HomeMy WebLinkAboutApplication and WC pF'Y`�R
�� ._�`_ ''�c TOWN OF YARMOUTH Ha�f
� �. � 1146 ROUTE 28, SOUTH YARMOUTH, MASSACH[TSETTS 02664-24451 -
Y. 4� ev '$ Telephone(508)398-2231, ext. 1241 Health
t�,°µtt Fas(508)760-3472 Division�
To: Yannouth Business Establishments C Roo ksp.w I N t�l
From: Bruce G. Murphy, Director � �����d�D
Yannouth Health Department� Utl: � 1 L014
Date: November 7, 2014 HEALTH DEPT.
Subject: Increase in License/Permit Fees
Please be aware that the Yannouth Boazd of Health, under the direction of the Yannouth Boazd
of Selectmen, has raised a number of license and permit 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 applica6on after January 1,2015.
However, if you fully complete the application, and submit it to the Yazmouth Health
Department with all required certifications and worker's compensation coverage information
(certificate of insurance OR completed �davit) arior 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 W1urlpooUVapor Baths $ 80.00
Tobacco Sa1es $ 95.00
Motels $ 55.00
Food Service 0-100 Seats $ 85.00 �85-00
Food Service Over I00 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: $ I15•00 u���c�.koN dic .
Total fees owed for your establishment: 20 0 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 DeCembeP 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 spring prior to opening" on the application.J
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d TOWN OF YARMOUTH BOARD OF HEALTH
��� APPLICATION FOR LICENSE/PERMIT -2015 Utl: � 1 ZU14
`� * Please complete form and attach ali necessary documents by Dece ber 4
Failure to do so will result in the return of your application pa k t. EPT.
ESTABLISHMENT NAME: T ID:
LOCATION ADDRESS: I 8 !o • � TEL.#: SD S '�G,.�' I!l
MAILING ADDRESS:
E-MAIL ADDRESS: L . C
OWNER NAME: E u
CORPORATION NAME (IF APPLICABLE):
MANAGER'S NAME: 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 Operato s) and attach a copy of the certification to this form.
1 �� Z:
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Pool operators must list a minimum of two employees currently certified in basic water safety, standazd 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 �le at your place of business.
i. 2•
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. � ria n� �'' Ow � �° 4 2.
PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
/9 , .
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 all 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.
1. / V /!'T 2.
3. 4•
RESTAURANT SEATING: TOTAL # �i5�
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
B&B $55 CABIN $55 MOTEL $I10
INN $55 CAMP $55 SWIMMWGPOOL$IlOea
=LODGE $55 L —009 =TRAILER PARK $105 _WHIRLPOOL $110ea.
FOOD SERVICE:
LICENSE REQUIRED FEE P$RMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
�0-IOO SEATS $125 �# �S—I`IS CONTINENTAL $35 NON-PROFIT $30
>]00 SEATS $200 �COMMON VIC. $60 � -r(s _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
_Q5,000 sq.ft. $150 —FROZEN DESSERT $40 _TOBACCO $ll0
NAMECHANGE: $15 AMOUNTDUE _ $ Z O .�O
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** ' �"` ���'���v
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ADMINIS`['RATIOIV'
Under Chapter 152,Section 25C, Subsection 6,the Town of Yarmouth is now required ta hol,d issuance or renewal
af any license or pennit to operate a business if a persan or company does not have a Certificate of Worker's
Com}�ensat�on Znsurance. THE ATTACHEA STATE WQI2KER'S COMPENSATIdN INSU72ANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR
CERT. dF INSURANCE ATTACFTED
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTA�CHED
Town of Yazmouth taxes and liens must be paid prior to renewal or issuance of your pertnits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES N4 _
MOTELS AND OTHER I�ODGING ESTABLISHMENTS
TRAIVSTENI'OCCUPANCY; Far purposes of the limitations ofIvlotel or Hotel use,Transient occupancy sha71 be
lirnited to the temporary and short term occupancy,ordinarily and customarily associated with motel and fiotel use.
T'ransient occupants must have and be able ta demanstrate that they maintain a principat place of residence
elsewhere.Transient occupancy shall generally refer to continuaus occupaticy 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
dwelling unit shall nof be considered transienf. Occupancy that is suhject to the callection of Raom Qccupancy
Excise, as defined in M.G,I,. c. 64CJ ar 834 CMR 64G, as arnended, shall generally be considered Transient.
POOLS
POOL QPENING:All swimming,wading and whirlpools which have been closed far the season must be inspected
by the Health Departsnent priox to opening. Contact the Health Dapartment to schedule thc inspection three(3)
days prior to opening. PLEASE NOTE: Peaple are NO"I'allawed to sit in the pool area until the pool has been
inspacted and opened.
