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Home My WebLink AboutApplication and WC � _ ._ _ / � ` p�{?aKria� dr�i�n�;��,�- • ��" TOWN OF YARMOUTH BOARD OF HEALTH APPLICATION FOR LICENSE I�' . ��-'� (]4 %U 13 � �" * Please complete form and attach ail nece' ` y' �c Failure to do so will result in the return Qf yoi3z application . , • ESTABLISHMENTNAME: tfr�r� �nc_ �bG�. � r��rmC�- TAXID: - LOCATION ADDRESS: 17S I�(V.(��l S�Y�Ft TEL.#: '�Ci�S� 7� I- � 7 7�, MAILING ADDRESS: E-MAIL ADDRESS: \ �1 ��1 ��. .CD'^� OWNERNAME: CVanC— iY�7-amYk1 � S CORPORATION NA E F APPLICABLE): C� , '� e � MANAGER'S NAME:�j z Y�C,t rn � � , u ✓✓/7 TEL.#: MAILINGADDRESS: 1-IS YYl/ia ✓� S�-n_.� � f. 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 Cardiopulmonary Resuscitation(CPR),having one certified employee on premises at a11 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. �2Xl �Arn� rl J�l;l.rv0 2. f�Q��1°,�. fit�-i� hr� PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. i. �►'1 tarn� � �,i�rr� 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 Aealth DepaMment will not use past years' records. You must provide new ' copies and maintain a file at your establishment. 1. `�E(l �i.�._r rU 2. J��' Y1 �S-e. �1i Q��. I Q _� � . HEIMLICH CERTIFICATIONS: �` ��^ - d .,.; _ . . � ._ All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at a11 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 maintain a £le at your place of business. 1. 2. 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 $55 INN $55 CAMP $55 SWIMMINGPOOL $80ea LODGE $55 TRAILERPARK $105 WHIRLPOOL $SOea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100SEATS $85 _CONTINENTAL $35 NON-PROFIT $30 �>100 SEATS $160 �-�' s' � �COMMON VIC. $60 � V- �" - _WHOLESALE $SO � —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. $225 VENDING-FOOD $25 —<25,000 sq.ft. $80 _FROZEN DESSERT $40 _TOBACCO $95 NnniE c[wNCE: $�s AMOUNT DUE _ $ 2?� ��' *****pLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** �� ` f � ADMINISTRATION ' . Under Chapter 152, Section 25C,Subsection 6,the Town of Yarmouth 15 nOw TequlTed t0 h0�d 1SSUaT1Ce OT TCllCWa�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 Yarmouth taaces 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 shall be 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 piace of residence elsewhere. Transient occupancy shall generally refer to continuous occupancy of not more than tl�irty(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 are 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. _ - - FGCiD S�Ri�ICE _ _ 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 Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health Deparhnent, or from the Town's website at www.yannouth.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, 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 13, 2013. 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: ��L`�\\'� SIGNATURE: � L�� PRINT NAME& TITLE: ��''1n��I��j�/' QV�ncv� UrfC� Re�. 