The URL can be used to link to this page

Home My WebLink AboutApplication and WC a TOWN OF YARMOUTH BOARD OF HEALTH -r �AS ; � � � � APPLICATION FOR LICENSE/PERNIIT - 2 1 , , �;.,a � f: .'�� J�� I I i * Piease complete form and attach all necessary doca�tt t� ber IS 2011. Failure to do so will result in the retum of y pp�''a ion ac EALTH DEPT. ESTABLISHMENT NAME�l� �m 0.. `I,�IG�✓�I G(,{"JI �_ TAX ID: _�� LOCATION ADDRESS: 1'7. � �'1 ��]t p�f TEL.#:S��-77/-777 G� MAILING ADDRESS: OWNER NAME: �VGi CORPORATION NAME APPLICABLE): ('�(J�m� ,., , T�rt G MANAGER'S NAME: P�P.n icr m,n �li rrt) TEL.#: MAII.ING 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 cunently certified in basic water safety, standard Fust Aid and Community Cazdiopulmonary Resuscitation (CPR). Please list Ihese 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. 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 certif"ication to this application. The Health Department will not use past years'records. You must provide new copies and maintain a f'ile at your establishment. 1. '__3�1�c 1a.j/ I'C� 2.�P�YZIS� ' �'1YY�'i PERSON IN CHARGE: Each food establishment must have at least one Person In Chazge (PIC) on site during hours of operation. 1. 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heunlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of employee certif'ications 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. ��n SLt-r r� 2. �YI � Wl'i + �"a_ 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMTT# _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 PERM[T# _0-100 SEATS $85 _CONTINENTAL $35 _NON-PROFIT $30 �>1005EATS $160 �� COMMONVIC. $60 �� 'U� _WHOLESALE $80 RETAII.SERVICE: —RESID.K[TCHEN $80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT k _<50 sq.ft. $50 _>25,000 sq.ft. $225 _VENDING-FOOD $25 _Q5,000 sq.ft. $80 _FROZEN DESSERT $40 _TOBACCO $95 NAME CHANGE: $15 AMOLTNT DUE _ $ 2 z o.O O *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*k��# 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 AFF'IDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED Y OR WORKER'S COMP. AFFIDAVTI' 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 11�TOT�LS EiND OTh'Eit i,f'tDGIPv�ESTAI3LISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be limited to the temporary and short term occupancy,ordinazily and customarily associated with motel and hotel use. Transient occupants must have and be able to demonsuate 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 aggegate 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 priar to opening. Contact the Health Department to schedule the inspection three(3)days pnor to opening.PI,EASE NOTE:People aze 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 standazd 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 OPEIVING: 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 required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtauied 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: uutside caies(i.e.,ou�aoor seatitig with waiieri wniucss service),iirust iiave priur appr�vai irai,�1ie Bun�•d of Health. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. NOTICE:Pernuts run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETLJRN THE COMPLETED RENEWAL APPLICATION(S) AND REQUII2ED FEE(S) BY DECEMBER 15, 2011. 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 TI'E PLAN. DATE: ��2/` —�� SIGNATURE: /l�� PRINT NAME&TITLE: ��/,� ��9�//,%�S Rev.10/25p 1 Client#:22600 2DIPARMA ACORDn CERTIFICATE OF LIABILITY INSURANCE OATE�MMIDOIYYYY) 11/16/2011 THIS C6RTIFICATE�3 ISSUED AS A MATTER OF iNFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS 'CERTIPICATE DOES NOT AFFIRMATIVELY OR NEGATNELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BE7WEEN THE ISSUING INSURER(S�,AUTHORIZED REPRESENTATVE OR PRODUCER,AND THE CERTIFICATE I10LDER. IMPORTANT:Ii Me eertiflwte hoWer is an ADDITIONAL INSURED,the poliey(les)must be endoned.M SUBROGATION IS WAIVED,subjeet to the terms and condRiona of the polley,certain polleies may require an endorsemenl.A sptement on this certMfwte does not wnfer Nghts to the certifleata holder in Ileu of such endorsemenqs�. VROWCER Dowling&O'Neil PXONE Insurance Agency � �,rt:508 775-1B20 � N„ 5087781218 973 lyannough Rd., PO Box 1990 �DRESS: Hyannis,MA 02601 INSURE S)AFFORpNG COVERAGE Nu�R iMsunertn:Guard Insurenee Group INBURED Calamari, Inc DBA DlParma Italian Table ��URER B: A/O Tasly Tidbks Realty Trust �MSURERC: 775 Mafn Street �NSUNERO: Wast Yartnouth, MA 02673 �MBURER E: IN9URER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFV THAT THE POLIqES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTlWDING ANY REQUIREMENi, TERM OR CONDR�ONOF ANV CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICA7E MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT 70 ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAV HAVE BEEN REDUCED BV PAID CLAIMS. L�RR ?VPE OF IN9UpANCE ADa-SUB POLIGY EFF M�Y EXP �wR9 INSR U POLICV NUMBER N GENERAL lJp&Llry EACHOCCURRENCE § COMMERCIALGENERALLIABILITV OAMAGET pE�p� S PREAl13E5 Ea CLAIMS-MqOE. ❑OCCUR MEDE%P(Myuriepenon) y PERSONAL 8 ADV INJURY f GENERALAGGREGATE 1 GEMLAGGREGATELIMITMPLIESPER: PRODUCTS-CAMP/OPAGG j POLICY PR6 �� s AUTOMO&LE LNBRJfV �MBI�NED'1SINGLE LIMIT ANYAUTO BO�ILYIWURY(Perpersq�) E ALLOWNEO � SCHEWLEO �T� AUT0.S BODILV INJURV(Peraai0enp S HIREDAUTOS q�Tpg�ED �E�AMAGE s E UNBRELLA WB p�CUR FACMOCCURRENCE S Q«WB CWMSMqDE AGGREGATE j DED RETENTION 5 A u�ErwRS.orECOM�"�iva m CAWC241862 6/01/2011 OW01/ZOt X �STATLL on+ s �FICPERIEIMTB�ERE7(�CIT.UDED�ECUTIVE� NIA E.L.EACHACCIDENT $�QQQ� If�yestl In Nu� E.L�ISEASE-Ep EMPLOVEE SS�O� DESCRIPTION OF OPEMTIONS Oebw E.L.DISEASE-POLICV LIMR $SOO�OOO DE8CNVIpN OF OPEIiAT10Nt I LOCATqN$I VEHICLES(AC�ch ACORD 701.AtlEkbnN Rpnarka$ehWyN.R mw�apac�N rpuked� Insuronce coverage is Iimited to the terms,condkions,exclusions,other I(mitations and endorsements. NotfHng contained in the certiflcata of insuranea shaU be deemed to have altered,waived,or extended the coverege provided by the policy provisions.Members are included under the workers wmpensation poiicy. (See Atfaehed Deuripdons) CERTIFlCATE HaDER CANCELLATON Town of Yarmouth gHOULD ANY OF THE ABOVE pE9C1tIgEp ppV��Eg gE CANCELLED BEFORE BOaId Of HBeI�I1 THE E%P�RAnON DATE THEREOF, NOiICE NIILL BE DELIVEREp IN ACCORDANCE VYITH THE POUCV PROVISIONS. 1746 Route 28 South Yarmouth, MA 02664 AUfXOR1�D REPRE$ENTA7NE �� 0 7988-2010 ACORD CORPORAnON.NI righb resarved. ACORD 25(2010/OS) 1 of 2 7he qCORD name and logo aro reglatered marks of ACORD #588169/M88168 L31