HomeMy WebLinkAboutApplication and WC oF'YAR* II
, �� --�"_ �a TOWN OF YARMOUTH H��f ,
�; ��`j„ 1]46 ROUTE 28, SOLJTH YARMOUTH,MASSACHUSETTS 02664- 1 Health
• �, ts • Telephone(508)398-2231,ext. 1241
T�"c"` Fa�c(508) 760-3472 Division
To: Yazmouth Business Establishments io�y s {�zzA ��������
� JAN 'i 3 2015
From: Bruce G. Murphy, Director
Yarmouth Health Department� HEALTH DEPT.
Date: November 7, 2014
Subject: Increase in License/Permit Fees '
--__ — - - -- _ __ j
Please be aware that the Yazmouth Board of Health, under the direction of the Yazmouth Board
of Selectmen, has raised a number of license and pemut fees issued through the Yazmouth
Health Department, effecrive Januazy 1, 2015.
Attached is the Yazmouth Business License/Pernut Application for 2015. You will note that the 'i
fees listed are 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 �I
Department with a11 required certifications and worker's compensation coverage information '
(certificate of insurance OR completed affidavit) orior 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 I
� �� �� �,blac WhirlpooUVapor Baths $ 80.00 I
r � ��obacco Sales $ 95.00 i
` (Mvte.; � $ 55.00
=- -100 Seats $ 85.00 8S•00
rv . .., ,- :
$&fJ Sosts,- — — _$ib'J.c'JO- ' - -- -
+> �etail FoGd Service<25,000 sq. ft. $ 80.00
`'"'� Re�ood Service >25,000 sq. ft. $225.00
Other fees owed but not listed above: ��O,p p i
v?�` " �� Total fees owed for your establishment: ��`�5•� I
_� I
NOTE: To 'be entitled to pay the current 2014 rates listed above, your I
business application, food and/or pool certificafions, along with worker's
compensation information must be received, or mailed (postmarked) on or
pl'ioe to DeCember 31, 2014. [Those establishments which open in the spring will be �
allowed to provide food and/or pool certifications prior to opening, however, you must note
"Will provide in the spring prior to opening" on the application.J
BGM/maf '
�
�
I
. ' i
« TOWN OF YARMOUTH BOARD OF HE
��� > * APPLICATION FOR LICEIV$�,� 1� a��'��� `� �`��� ��
� !
Please complete form and attach all ne,ce ocum �b� ece er � ,
Failure to do so will result in the�eturn_of�our application pac e . '
x
� ESTABLISHMENT NAME: � - ,
LOCATION ADDRESS: 0 J�. v`ft TEL.#: � '
MAILING ADDRESS: f'AM� '
E-MAIL ADDRESS: '
OWNER NAME: f� � �`j-}��f}S �
CORPORATION NAME (IF APPLICABLE): j
MANAGER'S NAME: TEL.#:
MAILING ADDRESS:
POOL CERTIFICATIONS:
The pool supervisor must be certi�ed as a Pool Operator,as required by State Iaw. Please list the designated ,
Pool Operator(s) and attach a copy of the certification to this form. �
--------- - - -
- - -- -- _ _ __ -- --
1. 2
Pool operators must list a minimuxn 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 file at your place of business.
l. 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 i
�Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000.
Y'lease 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.
i.' 2.
� . I
PER`SON IN E:
Eac�food establi ' ust have at least one Person In Charge (PIC) on site during hours of operadon.
�--�"'';l. '"�"""�,� li� - - - __ - Z. __ _ - _ —. - - _
ALLERGEN CERTIFICATIONS: '
All food servic� tablishments aze required to have at least one full-time employee who has Allergen certification,
as defined' Sfiate Sanitary Code for Food Service Establishments, 105 CMR 590.009(G)(3)(a). Please attach
co�i ertification to this application. The Health Deparhnent will not use past years' records. You must
� �rovide new copies and maintain a file at your establishment.
� ,�1. 2.
� ;.� � HEIMLICHCERTIFICATIONS: �
All food service establishments with 25 seats ar 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 tile at your place of business.
1. 2.
3. 4• i
RESTAURANT SEATING: TOTAL#
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
B&B $55 CABIN $55 M01'EL $110
INN $55 CAMP $55 SW[MMINGPOOL$110ea
LODGE $55 TRAILERPARK $105 _WHIRLPOOL $ll0ea
FOOD SERVICE: � �
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
�0-100SEATS $125 (S�/Sv CONTINENTAL $35 NON-PROFIT $30
>100 SEATS $200 �COMMON VIC. $60 �I _WHOLESALE $80
— —RES[D.KITCHEN $80
RETAIL SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# L[CENSE REQCiIRED FEE PERMIT#
<50 sq.ft. $50 >25,000 sq.ft. $285 VEND[NG-FOOD $25
<25,OOOsq.ft. $150 —FROZENDESSERT $40 _TOBACCO $110
NAME CHANGE: $l� AMOLTNT DUE _ $ l SS-04 ��'.
