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Home My WebLink AboutApplication and WC o�'�R'� �{. - _ _ __� TOWN OF YARMOUTH Ha�f �(�; � "3 1146 ROUTE 28, SOUTH YARMOUTH, MASSACHLJSETTS 02664-24451 - �• 4'j�r�eME�lt' � Telephone(508)398-2231,ext. 1241 Di sion � Fax(508) 760-3472 To: YazmouthBusinessEstablishments t�pEi2� (}iu. In1r� From: Bruce G. Murphy, Director � ��b�� Yarmouth Health Departsnent� �AN 'i 6 2015 Date: November 7, 2014 HEALTH DEPT. Subject: Increase in License/Permit Fees Please be awaze that the Yannouth Boazd of Health, under the direction of the Yarmouth Boazd of Selectmen, has raised a number of license and permit fees issued through the Yannouth Health Department, effective January 1, 2015. Altached 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 applicarion, and submit it to the Yannouth Health Department with all required certifications and worker's compensation coverage informa6on (certificate of insurance OR completed affidavit) urior 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 gs.oa FoodServiceflver160 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: � I 1 .00 i.opcse�cw+r.or, v�c. Total fees owed for your establishment: ��b.�o 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 Deeember 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 "Widl provide in the spring prior to opening" on the application.J BGM/maf _ __ . G,i��"�rDD �� Frt.r� 4F�� TOWN OF YARMOUTH BOARD OF HEA H �� APPLICATION FOR L��'AIS �1t�M�T'-� 15 �AN � 6 2015 * Please complete form and attach�II�ac�`36Gu�inen by 20 . Failure to do so will result i�the return�of qour a�' ' . ESTABLISHMENT NAME: Libe Hill Inn TAX ID• — LOCATION ADDRESS: 77 Main Street TEL.#: ��s76 MAILING ADDRESS: E-MAIL ADDRESS: J .a�c� OWNER NAME: CORPORATION NAME(IF APPLICABLE): MANAGER'S NAME: � TEL.#: ,S �.3��.317� 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. - I. _ 2. Pool operators must list a minimum of tw e p currently certified in basic water safety, standard First Aid and Community Cardiopulmonaty Resu it ' n C R), having one certified employee on premises at all times. Please list the employees below and a copies o 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. 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 file at your establishment. l.�L,q�/Ju "" 2. ��/ ��ia-(/1� PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. �. `��i��lL�� _ 2. _ 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. i. I l�,1/ �� a. 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-choking 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 m tain a file at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE'ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQIDRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# � B&B $55 CABIN $55 MOTEL $I10 � INN $55 CAMP $55 SWIMMINGPOOL$IlOea. �� TLODGE $55 �-.� _TRAILERPARK $105 _WHIRLPOOL $IlOea '.. FOOD SERVICE: LICENSE RE UIRED FEE P I LICENSE RE UIRED FEE PERMIT# LICENSE RE UIRED FEE PERMIT# � I 0-100 SEATS $125 l� � CONTINENTAL $35 NON-PROFIT $30 '. =>100 SEATS $200 �COMMON VIC. $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 Q5,000 sq.ft. $150 _FROZEN DESSERT $40 _TOBACCO $110 �. NnmE cxnrrcE: $is AMOUNT DUE _ $ 24 0 .bo *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*"*"• " ' I ADMINISTRATION 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 .,, AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED J OR /j WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must b d pri, renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: � S NO MOTELS AND ER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations ofMotel 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 shall generally refer to continuous occupancy of not more than thirry(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 Deparhnent prior to opening. Contact the Health Department to schedule the inspection three(3) days prior to opening. PLEASE NOTE: People aze 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 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 SEASONAL FOOD SERVICE OPENING: I All food service establishments must be inspected by the Health Department prior to opening. Please contact the i 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 required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtamed at the Health Deparhnent,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 Departxnent. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until 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,prepazation,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 RE'I'tJRN 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.), MiJST BE REPORTED TO AND PP OVED BY THE BOARD OF HEALTH PRIOR TO COMMEN M T. RENOVATIONS MAY RE A SITE PL N. DATE: SIGNATURE: ` PRINT NAME & TITLE: Rev. I I/03/I4 � The Commonwealth ofMassachusetts Department of Industrial Accidents Office ofinvestigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Annlicant Information Please Print Legiblv Business/Organization Name: Liberty Hill Inn ee Address: Rte 6A .,��+ti o...r �nn n2675 City/State/Zip: Phone#: ��^ ,�� 76 Are you an employer? Check the appropriate box: Business Type(required): 1.❑ I r with�_employees(full and/ 5. ❑ Retail _ part-time " . 6. ❑ RestaurantBaz/Eating Establishment 2.�I am a sole propnetor 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 corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4), and we have �0.❑ Manufacturing no employees. [No workers' comp. insurance required]* 11.❑ Health Caze 4.❑ We are a non-profit organization, staffed by volunteers, �� with no employees. [No workers' comp. insurance req.] 12�Other �, •Any applicant thaz checks box#]must aLso fill out the section below showing their workers'compensation policy i¢formatioa. **If the coxpomte officers have exemp[ed themselves,b�x[the corporation has other employees,a workecs'compensation policy is required and such an organizatio¢should check box#I. � I am an emplayer that is providin�'w�orkers' /o�mpensation/�sur ce for my employees. Below is the po[icy injormation. Insurance Company Name: !�/JQ�i[ �1n.I� L/ � Insurer's Address: 7Z"�—/�� d /�(� ��d y City/State/Zip: D — O Policy#or Self-ins. Lic.# k/� D �3S'S� 3� Expiration Date: Attach a copy of the workers' compensation policy declaration page(showing the poticy nnmber a d e iration date). _ __ Failure to secure coyerage as reguired under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a _ _ ____ _-- _- - - -- fine up to$I,500.00 and/or one-yeaz 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 forwazded to the Office of Inves6gations of the DIA for insurance covernge verification. I do hereby certify, r the a' s a nalties ojperjury that the information provided above tru d correct. / Si ature: Date: Phone#: Official use only. Do not write in this area,to be completed by city or town ojficiaG City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2. Building Department 3. City/Town Clerk 4.Liceasing Board 5. Selectmen's Office 6.Other Contact Person: Phoue#: ' www.mass.gov/dia �