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Home My WebLink AboutApplication and WC I ; I o�'�'�R � � _ _ `�o TOWN OF YARMOUTH Boazdof ,�. - s � Health � �.. `j 1146 ROUTE 28, SOUTH YARMOUTH,MASSACHLJSETTS 02664-24451 Health E': 4,r t:� 'r Telephone(508)398-2231,ext. 1241 Division ' lA�M6 Fa.�c(508)760-3472 � To: Yarmouth Business Establishments -gy�,nis Ice Cream � /� d/b/a Bass River Beach Concession From: Bruce G. Murphy, Director U P.O. Box 551 Yarmouth Health Department�` South Dennis, MA 02 60 ar�c�od�i� Date: November 7, 2014 ut� � 0 "lUt4 Subject: Increase in License/Permit Fees HEAI TM QEPT_ Please be aware that the Yarmouth Boazd of Health, under the direction of the Yarmouth Board of Selectmen, has raised a number of license and permit fees issued through the Yarmouth Health Department, effective January 1, 2015. Attached is the Yarmouth Business License/Permit Application far 2015. You will note that the fees listed are 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 Yazmouth Health Department with all required certifications and worker's compensation coverage informarion (cerhificate 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 Sa1es $ 95.00 Motels $ 55.00 Food Service 0-100 Seats $ 85.00 85.oa Food Service�verTDO Seats $160At� 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 establislunent: $85.00 NOTE: To be entitled to pay the current 2014 rates listed above, your business application, food and/or poot certifications, along with worker's compensation information must be received, or mailed (postmarked) on or prior to December 31, 2014. [77tose estabdishments which open in the spring will be allowed to provide food and/or pool certif:cations prior to opening, however, you must note "Will provide in the spring prior to opening" on the appdication.J BGM/maf . �.,^�°�`. r'^ �'^ "y h.__ "-jy, a�s�'��'�C�� ...n , , t3 �. � � TOWN OF YARMOUTH BOARD OF HEALTH �� APPLICATION FOR LICENSE/P T;�2ais �t� � � Z014 * Please com lete form and attach all necess dor� ��t� y�ec r I DEPT. Failure to do so will result in the retum bf y6ur appYication pac . ESTABLISHMENT NAME: ctnvn.�o � TAX ID: � LOCATION ADDRESS: (30.00 ►Zin�z, (��,.,��.�,-� TEL#• MAILING ADDRESS:��lo Gha.v,rpQ�i�,��oin..�:�o W�fl o a 6�0 _ E-MAILADDRESS: aPAChC�h� C2CCion)�� Av� . CJ�,., OWNER NAME: CORPORATION NAME (IF APPLICABLE): � � MANAGER'S NAME: �.�rJ�p f} 13 tl IQ h� TEL.#: S D S- 77��00 �J MAILING ADDRESS: C'19 h, � 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 minimum of two employees currently certified in basic water safety, standard 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. 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 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. 1. 1 NDR c�'I�iJRh� 2. a � ��9rY-, C�[�'(J� w PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. 1. �-l� �Jl�t� �t3U� l.� 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. 1. �..�N D � ) l�1� 2. Lc� f �� (p n�, C�Zi U i2 l� 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-cholung 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 sud-maintain a file at your place of business. 1. .-�' 2. 3. 4. RESTALJRANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED. FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $I10 INN $55 CAMP $55 SWIMMINGPOOL$110ea LODGE $55 TRAILERPARK $105 _WHIRLPOOL $110ea FOOD SERVICE: LICENSE REQUIRED FEE PERMI # LICENSE REQUIRED FEE PERMIT# LICENSE RE�UIRED FEE PERMIT# �0-100SEATS $125 �t� _CONTINENTAL $35 NON-PRO IT $30 >100 SEATS $200 COMMON VIC. $60 WHOLESALE $80 — — —RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT N LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMiT# <50 sq.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 <25,OOOsq.ft. $150 —FROZENDESSERT $40 _TOBACCO $110 , NAMECHANGE: $15 , �-�AMOUNTDUE _ $ 2 ��.00 S � ,JU r-�"', .-� ' l�Qc`c�' 85 •O� **"**PLEASE TURN OVER AT�1D COMPLETE OTHER SIDE OF FORM***** ---- �t�iZ�5 f2�3o`i� , ��. I ' i � , i ,_ ADMINISTRATION i Under Chapter 152, Section 25C,Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal j of any license or perxnit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORK�R'S COMPENSATION INSURANCE i AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR , CERT. OF INSURANCE ATTACHED � OR � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED ✓J Town of Yannouth taxes and liens must be paid prior to renewal or issuance of your pernuts. PLEASE CHECK APPROPRIATELY IF PAID: I YES � NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations ofMotel or Hotel use,Transient occupancy shali 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 Departxnent 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 un61 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 wvered within seven(7)days of closing. FOOD SERVICE SEASONAL FOOD SERVICE OPENING: All food service establishments 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.yarmouth.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 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 RESPONSIBILTI'Y 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 A SITE PLAN. DATE: )��o��'�`� SIGNATURE: ,� y � ( - /,,.�r�.— I PRINT NAME & TITLE: �-un.oi+ Rev. 11/03/14 � t� The Commonwealth ofMassachusetts Department of Industrial Accidents O�ce oflnvestigations ' 1 Congress Street, Suite I00 Boston, MA 02I14-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Aaalicant Information Please Print Legiblv Business/Organization Name:��Y'f31✓N!S /C� C�c f�/"' ��/�«Ssla� Address: AN � � City/State/Zip: ,S� ��N/vf S /� � Phone #: �� -��' �7��3� Are you an employer?Check the appropriate bos: Business Type(required): 1.,(� I am a employer with�employees(full and/ 5. ❑Retai] , o_r_part-time .�* ___ 6. �estaurantlBaz/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.❑ VJe are a corporauon and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4),and we have I 0.0 Manufacturing 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#I mus[also fill out the section below showing the'v worke=s'compensation policy infoimation. +•If the coxporate officeis have exemp[ed themselves,but ihe corporation has otha employees,a workers'compeusarion policy is reqnired and such an organization should checic box#I. I am an employer that is providing warkers'compensation insurance for my employees. Below is the policy information Insurance Company Name: l��'�fJ�¢� ��.�'�K-�t-s Insurer's Address: �� C. !�/G�0/`� /1./1 �r CiTy/State/Zip: Policy#or Self-ins.Lic. # L✓�C ��c7�a2 � ` �� !�Expiration Date:��"� � Attach a copy of the workers' compensa6on policy declaration page(showing the policy number d es iration date). Failure to_secure co_vera�;e as required under Section 25A o_f_MGL a 152 can 1_ead to the imposiUon of_cr'uninal penalties 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 forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify,under the pains and pena[ties ojperjury that the information provided above is true and conect. Sig�ature• � r..,r ��ttx�r Date: �d—la'�/� �{ Phone#• ��O � 7�6 '" �� v Official use only. Do not write in this area,to be campleted by city or town official City or Town: PermitlLicense# Issuing Authorily(circle one): 1.Board of Health 2. Building Departmeut 3.City/Town Clerk 4.Licensing Board 5. Selectmen's Office 6.Other ,.,, �� , :�� Contact Person: Phone#: www.mass.gov/dia