PQOL WATER TESTING: The water must be tested for pseudomonas,total caliform and standard plate count
by a State certified lab, and submitted to the Ilealth Departrnent three (3} days prior to opening, and quarteriy
Yhereafter.
P4C1L CLOSING: Euery outdoor in graund swimming paal must be drained or covered within seven(7)days of
closing.
FOOD SF,I2VICE
SEASONAL FOOD SERVICE QPENING:
All food service establishments must be inspected by the Health Department prior to opening. Please contaet the
Health Department to schedule the inspection thz�ee{3)days prior to opening.
CATERiNG P4LICY:
Anyone who caters within the Town of Yarmouth must notify the Yumouth Health Deparhnent by filing the
reqwred Temparary Food Service Applacation form 72 hours priar ta the caYered event. These forms can be
obtained at the Health Department,or from the Town's website at www.varrnouth.ma.us under Health Deparhnent,
Downloadable Forms.
FROZEN DESSERTS:
Frozen desserts must be tested by a State certified 1ab prior to apening and monthly thereafter,with sample results
submitted to the Health Depazcment. FaiIure to do so will result in the suspension or revocation of your Frozen
Dessert Permit untii the above terms have been met.
OUT'SIDE CAFES:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior appraval from the Boazd of Haalth.
OUTDOOR COOHING:
Outdaor cooking,preparation,or display ofany faod prodnct by a retail ar food service establishment is prohibited.
NOTICE:Pertnits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO R ETUF2N
THE COMPLETEI}R.ENEWAL APPLICATIflN{S}AND REQUIRED FEE(S}BY DECEMBER 15, 2014.
ALL I2ENOVATIONS Td ANY FOOD ESTABLISHMENT, MO"CEL R POOL (i.e., PAIN7"ING, NEW
EQIIIPMFNT,ETC.}, MUST BE REPORTED TO�ND APPRdVED BY HE BOARD OF HEAI,TH PRFt3R
TO COMMEN EMENT. RENOVATIQNS MAY RE UIRE A SITE P .
llATE: a? SIGNATURE:
PRiNT NAME& TITLE:_�r 1_�.Li_ p _
Rev.iil03fl4
' ` t� The Commonwealth ofMassachusetts
Department of Industrial Accidents
Office of Investigations
� I Congress Street, Suite l00
Boston, MA 02I14-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Apalicant Information Please Print Legiblv
Business/Organization Name: �-�,,,,4 ��,�, �
d.�,�..�
Address: ��6 Main Street / Route 6A
City/State/Zip: Phone #: , �Q p � _��p o1 ' � /� 1
Are you an employer? Check the appropriate box: Business Type(required):
1.❑ I am a employer with employees(full and/ 5. ❑ Retail
orpart-rime).* 6. ❑ RestaurantBaz/Eating Establishment
— —
2.� I am a sole proprietor or partnership and have no 7, � O�ce 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 aze a corporarion and its officers have exercised 9. ❑ Entertainment
their right of exemption per c. 152, §1(4), and we have 10.❑ Manufacturing
no employees. [No workers' comp. insurance required]* I 1.� Health Care
4.❑ We aze a non-profit organization, stafFed by volunteers,
with no employees. [No workers' comp. insurance req.] 12.❑ Other
*Any applic�t that checks box#1 must also fill out the sec[ion below s6owing their workers'compeasation policy informatioa.
**If the co:pornte officeis have exempted themselves,but the corporatlon has other employees,a workers'compensation policy is required and such an
organization should check box#1.
I am an emp[oyer that is providing workers'compensation insurance for my emp[oyees. Be[aw is the policy informatdon.
Insurance Company Name:
Insurer's Address:
City/State/Zip:
Policy#or Self-ins. Lic. # Expiration Date:
Attach a copy of the workers' compensation policy declaration page(showing the policy nnmber and eapiration date).
Failure to secure coverage as require_d_under Section 25A of MGL c. 152 can lead to the imposition of criminal penakies of a
__ - _ _ _ - - -
fine up to $1,500.00 and/or one-year 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 forwarded to the Office of
Investigations of the DIA for ins ce coverage verifica6on.
I do hereby ce Jy,under the p ins an pena[ties ofperjury thai the information provided abov is true nd c rect.
Si ature: Date: '� �
Phone#:
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of HealtL 2. Building Department 3. City/Town Clerk 4.Licensing Board 5. Selectmen's Office
6. Other
Contact Person: Phone#:
www.mass.gov/dia