****•PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***"* '��,
}
: I
, ;
-:ri, : ,;,_: ADMINISTRATION �
Under Ch2pter 152,Section 25C, Subsection 6,the Town of 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 ATTACHED STATE WORKER'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR
CERT. OF INSURANCE ATTACHED '
OR �
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED �
Town of Yarxnouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES NO
MOTELS AND OTHER LODGING ESTABLISHMENTS
TRANSIENT OCCUPANCY: For ptuposes ofthe limitations of Motel or Hotel use,Transient occupancy shall be
limited to the temporary and short term occupancy,ordinarily and customarily associated with motel and hotel use.
Transient occupants must have and be able to demonstrate that they maintain a principal place of residence
elsewhere.Transient occupancy sha11 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
dwelling unit shall not be considered transient. Occupancy that is subject to the collection of Room Occupancy
Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient. �
I
POOLS
POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected
by the Health Department prior to opening. Contact the Health Department to schedule the inspection three(3) �
days prior to opening. PLEASE NOTE: People are NOT allowed to sit in the pool area until the pool has been �
inspected and opened.
POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate co
by a State certified lab, and submitted to the Health Department three (3) days prior to opening, an y
thereafter.
,
POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered wi � seven(7)days of
closing. •- -
FOOD SEAVICE - - - ---- �--� 1
SEASONAL FOOD SERVICE OPENING: � � - ��
All food service establishments must be inspected by the Health Department prior to openiug. P�ease contact the
Health Deparhnent to schedule the inspection three (3) days prior to opemng.
CATERING POLICY:
Anyone who caters within the Town of Yannouth must notify the Yarmouth Health Department by �
required Temporary Food Service Application form 72 hours prior to the catered even�: These forms can b�
obtained at the Health Department,or from the Town's website at www.yarmouth.ma.us under Health Departmen
Downloadable Forms.
.�
FROZEN DESSERTS: '-•
Frozen desserts must be tested by a State certified lab prior to opening and monthly thereafter,with sample results
submitted to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen
Dessert Pernut unril the above terms have been met.
OUTSIDE CAFES:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Boazd of Health. ,
OUTDOOR COOHING:
Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. I
_ _ --___ - ._ _ _ _ _—_ _ _ _ ---_
_---- ___
NOTICE:Pemuts run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETCJRN
THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 15, 2014.
ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY REQUIRE t�ITE PLAN.
DATE: /—� �i — ! � SIGNATURE: �l �' X��, ��� �1-�
PR1N"I'NAME& TITLE: (�A S l �.14 S P � I C � � \ I/a �
�
Rev. 11/03/14
�
' ' � The Commonwealth ofMassachusetts I
' Department oflndustrial Accidents
Offace oflnvestigations ,
1 Congress Street, Suite I00 '
� Boston, MA 02114-2017 '�
www.mass.gov/dia �
Workers' Compensation Insurance Affidavit: General Businesses (
Aunlicant Information Please Print Leeiblv �I
Business/OrganizationName:�dL`�f r/S'£ � ��Z�
Address:�0a� O�G ��
O�G6y/
City/State/Zip: D �U Phone#: JfU�d'3��— G�.`fY �
Are ou an employer?Check e appropriate bos: Business Type(required): �
1.[� I am a employer with�employees(full and/ 5. ❑ Retail �I
or part-time).* 6. RestaurantBar/Eating 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 aze a corporarion and its officers have exercised 9. ❑ Entertainment
their right of exemption per c. I 52, §1(4),and we have 10.❑ Manufacturing I
no employees. [No workers' comp. insurance required]* 11.� Health Caze
4.❑ We aze a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp. insurance req.] 12.❑ Other
•Any applicant thffi checks box#I must aLso 5ll out the section below showing the'v workers'compensation policy information.
•'If the cocporete officers kiave exempted themselves,bia.the corpora6on has otha employees,a workers'compensazion poficy is required and such an
organization should check box#I. �
I am an employer that isproviding workers'compensation insurance for»ry employees. Below is the policy information. I
' Insurance Company Name:�_( ���T Y �V �U (� �
�' Insurer's Address: � iJ g � � �S c9 2
� c,Tyisraz�z�P: A d..l1�V` �J �-4 c��i �?2 � � �o rL
� Policy#or Self-ins.Lic. # f,- �S2.i 1 O '��?- f1 ('�(� G Expiration Date:
At�a copy of the workers' co�mpe ti n policy declaration page(showing the policy nnmber and ezpiration date).
_,:,,,,,,Fgili�, e covera e as reyuired under Secuon 25A of MGL c, 152 can lead to the im�osirion of criminal penalties of a _
f�e�tp to$1, �D.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP V✓ORK ORDER and a fine I
of'upto$250.00 a day against the violator. Be advised that a copy of this statement may be forwazded to the Office of ,
' Investigations of t�,te DIA for insurance coverage verification. '
� '
I do hereby certify,uM r thepains aedpenalties ofperjury that the dnformation provided above is true and correcG �I
� Sienature•� � � ���D � Date•C� I' � — � � ��I
r
Phone#: d II
Ojfcial use only. Do not write in thu area,to be completed by city or town officiaL
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