HomeMy WebLinkAboutApplication and WC i �
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�� -�'__ ��c TOWN OF YARMOUTH Ha�f ,
� —.-. �`y 1146 ROUTE 28, SOUTH YARMOUTH, MASSACHiJSETTS 02664-24451 - '
H i��rAceEEa��`� Telephone(508)398-2231, ext. 1241 Div s�n
FaY(508) 760-3472
To: Yarmouth Business Establishments RC�6C�oMC�D
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From: Bruce G. Murphy, Director
Yarmouth Health Deparhnent� HEALTH DEPT.
Date: November 7, 2014
Subject: Increase in License/Permit Fees
Please be awaze 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 Yannouth 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 Swimming Pools $ 80.00 0.00
Public WhirlpooUVapor Baths $ 80.00
Tobacco Sales $ 95.00
Motels $ 55.00 ,��,�p
Food Service 0-100 Seats $ 85.00
- Focd Sen=ice-��er 1J0 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: � I35•Oa
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 spring prior to opening" on the application.J
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yA N K E� U�u�cG t
a . TOWN OF YARMOUTH BOARD OF HEALTH
� � APPLICATION FOR LICENSE/PERMIT-2015 _� �x
'�t�� �
''' * Please complete form and attach all necessary document� cem�ier IS.20I4.
Failure to do so will result in the return of your application pa�ket. -
ESTABLISHMENT NAME: �/,4n/rl iri�1.,�%�' TAX ID• �'�/- '
LOCATIONADDRESS:�S� /L/.4in/ lJ� ��d?M�!/'li TEL.#: 5��� 77�' ��t3�
MAILING ADDRESS: S t
E-MAIL ADDRESS: �-✓�,y >/J/I�Y.E7c �` �i z .ve%
OWNER NAME:
CORPORATION NAME (IF APPLICABLE):
MANAGER'S NAME: ��`;Lh/�x% /3/�-�uC�f7� TEL.#: SD� 77�' Y�3,�
MAILINGADDRESS: -7 C�L-.C�Vl,C2?91� � l�l�L-�i �//12�7d��T:ff� �'/�9- /i�?3
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the desigiated
Pool Operator(s) and attach a copy of the certification to this form.
- - -
1. �,t�i[x' ��/ii St�/c% 2•
Pool operators must list a minimuxn 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.
L �..Jrsfti� ��s,2,�i',� 2. �,�}fCK' ��✓,U S
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 Establislunents, 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 Tile at your establishment.
1. 2•
PERSON IN CHARGE:
Each food establishment must have at least one Person In Chazge (PIC) on site during hours of operation.
L - __ _ �
�.
ALLERGEN CERTIFICATIONS:
All food service establishments aze 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 f►le at your place of business.
1. 2•
3. 4.
RESTAURANT SEATING: TOTAL#
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LJCENSE REQUIRED FEE P T#
B&B $55 CABIN $55 f MOTEL $110 ��6`��{
—INN $55 CAMP $55 �SWIMM[NGPOOL$110ea�1�`{
LODGE $55 TRA[LER PARK $105 _WHIRLPOOL $110ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
0-100 SEATS $125 _CONTINENTAL $35 NON-PROFIT $30
>1005EATS $200 COMMONV[C. $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
=<25,000 sq.fl. $150 —FROZEN DESSERT $40 _TOBACCO $110
NAME CHANGE: $15 AMOUNT DUE _ $ Z2-o �o 0
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***�*�*" ��� �'"`� � �����
C�Z�r�103�'-t�3 l2�31�I�
, .
ADMINISTRATION
t7nder Chaptar 152, Section 25C,Subseetion 6,the Town of Yarm<>uth is now required to hold issuance or renewal
of any license ar permit to operate a business if a person or company does nat have a Certificate of Worker's
Compensation Iqsurartce. THE ATTACHEI) STATE WOIiKL:R"�r' CCIMPENSATION INSUI2ANCE
AFFIDAVIT MUST BE COMPLETGD AND SIGNED, OI2
CERT. OP INS(JRANCE ATTACHED
OR
WQRKER'S C4MP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth taxes and liens must be paid prior fo renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
XES NO
MO'TELS ANT? QTHER L011GING ESTABLISHMEIVTS
TRANSIENT OCCUPANCY: For purposes ofthe Iimitations of Motel or Hotel use,Transient occupancy shall be
limited to the temporary and shorC term accupancy,ordinarily and custamarily assaeiated with matei and hatel use.
Transient occupants must have and be able to demonstrate that theq maintain a principal place of residenca
elsewhere.Transient oacupancy shaIl generally refer to continuous occupancy o£not more than thirty(30}days,and
an aggregate af not more than ninety(40}days within any six(6}month periad. Use of a guest unit as a residence or
dwelling unit sha11 not be considered transient. Occupancy that is subject to the callection of Roon� Occupancy
Excise, as defined in M.G.L. c. 64G or $30 CMR 64G, as amended, shall generatly be considered Transient.
