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Cayuga County Health Department January 27, 2004 Page 1 of 9 CAYUGA COUNTY HEALTH DEPARTMENT Elane M. Daly, RN, BSN Director of Health & Human Services CLEAN INDOOR AIR ACT WAIVER APPLICATION Instructions to the Applicant Applying for a Waiver The following submission guidelines and documentation requirements are for all applicants: • All information provided as part of the application package must be either typed or printed clearly in ink The name of the applicant or entity must be the same on all supporting documentation submitted • • The application for registration must be completed and signed where indicated • All applicants must have a current, valid permit to operate a food service establishment (if applicable) issued by the Cayuga County Health Department APPLICATION SECTION A – Indicate with an basis for which waiver is sought: Undue Financial Hardship – Complete Sections A, B, C, D, F, G, H, I, and submit required attachments Factors Which Would Render Compliance Unreasonable – Complete Sections A, B, C, E, F, G, H, and submit required attachments SECTION B – Complete Items 1 – 7 below: Name of Applicant: 1. Name of (Check One) Corporation, LLC, Partnership, or Individual: 2. Trade Name/DBA: Building Number: Street: City: State: Zip Code: Telephone: 3. 4. 5. Current Hours of Operation: Sunday Monday Tuesday Wednesday Thursday Friday Saturday Open Close 6. ---PAGE BREAK--- Cayuga County Health Department January 27, 2004 Page 2 of 9 Section C - Complete Items 1 – 3 for all Owners, Partners, Corporation Officers, Principals. Attach additional sheets if necessary. Last Name: First Name: Title: Building Number: Street: City: State: Zip Code: Telephone: 1. 2. 3. Last Name: First Name: Title: Building Number: Street: City: State: Zip Code: Telephone: 1. 2. 3. Last Name: First Name: Title: Building Number: Street: City: State: Zip Code: Telephone: 1. 2. 3. Last Name: First Name: Title: Building Number: Street: City: State: Zip Code: Telephone: 1. 2. 3. Last Name: First Name: Title: Building Number: Street: City: State: Zip Code: Telephone: 1. 2. 3. ---PAGE BREAK--- Cayuga County Health Department January 27, 2004 Page 3 of 9 SECTION D – Financial Factors Use this section to provide details on financial hardship. Since the enactment of the law: (Circle Yes or No) 1. Have you experienced a change in sales receipts? Yes No Please explain why you feel this change is directly related to the Clean Indoor Air Act, and provide supporting documentation. Attach copies of sales receipt information certified by a CPA from August 1, 2001 through the end of the month prior to the date of application (or total period of operation for new businesses). If you report sales receipts to the New York State Department of Taxation and Finance, you may submit a copy of this in lieu of the CPA certification. All Lotto sales receipts (if included) must be reported separately. (Lotto sales will not be used in the determination of financial hardship.) 2. Please summarize the sales figures from the above sales receipt information on the Table in Section I on Page 9 of 9 of this application. 3. Please attach supporting documentation on the corresponding changes in purchasing patterns at your business for the current period as compared to before the implementation of the Clean Indoor Air Act. 4. Please attach supporting documentation to demonstrate a significant reduction in staff for the current period as compared to before the implementation of the Clean Indoor Air Act. (Circle Yes or No) 5. Have there been any outside factors that may have affected Yes No your sales receipts? Changes in hours of operation New competing business established in immediate vicinity Construction near establishment Major change in menu Major change in target audience Major change in lotto sales Power outages Severe weather Fire, flood, or other catastrophe causing a shutdown No No No No No No No No No No No No No No Renovation of the premises Labor dispute Sidewalk or street repairs Installation of parking meters, or other factors affection parking Change in marketing/advertising Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes ---PAGE BREAK--- Cayuga County Health Department January 27, 2004 Page 4 of 9 Inspections and actions by government enforcement entities Yes No Yes No Yes No Yes No with respect to the applicant’s liquor office Health Inspections and enforcement actions Lower blood alcohol levels enforced Other factors Explanation of outside factors for which you answered yes 6. Please describe all efforts that have been made to operate the facility as a smoke-free environment in full compliance with the amended Clean Indoor Air Act. Attach additional sheets of paper if necessary. Explanation ---PAGE BREAK--- Cayuga County Health Department January 27, 2004 Page 5 of 9 SECTION E – Other Factors (Note: Do not complete this section if filing for financial hardship only.) Use this section to fully outline any other factors that would render compliance unreasonable. (Please type or print legibly. You may attach additional sheets of paper if necessary.) ---PAGE BREAK--- Cayuga County Health Department January 27, 2004 Page 6 of 9 SECTION F - Plan Under the New York State Clean Indoor Air Act, every waiver granted shall be subject to such conditions or restrictions as may be necessary to minimize the adverse effects of the waiver upon persons subject to an involuntary exposure to second-hand smoke and to ensure that the waiver is consistent with the general purpose of the Act. 1) Please detail your plan to minimize the adverse effects from exposure to second hand smoke on the public, suppliers, contractors, your employees and other persons who may have reason to be in your establishment. Attach a diagram of the facility and detailed information concerning equipment, such as ventilation equipment, that is proposed as part of this effort. Include room capacities. (Attach typed plan or print legibly below.) 