10/08/13 Client#: 22600 2DIPARMA •ACORD�., CERTIFICATE OF LIABILITY INSURANCE onre�mnvoonvvv� 10/3012013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVEIY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must 6e endorsed.If SUBROGATION IS WAIVED,subject to the terms and contlitions of the policy,certain policlas may require an endorsemenL A statement on this certificale does not confer rights to lhe certifiwte holder in lieu of such endorsement(s). CO A PROOUCER NAME. __ " _ - —__ _"._ __ Dowling&O'Neil sa°N E,n:508_775_1620 _ . _ __ Fa"xc,r+�p 5087781218 Insurence Agency E�M^�� - �� no�aess__._ .—._...—— .___._—__ ._-.___ 9731yannough Rd., PO Box 1990 wsuaea�s�nFFoaowccoveance _ . _ ,_ _rvnica_ Hyannis,MA 02601 iHsuRERA:Guard Insurance Group � _ INSUREO MSURERe: � __ Calamari, Inc DBA DiParma Italian Table �NSURER C'. A/O Tasty Tidbits Reaity Trust INSURER 0: _ . 175 Main Street iNsueea E�, _ WestYa�mouth, MA 02673 INSURERF: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE WSURED NAMED ABWE FOR THE POLICV PERIOD INDICATED. NOTWITHSTANDING ANY RE�UIREMENT, TERM OR CON�ITIONOF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY 8E ISSUED OR MAY PERTAW, THE INSURANCE AFFOR�EO 8Y THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERb15, EXCLUSIONJ' AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. TYPEOFINSURANCE A�DLSUBR POLICYEFF POLICYEXP �Tq NSR POLICYNUMBER IMMIDDIYVYVZ(MMIO�IYVYY) . _LIMITS _.._....___-.. _..—'_—__ p ceaeanuinai�rcv CABP408234 06/15/2013 06/15/201 EncnoccuRaervce s1000000 pAMAGE TO RENTE� X GOMMEFCIALGENEfiALLIABILITY PREMISES Eaoccurrencn �SOyOOO__ __. �� CLAIMS-MADE �OCCUR ME�E%P(Anyonaperson) $S OOO PERSONALflA�VINJUNY 5'I�OOO�OOO ..__ -._""_ _-_— GENERALAGGREGATE $Y�OOO�OOO . . ..._ ""--- __ GEN'LAGGREGATEIIMITAPPLIESPER'. PRODUCTS_ COMPIOPAGG� S� OOOOOO_ _ _I POLICY.I.. 1 jt��_LLOC_ _ b - __'— _ --____ _- _._ _._-. __._ COMBMED SINGLE LIMIT AVTOMOHILELIP9I�ITY E_ccitlenl . ._"_ 5_. _.. __.__ _.- ANYAUTO BODILYINJURY(Perperson) 5 � lLLLOWNED SCHEDULED BO�ILYINJURY(Peraccitlenp 8 aUToS ._._ AUTOS ------ __. ___— — ___._ ._._ _. NON-OWNED Pe�ra cRiaeniOAMAGE S HIFEO A11N5 AUTOS -- S UMBRELLALIAB OCCUR EACHOCCURRENCE 3 _ E%CESSLIAB CLAIMS-MAOE AGGREGATE 5 OED NETENTION$ 5 - A WORKERSGOMPENSATION �',AW(�`46]590 6/0112013 06/01/201 X WCSTATU� OTH� AN�EMPLOTERS'LIA8ILITY - ANl'PNOPRIETpFlPARTNEWEXEC�TIVE� E.LEACHACCIDENT SSOO�OO OFFICERIMEMBEftEXCWDE01 �.J NIA — (Mantlamry in NH) EL OISEASE-EA EMPLOYEE $5��000 ��vos,tlexiso<�naur DESCRIPI'IONOFOPERATIONSOnIow EL�ISEASE=POLICYLIMIT 5$OO,OOO ._ �� LiquorLiahility CABP408234 6/15/2013 06/15/201 $1,000,000 OESCRIPTION OF OPERNTIONS I LOCATIONS I VEHICLES(Altach ACORD 101,Adtli�ional Rama�ks Schatlula,if more space is�aquiretl� Insurance coverage is limited fo the terms,conditions,exclusions,other limitations and endorsemeots. Nothing contained in the certificate of . insurance shall be deemed to have a�tered,waived,or extended the coverage provided by the policy provisions. Members are included under the workers compensation policy. (See Attached Descriptions) � CERTIFICATE HOLDER CANCELLATION Town of Yarmouth SHOULD ANV OF THE ABOVE DESCRIBED POLICIES BE CANCELLEO BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERE� IN Board of Health ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 South Yarmouth, MA 02664 nurHoaizeo aevaeseNlwnve �' �(:C!+-••• c01988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 of 2 The ACORD name and logo are regisleretl marks of ACORD #S119973/M119970 EAM