POOLS
POOL OPENINCx:All swimming,wading and whirlpools which have been closed for the season rnust be inspected
by thc Health I}epartment prior to opening. Contact the Health Department to schedule the inspection three(3}
days prior to opening. PLEASB NOTF: People are NOT allowed to sit in the poal area until tkse paol has been
inspected and opened.
POOL WATER TESTING: The water must be tested for pseudomonas,total colrform and standazd plate count
by a Statc certified lab, and submitted to the Health Department three (3) days prior to opening, and quarterly
thereafter.
POOL CLOSING: Every autdoor in ground swimming pool rnust be arained or covered within seven(7)days of
closing.
FOOD SERVICE
SEASONAL TOOD SERVICE OPEIVING:
All foad service establishments rnust be inspected by the Health Department prior ta opening. Please contact the
Health Department to schedule the inspection three (3) days prior to opening.
CATERING POLICY:
Anyone who caters within the Town af Yarmauth must natify the Yarmouth Heaith Department by filing tha
required Temporary Faod Service Application form 72 hours prior to the catered event. These forms can be
obtained at the Health I)epartment,or from the Town's website at wtivw.yarmouth.maus under Health I}epartsnent,
Downioadable Forms.
FROZEN DESSERTS:
Frozen desserts must be tested by a State certified lab prior to opening and tnonthly thereafter,with sample results
submitted to fhe Health Deparhnent. Failure to do so will result in the suspension or revacation of your Frpzen
Dessert Fermit until the above terms have been met.
OUTSIDE CAFES:
C}utside cafes(i.e.,autdoar seating with waiterlwaitress service},must have prior approval from the Board ofHeatth.
OUTD4CIR COOKING:
Outdoor cooking,preparation,�r display of any fpod product by a retail ar food service esYablishment is prohibited.
NQTICE:Pernuts run annually frorn January 1 ta December 31. IT IS"YOUR I2ESPQNSIBILITY TQ R�TURN
THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 15, 2014.
ALL REN4VATIONS TO ANY POOD BSTABLISHMENT, MQTEL OR PQOL (i.e., PAINTING, NEW
EQUIPMENT, ETC.), MUST BE REPQRTED'TO AND APPROVEI7 BY THE BCIARD OP HBALTH PRIOR
T{J C4MMENCEMENT. RENOVAT'IONS MAY REQUIRE A SITP PLAN.
DATE: SIGNATURE:
PRINT NAME & TITLE:
Rav. 11l03/14
' � t� The Commonwealth ofMassachusetts
Department of Industrial Accidents
Office oflnvestigations
' 1 Congress Street, Suite l00
Boston, MA 02114-2017
www.inass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Analicant Information Please Print Legiblv
Business/Organization Name: y�/tJ,�' ►�/«�� /�/frl�G
Address: �Ts /✓/s3-� � S�
Ciry/State/Zip: �i.� �'�,����}� �¢ D Z�7 3 Phone#: ,57)�-77S �-2��3�
Are y an employer? Check the appropriate bos: Business Type(required):
1. I am a employer with�employees(full and/ 5. ❑ Retail
or part-rime).* 6. ❑ RestaurantlBaz/Eating Establishment
— — - - _ .
2. �am a soIe 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] g• ❑Non-profit
3.❑ We aze a corporation and its officers have exercised 9. ❑ Entertainment
their right of exemption per c. 152, §1(4), and we have 10.0 Manufacturing
no employees. [No workers' comp. insurance required]*
4.❑ We aze a non-profit organization, staffed by volunteers, 11.❑ ealth Caze
with no employees. [No workers' comp. insurance req.] 12. Other /�77�'j
*Any applicant that checks box#1 must also 5ll out the section below showing their workers'compensa[ion policy infolmation.
**If the coxporete office=s have exempted themselves,but the corporation has other employees,a workers'wmpensation policy is required and such an
organization should check box#l.
I am an emp[oyer that is providing workers'compensation insurance for my emp[oyees. Below is the policy informarion.
Insurance Company Name: �/ f�l �/:'✓1118L— >N.S� �O
Insurer's Address: /`�U /3UX h�%��
City/State/Zip: G(J'C�/�jLl�ik� � J�l� ��/���/��
�Ui y �
Policy#or Self-ins. Lic. # A 1�C "'� '� 7�L��Z�s�S�cpiration Date: �/fr �(_S
Attach a copy of the workers' compensation policy declaration page(showing the policy number and eapiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-yeaz imprisonment, as well as civilpenalties in the form of a STOP WORK ORI�ER 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
Invesrigations of the DIA for insurance coverage verification.
I do hereby cenify,und - pains and penalties o rjury that the information provided above is true and correct.
Si ature: � d� Date: � � � d �
Phone#: ' ' �c�
O�ci e only. Do not write in this area,to be completed by city or town officiaG
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2. Building Department 3. City/Town Clerk 4.Licensing Board 5. Selectmen's Office
6.Other
Contact Person: Phone#:
www.mass.gov/dia