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Home My WebLink AboutApplication and WC TOWN OF YARMOU'�H BOARD OP�HE� � �'� � �v�"�'& „ " � ` .'. �'�� APPLICATION FOR LICENS��I��R�NI1T-2013 t�i+�'(� DEC 21 2012 �� * Please complete form and attach all necess�y document�Dece er ��?T. Failure to do so will result in the return of your application pa . -- ESTABLISHMENT NAME:�� f 1 TAX ID: . LOCATION ADDRESS: 1-1� � � ,n �� o �' TEL.#: MAILING ADDRESS: OWNER NAME: L V CORPORATION NAME�I APPLICABLE):��y�, ,rl�Yl L' � MANAGER'S NAME: i`�'�Y1 �c�m � n .'S�[_ r.-d TEL.#: �oy-77 �- 1��/ 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. 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). Please list these employees 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. 2. 3. 4. rOOD 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.�� m i�n ��t.c_r � (� 2. .�C,�l" �\C4il PERSON IN CHARGE: Ba�ch food establishment have at least one Person In Charge(PIC) on site during hours of operation. 1. l]•2-r'�hf(t1��1 �U�'� 2. �2\� �.�� 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 maintain a file at your place of business. 1. �f'tL��CI�YY�� JIJC�� 2. 3. a 4. RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT Yt LICENSE REQUIRED FEE PERMIT# _B&B $55 _CAB1N $55 _MOTEL $55 _INN $55 _CAMP $55 _SWIMMING POOL $80ea. _LODGE $55 _TRAILERPt1RK $105 _WHIRLPOOL $80ea. FOOD SERV[CE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIREll FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _0-100 SEATS $85 _CONTINENTAL $35 NON-PROFIT $30 I >100 SEATS $160 ��13—�31 I COMMON VIC. $60 � 13—b8� _WHOLESALE $80 RETAIL SERVICE: —RESID.KITCHEN $80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERIvIIT# _<50 sq.ft. $50 _>25,000 sq.R. $225 VENDING-FOOD $25 _<25,000 sq.ft. $RO _FROZEN DESSERT $40 TOBACCO $95 NAMECHANGE: $15 AMOUNTDUE _ $ 220.00 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** \ H . 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 Yarmouth taxes 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 ar 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 ofnot 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 priar to opening. Contact the Health Department to schedule the inspection three(3)days prior to opening.PLEASE NOTE: People are NOT allowed to sit m 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: All food service establishments must be inspected by the Health Department prior to opening. Please contact the Health Deparhnent to schedule the inspection three (3) days priar 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 Department,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 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 15, 2012. 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 RE� AN. � DATE: �� 'L SIGNATURE: � j PRINT NAME & TITLE: �''V Q��va �(11 _ Rev. 10/09/12 Client#:22600 2DIPARMA .4CG�'tD,� CERTIFICATE OF LIABILITY INSURANCE DATE�MM/DDM/YY) � 11/07@012 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTRUTE A CONTRACT BEiWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT;If the certiTicate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed.If SUBROGATION IS WAIVED,subject to the terms and conditions of the poliey,eertaln policies may require an endorsement.A statement on this certificate does not confer rights to the certiflcate holder in lieu of such endorsement(s). PRODUCER NAME: T Dowling&O'Neil PHONE 508 775-7620 5087781218 ac wo ��: ac,No: Insurance Agency E-MAIL ADDRE55: 973 lyannough Rd., PO Box 1990 INSURER(5�AFFORDING COVERA NAIC M Hyannis, MA 02601 msunena:Zurich Insurence Company _ INSURED iNsuRERe:Guard Insurance Group ,L Calamari, Inc DBA DiParma Italian Table INSURERG: 1 � A/O Tasty Tidbits Realty Trust MSURER D: e y I_ 175 Main Street INSURER E: West Yarmouth, MA 02673 �- INSURER F: COVERAGES C'cRTIFICATE NUM6ER: REVISION NUMBER: THIS IS TO CERTIFV THAT THE POLICIES OF INSURANCE LISTED BELOW HAVEBEENISSUED TOTHE INSURED NAMEDABOVE FORTHE POLICVPERIOD INDICATED. NOTWITHSTANDING ANY RE�UIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POIICIES. LIMITS SHOWN MAV HAVE BEEN REDUCED BY PAID CLAIMS. �pR T'PEOFINSURANCE NSRLNND POLICVNUMBER MMIDDYEFF MM/DDr�P LIMITS A GENERALLIABILITY PPSO4179976 6N5/2012 06/15/201 FACHOCCURRENCE $� 0��Q�� X COMMERCIAL GENERAL LIABILITV PREMISES EaEooa�"°rence $2SO OOO cuin+s-rmnoe ❑X occua MEOEXP(Myaneperwn) 55000 PERSONAL&AOVINJURV s1 000000 GENERALAGGREGATE $Y�OOO�OOO GEN'LAGGREGATELIMITAPPLIESPER: PRODUCTS-COMP/OPAGG $��OOO�OOO POLICV JEa LOC $ AUTOMOBILE LNBILRY COMBINED SINGLE IIMIT Ea xdtlent $ ANV AUTO BODILY INJURV(Perperson) E ALLOWNED SCHE�ULED BODILVINJURY(Peracdtlent) 5 AUTOS NON OWNE� PROPERTYDAMAGE E HIREDAUTOS AUT0.S Peracdtlent E UMBRELLALIAB pCCUR EACHOCCURRENCE E EXCE55 LIAB CLAIMSMADE AGGREGATE $ DED RETENTION$ S B WORKERSCOMPENSAiION CAWC354096 B/O�/YO'IY OG/O�/YO� X WCSTATU- OTH- AND EMPLOVERS'LIABILRY ANV PROPRIETOF/PARTNER/EXECUTNE y I N E.L EACH ACCIDENT SSOO OOO OFFICER/MEMBER EJ(CLUDEO? � N/X (Mantlatory in NH) E.L.DISEASE-FA EMPLOVEE $SOO OOO If yas,describe untler �ESCRIPTION OF OPERATIONS below E.L.�ISEASE-POLICV LIMIT $SOO�OOO A Liquor Liability PPSO4179976 6N5/2012 06N5/201 $1,000,000 DESCRIMION OF OPERATIONS/LOGA710NS/VEHIGLES(Albeh AGORO 101,Atltlltional Remarks Schedule,i(more space Is mquired) Insurance coverage is limited to the terms,conditions,exclusions,other limitations and endorsements. Nothing contained in the certi£cate of insurance shall be deemed to have altered,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 7HE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVEREU IN Board of Health ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 South Yarmouth, MA 02664 AUTHORIZED REPRESENTATIVE 'Wf....� �� OO 1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010I05) � pf 2 The ACORD name and logo are registered marks of ACORD #5102977/M102976 LS1 " - : � DESCRIPTIONS (Continued from Page 1) SAGITTA 25.3(2010105) 2 of 2 #51029771M102976