HomeMy WebLinkAboutApplication and WC F � I
o .�_YAR� I
n�� _ _ �_� TOWN OF YARMOUTH H�of
� � `j I 146 ROUTE 28, SOUTH YARMOUTH,MASSACHUSETTS 02664-24451 - ';
�. *,r ��� :r Telephone(508)398-2231,ext. 1241 Di s�n
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To: Yazmouth Business Establishments MA�{FtA W ER I N N ,AN '� ��y �
_ Nf� tir+;�� c5M'i
^ r-��� � HEALTH DEPT, i
From: Bruce G. Murphy, Director ���
Yarmouth Health Department� � � �'� ;
Date: November 7, 2014 k , � �'"� '
� `.'�,����p ..�
Subject: Increase in License/Permit Fees
,
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Please be awaze that the Yazmouth Boazd of Health, under the direction of the Yarmouth Boazd '
of Selectmen, has raised a number of license and pernut fees issued through the Yarmouth !,
Health Department, effective January 1,2015. I
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i
Attached is the Yarmouth Business License/Permit Application for 2015. You will note that the i
fees listed aze the fees effective January 1, 2015. These fees will be due if you complete and I
submit the application after January 1, 2015. i
However, if you fully complete the application, and submit it to the Yarmouth Health i
Department with all required certifications and worker's compensation coverage information
(certificate of insurance OR completed affidavit) nrior to December 31, 2014, you will be
allowed to pay the 2014 rates for the following licenses:
Current 2014 Fee I
Public Swuvming Pools $ 80.00
Public WhirlpooUVapor Baths $ 80.00 '
Tobacco Sales $ 95.00
Motels $ 55.00 SS.
Food Service 0-100 Seats $ 85.00
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- �otrd Service Ovei IODSeat§_ �160.60 -
Retail Food Service CL5,000 sq. ft. $ 80.00 I
Retail Food Service>25,000 sq. ft. $225.00
Other fees owed but not listed above:
Total fees owed for your establishment: 6S-oo
NOTE: To be entitled to pay the current 2014 rates listed above, your I'
business application, food and/or pool certifications, along with worker's
compensation information must be received, or mailed (postmarked) on or
prior to December 31, 2014. [Those establishments which open in the spring will be
aldowed to provide food and/or pool cerrifications prior to opening, however, you must note
"Will provide in the spring prdor to opening" on the application.J
BGM/maf �
` ' MR�t�uss,,,�c—�lNn1 �
a TOWN OF YARMOUTH BOARD OF HEALTH
; ��� APPLICATION FOR LICENSE/PERMIT -2015 �
* Please complete form and attach a11 necessary documents by December I5.2014. �
Failure to do so will result in the return of your applicahon packet.
ESTABLISHMENTNAME: �/� l�N ID: - ( rI
LOCATION ADDRESS: �01{ 1�10.i�� GV--it2$ .�•�'�'M�� TEL.#: �T�tc -5�2�(�
MAILING ADDRESS: �bu �C�da-cN��`Cx�$k ��$ \N.y�U ^MQ - O�-6��3_
E-MAIL ADDRESS: l.p-W • \'N N '� • Cp
OWNERNAME: C. l�L
CORPORATION NAME (IF APPLICABLE): e1�S• i�'�^ �
MANAGER'S NAME: O� . TEL.#:
1�1AILINGAnDRESS: A'�N. �P�'�l• a -0 6'1 ,
POOL CERTIFICATIONS: I
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.
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1. 2 - - ;
Pool operators must list a minimum of two employees currently certified in basic water safety, standard 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�le at your place of business.
1. �.t� A 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 uew copies and maintain a file at your establishment.
1. 2•
PERSON IN CHARGE: II�
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
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1. 2•
ALLERGEN CERTIFICATIONS:
All food service establishments aze required to haue 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 establishxnents with 25 seats or more must have at least one employee trained in the Heunlich
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. 2•
3, 4.
RESTAURANT SEATING: TOTAL# I
i
OFFICE USE ONLY
Loucwc:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
B&B $55 CABIN $55 �MOTEL $110 �/.5��,�
—INN $55 CAMP $55 SWIMMINGPOOL$1t0ea
LODGE $55 TRAILERPARK $I05 _WHIRLPOOL $ll0ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# � LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERM[T#
0-100 SEATS $125 _CONTINENTAL $35 NON-PROFIT $30
—>100 SEATS $200 _COMMON VIC. $60 WHOLESALE $80
— —RESID.KITCHEN $80
RETAIL SERVICE:
LICENSE REQUIRED FEE PERM[T# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
<50 sq.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25
=<25,000 sq.ft. $150 _FROZEN DESSERT $40 _TOBACCO $110
NAME CHANGE: $15 AMOLTNT DUE _ $ I I� .06
***•*pLEASE TURN OVERAND COMPLETE OTHER SIDE OF FORM*****
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ADMINISTRATION r
t �
Under Chapter 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 i
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR
CERT. OF INSURANCE ATTACHED
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yannouth 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 purposes of the limitations of Motel or Hotel use,Transient occupancy shalt�e �
limited to the temporary and short term occupancy,ordinarily and customazily 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 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
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.
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 Deparhnent to schedule the inspection three(3) �
days prior to opening. PLEASE NOTE: People are NOT allowed to siY in the pool area until the pool has been i
inspected and opened.
POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standazd plate count
by a State certified lab, and submitted to the Health Department three (3) days prior to opening, and quarterly
thereafter.
POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of
closing.
FOOD SERVICE I
SEASONAL FOOD SERVICE OPENING:
All food service establishxnents must be inspected by the Health Department prior to opening. Please contact the
Health Department to schedule the inspection three (3) days prior to opening.
CATERING POLICY:
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the i
required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be ,
obtained at the Health Department,or from the Town's website at www.varmouth.ma.us under Health Department, ,
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 revocarion of your Frozen I
Dessert Permit until the above terms have been met. i
OUTSIDE CAFES:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Boazd of Health. I�
OUTDOOR COOKING:
Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited.
NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN
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 A SITE PLAN.
DATE: SIGNATURE:
PRINT NAME &TITLE:
Rev. I1/03/14
r � � The Commonwealth ofMassachusetts '
Department oflndustrial Accidents
a Office oflnvestigalions
�
' I Congress Street, Suite 1 DO i
Boston, MA 02114-2017 �
www.mass.gov/dia !
Workers' Compensation Insurance Affidavit: General Businesses
Analicant Information Please Print Legiblv
Business/Organization Name: �`6�o..y �e�w-�'sS_ �'Y�'n . I
�
Address: 's--J�� . '�'��,��Y1 S��'� • I
City/State/Zip: 4�l •�h'�'M�i1�� Phone#: ��' g`�1 - �-t ~1l5�
Are you an employer?Check the appropriate bos: Business Type(required):
1.❑ I am a employer with employees(full and/ 5. ❑ Retail
orpart-timeZ.'_ _ 6. ❑ RestauranUBar/Eahng Establishment
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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. 152, §1(4),and we have �0.0 Manufachiring
no employees. [No workers' comp.insurance required)* 11.� Health Care
4.❑ We aze a non-profit organization,staffed by volunteers,
with no employees. [No workers' comp. insurance req.] 12.❑ Other
*Any applicant that checks box NI mus[also&II out the section below showing the'v workers'compensalion policy information.
**If the cocporate officeis have exempted themselves,but the coiporation has other employees,a workers'compensakion policy is required and such an
organi�ation should check box#1. �
I am an employer that isproviding workers'comIpensation insurance for my employees. Below is the policy information. ,
Insurance Company Name: ��_�1\2_t,��1 • �?1�'�C3.`�Ge . !
Insurer'sAddress: �J�• �Ma-�� SC'��'� •
CiTy/State/Zip: �l� . �} O,'�`M 01I�I��' � '� - O a--6 �� i
Policy#or Self-ins.Lic. # Expirafion Date: �I
AttacL a copy of the workers' compensation policy declaration page(showing the poticy nnmber and ezpiration date).
Failure to secwe coveraga-�required under�eFtion 25A of T�?(;T.0 152_can lead to th2_i1T11lasiLinn nf cri �m_n_a1_raaalties�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
Inves6ga6ons of the DIA for insurance covemge verificafion.
I do hereby ce ' nder t ' s a enaliies ofperjury that the information provided above is�i{e and conecG �
Si ahve: ' Date: � 1 � �� �
Phone#: - U'� - 6'6 ��
Of,ficial use only. Do not wrtte in this area,to be completed by city or town officiaL
City or Town: PermitlLicense#
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
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NOTICE � � NOTICE
TO � a TO
:
EMPLOYEES << EMPLOYEES '
♦V
p� V�
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The Commonwealth .of Massachusetts I
DEPARTMENT OF INDUSTRIAL ACCIDENTS
600 Washington Street, Boston,Massachusetts 021ll ',
617-72'7-4900 — http://www mass.gov/dia '
As r uired by Massachusetts General I.aw,Chapter 152,Sections 21,22&30,this will give you notice that I
I�we) have provided for payment to our injured employees under the above mentioned chapter by
msunng w�th:
TFE TRAVELERS INSURANCE C�PANIES
NAME OF INSURANCE COMPANY
P.O. BOX 1450 �I
MI�LEBORO MA 02344-1450
ADDRESS OF INSURANCE COMPANY
(7PJ1�-6800245-0-14) 05-22-14 TO 05-22-15
POLICY NUMBER EFFEGTIVE DATES ',
� SCHLEfaEL & SCHLEC�L INS 34 MAIN STREET I�
� Y�ST YARMKKJTH MA 02673
� NAME OF INSURANCE AGENT ADDRESS PHONE# ,
� '
a� BRIDC� OVER (�RPORATION 1 SIDDHARTH LArE
'� FqLBR00K
°� MA 02343
"� EMPLOYER ADDRESS
�
�
.� EMPLOYER'S WORKERS COMPENSATION OFFICER(IF ANY) DATE
� MEDICAL TREATMENT
�
^� The above named insurer is required in cases of personat injuri� arising out of and in the course of
� employment to furaish adequate and reasonable h�pital and medical services in accprdance with the
a
°� provisions of the Workers' Compensation Act A copy of the First Report of Injury must be given to the
'� injured employee. The employee may select his or her own physiciaa The reasonable cost of the services �
� pmvided by the treating physiciaa will be paid by the insurer, if the treatment is necessary and reasonabiy i
•� connected to ihe �rk related injury. In cases requiring h�pitat attention, employces are hereby noti6ed ;
that the insurer has arranged for such attention at the '
I
NAME OF HOSPITAL ADDRESS
,,,�, „��,�2 TO BE POSTED BY EMPLOYER