2) In order to be consistent with the general purpose of the law, you must notify your employees that you have applied for a waiver and of your plans to minimize involuntary exposure to second-hand smoke. Check here to indicate that this has been accomplished. The employer shall at a minimum keep a record that the employee has acknowledged that he/she has been informed of the smoking waiver application. These acknowledgements shall be available for Health Department review. 3) How do you plan to ensure that any waiver granted would be consistent with the general purpose of the Act which is “…to preserve and improve the health, comfort and environment of the people of the state by limiting exposure to tobacco smoke.” If a waiver is issued, will this facility be advertised as a smoking facility? 4) The Health & Human Services Department will require as a condition of any waiver issued, that, if physical modification of the establishment is required, a building permit be obtained from the Code Enforcement Officer prior to construction and a certificate of compliance be obtained upon completion of construction. Check here to indicate that this condition will be complied with. ---PAGE BREAK--- Cayuga County Health Department January 27, 2004 Page 7 of 9 SECTION G – Checklist of all required attachments: 1. Established businesses- Provide copies of sales receipts reported on the NYS Taxation and Finance Form ST-809 or sales receipts certified by a CPA, from August 1, 2001 to the month prior to the date of this application. 2. New businesses- the same documentation as described above must be submitted for the number of months in operation. 3. Copy of a New York State Certificate of Authority to Collect Sales Tax and proof of federal EIN: (The address on the New York State Certificate of Authority must match the address of the establishment site.) 4. Copy of: If Individual Owner Business Certificate of Ownership (and d/b/a if applicable) If Corporation Proof of Incorporation (All of the following items are required): 1. Filing Receipt or Authority to Conduct Business, issued by NYS Secretary of State (original or photocopy showing blue watermark seal is acceptable). 2. Corporate resolution or minutes of most recent annual meeting, listing the current principal officers of the corporation and dated no earlier than one year preceding the date of application. If Partnership 1. Business Certificate of Partnership 2. Current partnership agreement 5. Provide documentation of any change in purchases (if not already identified in Section D-3). 6. Provide documentation of any reduction in staff (as required in Section D-4). 7. Application fee in the amount of $150.00. Make check or money order payable to Cayuga County Health Department. 8. Provide completed table in Section 1 of this application. Optional If submitting employee data to demonstrate a significant reduction in staff, please provide: 1) Copy of your NYS Employer Registration for Unemployment Insurance. Withholding, and Wage Reporting, NYS-100; and 2) copies of your NYS Labor Department Quarterly Combined Withholding, Wage Reporting, and Unemployment Insurance Returns (NYS-45-MN and NYS-45-ATT-MN, if applicable) from August 1, 2001, through the end of the month prior to the date of this application. The applicant may black out employer registration number, withholding identification number, and employee social security numbers from NYS-45-MN or NYS-45-ATT-MN forms. This is the only employee data that will be accepted. Note: The Cayuga County Health Department reserves the right to request additional information necessary to make a final decision. ---PAGE BREAK--- Cayuga County Health Department January 27, 2004 Page 8 of 9 SECTION H - Acknowledgement and Certification I, , state that I am the (Title) of have completed the above application and that the statements (Facility Name) made therein and the documents submitted are truthful to the best of my knowledge. I further acknowledge that I and the persons I represent are fully aware of the consequences, including the forfeitures and civil and criminal penalties, which may result if any statement and document provided is determined to be false. Dated: Signature: Sworn to before me this day 200_ . Notary Public SUBMITTING THE APPLICATION: Submit the completed application and supporting documents to: Cayuga County Health Department Division of Environmental Health 160 Genesee St. 2nd Floor Auburn, New York 13021 The application will be reviewed to ensure that all forms have been correctly completed and that all required documentation is presented. If all required documentation is not provided, you will be notified, and your application will not be processed until it is complete. PLEASE DO NOT WRITE IN THIS BOX Date Received Complete Yes No Approved Denied Missing Documentation Reason for Denial Note: The Cayuga County Health Department reserves the right to change the application and/or application process.