing the
required Tempo Food Service Application form 72 hours prior to the catered event. These forms can be
obtained at the He�a th Department,ar fram the Town's website at www.yarmouth.ma.us under Health 17epartment,
Dowxilaadable F'orms.
FROZEN DESSE12T5:
Frozen desserts must be tested by a State certified lab prior to opening and rnonthly thereafter,with sample results
submitted to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen
I7essert Permit until the abave terms hava been met.
OUTSIDE CAFES:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health.
OUTDOC)R COOHING:
Outdoor cooking,preparation,or display of any food product My a retail pr food service establishmettt is prohibxted.
NOTICE:Permits run annually from January 1 ta December 31. IT IS YOUR I2ESPONSIBILITY TO RET'URN
THE CdMPLETEI}RENEWAL APPLICATIOIV(S}AND R�QUIREI?FEE{S} BX DECEMBER 15, 2Q14.
ALL RENOVATIONS TO ANY FOOD ESTABY�TSHMEI� , MOTEL OR POOL (i.e., PAINTING, NEW
EQIIIPMENT, ETC.}, MUST BE REPORTED TO A�iD AP�OVED BX THE BOARI}C}F HEALTH PRIOR
TO COMMENCE1v1ENT. RENOVATICINS MAY iJI A 3ITE PLAN.
DAT�:'C�cc: �."lrN2�iL�SIGNATURE: -��. :,.
PRINT NAME& TITLE: �q,..�t,., �.....t�3yS p cE,.�c�s�_
� Rev. ll103t74 ^
' ' � The Commonwealth ofMassachusetts
Department of Industrial Accidents
Offace of Investigations
I Cangress Street, Suite I00
Boston, MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Aunlicant Information Please Print Legiblv
Business/OrganizationName: �N� vc-r-,.�c�s �-,.,a�
Address: I �� �Zou—c�� 6A `�larz�c�;r� avrL-7 ��-�,� c�:1— �"IS
City/State/Zip: O 2 ��S Phone #: �p g 3� S `i� o�t ,
Are you an employer? Check the appropriate box: Business Type(required):
1.❑ I am a employer with N p employees(full and/ 5. ❑ Retail
�r�art_time�.* 6. ❑ RestaurantlBaz/Earing 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 required] 8• ❑ Non-profit
3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment
their right of exemption per c. 152, §1(4), and we have �0.0 Manufacturing
no employees. [No workers' comp. insurance required]* 11.❑ Health Care
4.❑ We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp. insurance req.] 12.❑ Other P��c> .a,-�r7 ��+�n��-1S� .
'Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy infotmation.
*'If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an
organiTetion should checkbox#1.
I am an employer that is providing workers'compensation insurance for my employees Below is the policy information.
Inswance Company Name: t�!�/�
Insurer's Address:
City/State/Zip:
Policy#or Self-ins. Lic. # Expiration Date:
Attach a copy of the workers' compensation policy declaralion page(showing the policy number and expiration date).
Failure to.secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalries of a
- -
fine up to$1,500.00 and/or one-yeaz imprisonment,as well as civil penalties in the form of a STOP WORK ORD�$and a�ine-
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
Invesrigatio e A forinsurance coverage verifica6on.
I do hereby ce ' ,u der the pains and penalties of perjury that the dnformation provided above is true and correct.
S�ature: l � Date: ��t u�� 2S���j
Phone#: e-�- U�6 3'( �—j �1 l � �
Official use only. Do not write in this area,to be completed by city or town offaciaL
City or Town: PermitlLicense#
Issuing Authority(circle one):
1.Board of Health 2. Building Department 3. City/'I'own Clerk 4.Licensing Board 5. Selectmen's Office
6.Other
Contact Person: Phone#:
www.mass.gov/dia