HomeMy WebLinkAboutApplication and WC oF�Y`qR
�� • �` _�`�a TOWN OF YARMOUTH Ha�f
� —._. � "� 1146 ROUTE 28, SOUTH YARMOUTH,MASSACHCJSETTS 02664-24451 -
�. �'' A c ME�e/ 'r Telephone(508)398-2231, ext. 1241 Div si n
Fa�c(508)760-3472
To: Yazmouth Business Establishments �p�,� Z; (�,zza+ �c�CK-Q�`'t --- ----- - --�
From: Bruce G. Murphy, Director � � ,� ,
Yazmouth Health Department� � Q��� " � f 5
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Date: November 7, 2014 -
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Subject: Increase in License/Permit Fees �� ¢�� ` � K ``'
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Please be awaze that the Yazmouth Boazd of Health, under the direction of the Yannouth Board �� �
of Selectmen, has raised a number of license and permit fees issued through the Yarmouth $(g
Health Department, effective January 1, 2015. �
Attached is the Yarmouth Business License/Permit Application for 2015. You will note that the ��
�
fees listed are the fees effective Januazy 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
Public WhirlpooUVapor Baths $ 80.00
Tobacco Sales $ 95.00
Motels $ 55.00
Food Service 0-100 Seats $ 85.00 $ 85•00
Food Service Over 100 Seats $160.00
Retail Food Service C25,000 sq. ft. $ 80.00
Retail Food Service>25,000 sq. ft. $225.00
Other fees owed but not listed above: �loo.00 �N��«.'���ZE+'
�ESSEQ-T
Total fees owed for your establishment: l$5.00
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
pelor to December 31, 2014. [7'hose 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 springprior to opening" on the applieation.J
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d TOWN OF YARMOUTH BOARD OF HEALTH
��� APPLICATION FOR LICENSE/PERMIT -2015
* Please complete form and attach all necessary documents by December l5 2014.
Failure to do so will result in the return of your application pac et.
ESTABLISHMENT NAME: n i 4 TAX ID: I 6
LOCATION ADDRESS: �)�-1 11 c y �. � � ��pv� �:1t,��4.rt'; TEL.#: �-U�- R�"I-l4 4'S
MAILING ADDRESS: y`�1 Ilc '��, , w-`lav�,,A���'4� �.�c o} b''F�.
E-MAIL ADDRESS:
OWNERNAME: ' ��t Cf'��+\ �
CORPORATION NAME (IF APPLICAB,LE): GcS,�Jknj ��l�-
MANAGER'S NAME: -S�te C,t��t1t, TEL.#:
MAILINGADDRESS: Cn�-o
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.
1. 2.
Pool operators must list a minnnum of two employees currently certified in basic water safety, standard First Aid
and Communiry 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. 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 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 file at your establishment.
�. `� ��,,�� _2. �N���n�o l�
PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
i. �a� C,��E� 2. 1�1�-t�..�n w Q�.�
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. �Dk ��t\� 2. l�le'Sn�W9Y� V/2r'l¢..'t
HEIMLICH CERTIFICATIONS:
All food service establishxnents 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. '�s� ���0 2. /�'��"SM/�) VU C�L2y
3. 4•
RESTAURANT SEATING: TOTAL# �
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
B&B $55 CABIN $55 MOTEL $110
INN $55 CAMP $55 SWIMMINGPOOL$110ea.
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 .�r�162 CONTINENTAL $35 NON-PROFIT $30
>I00 SEATS $200 �COMMON VIC. $60 �S _�OLESALE $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.ft. $150 � �FROZEN DESSERT $40 �!3 _TOBACCO $110
NAME CHANGE: $IS AMOUNT DUE _ $ Z Z S•O C7 ��.
•****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***•* '�.
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
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yannouth taxes and liens must be paid prior 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 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 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 Department to schedule the inspection three (3)
days prior to opening. PLEASE NOTE: People aze NOT allowed to sit in the pool azea 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:
All food service establishments must be inspected by the Health Deparhnent 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 Yarxnouth 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 Department,or from the Town's website at www.varmouthma.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 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 ofHealth.
OUTDOOR COOHING:
_ Outdoor cooki�re�aration,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 SITE PLAN.
DATE: � I?,� �� SIGNATURE:
PRINT NAME& TITLE: �S�'� ���� �`re''"'�'�"���
Rev. 11/03/14
� � � The Commonwealth ofMassachusetts
Department oflndustrialAccidents
Offace of Investigations
' I Congress Street, Suite 100
Boston,MA 02I14-20U
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Leeiblv
Business/Organization Name: (l�`, I,� ?�, V���.� � �c.e tne�r-�
Address: y�-1 r1 r `�� u!.��cM�.,TK !w� �3�6�('�
City/State/Zip: w' .y.�„ ,na�•1�1 nnh �aG'�'> Phone #: "�b� - 9 S� -� `� �+ �
Are you an employer?Check the appropriate box: Business Type(required):
1.❑ I am a employer with employees(full and/ 5. ❑ Retail
or part-ume).* 6.�] RestaurantJBaz/Eating Establishment
2.❑ I am a sole proprietor or parmership 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 10.❑ Manufacturing
no employees. [No workers' comp. inswance required]* I1.❑ Heakh Cue
4.❑ W e are a non-profit organizarion,staffed by volunteers,
with no employees. [No workers' comp. insurance req.] 12.� Other
•Any applicmrt thaz checks box#1 mus[also 5ll oui the section below showing the'u workers'compensation policy information.
**If the coipornte officers have exempted themselves,but the corporation has other employees,a workets'compensation policy is required and such an
organization should check box#1. � �
I am an emp[oyer that isproviding workers'compensation insurance for my employees. Below is thepolicy information.
Insurance Company Name: G�°��
Insurer's Address:
City/State/Zip:
Policy#or Self-ins.Lic.# �,�vJ C 5� 1\3�1- Expuation Date: U�� S�� �'
Attach a copy of the workers' compensafion policy declaration page(showing the policy number and ezpirafion date).
Failure to secure coverage zs required under SecUon 25A of MGL c. 152 can lead to the imposition of criminal penalUes of a __
fine up to$1,500.00 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
Invesrigarions of the DIA for insurance coverage verifica6on.
I do hereby certify,under e pains and penalties of perjury that the information provided above is true and correct.
Sienature• t!a��� Date: yI3 I �� '
Phone#: `��- �1'��''�"`� � �
Official use only. Do not write in this area,to be completed by city or town officiaL
City or Town: Permit/License#
Issuing Authority(cirde one):
1.Board of HealtL 2. Building Department 3. City/Town Clerk 4.Licensing Board 5. Selectmen's Oftice
6.Other
Contact Person: Phone#:
www.mass.gov/dia