The URL can be used to link to this page

Home My WebLink AboutApplication and WC -` _�,D, Pa�M�s . � � TOWN OF YARMOUTH BOARD OF��ALTFI � " � � APPLICATION FOR LICENSE/��#'I�,T-�2011 �� .F= �,�� * Please comrlete form and attach all necessar}f d�cuments-by Decemb I S 2010 I Failure to do so will result in the return�f your application pac t. H�q j �;� ESTABLISHMENT NAI��E: � O�/MQ TAX ID: LOCATIONADDRESS: �-]� q� �, �'� w, �a.mc..'fi') TEL #: �-�� 1- 777b MAILINGADDRESS: _Su.r�r�P OWNERNAME:�VGt �,�ry�hof i� CORPORATION NAME�(IF � PLICABLE): �iY\n,,,t.�r ��.�L MANAGER'S NAME��nr�, n—c�la�.rr�� TEL.#: ,�i�Ok- 'll l- l-�)� MAILINGADDRESS: 1"l`� YY�(�.,^ �t�n„L 1�� y� ,,,n ,-n,� rn� oaco� � POOL CERTIFICATIONS: The poot supervisor must be certified as a Pool Operator, as required by State law. Please list the designated Pool Operator(s) and attach a copy ef the certification to this foi7n. I. Z. Pool operators must list a mniimum of two employees cun•ently certified in basic�vater safety,standard Fn•st Aid azid Community Cardiopulmonary Resuscitation(CPR). Please list these empioyees below and attach copies ofemployee cei7ifications to this forni. The Health Department will not use past years' records. You must provide new copies and maintain a �le at your place of business. L 2. �� 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establislunents az�e requn•ed to have at least one full-time employee who is certified as a Food Protection Manager, as defined 'u� die State Sanitary Code for Food Seivice Establishments, 105 CMR 590.000. Please attach copies of certification to this applicatiou. The Health Department will not use past years' records. You must provide new copies and maintain a file at y�our establishment. i��l� � �cc rv1 � r r�S z. ► C�p� h,t PERSON IN CHARGE: ��r�,�� Each :ood establislunent must have at least one Person In Charge (PIC) un site during hours of operation. i�2r� 1 a-�m i �l �.� .r r n 2. HEIMLICH CERTIFICATIONS: All food seivice establishments with 25 seats or more must have at least one employee uained in the Heimlich Maneuver on the premises at all fvnes. Piease list your employees tranied in anti-chokuig procedures belo�v and attach copies of employee certifications to this forni. The Health Department will not use past years' records. You must provide new copies and maintain a �le at,your place of business. 1.�t'11C1(ni(1 � )t.LYYl7 2�2(11SP 1�1iG�'t-�e�1QG1 �� 3. J 4. RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LODGISG: LICENSE REQUIRED FEE PERMII'# LICENSE REQUIRED FEE PE&�fIT� LICENSE REQUIRED FEE PERh4I7 a _B&B S55 _CABIN S55 \10TEL S55 _INN S5� _CA:YIP 5» _ _S\b"IMMINGPOOL SSOea. � LODGE S55 _IRAILERPARK 510� ��`HIRLPOOL SROea. FOOD SER\'ICE: � LICENSE REQUIRED FEE PERVtff= LICENSE REQUIRED FEE PERbIIl"€ LICENSE REQUIRED FEE PERMIi� _0-100 SEATS S35 _CONTINENTAL S35 NON-PROAI' S30 �>100 SEATS 5160 (—OSO ( COD�L�fON VIC S60 �(�,� _�i�'HOLESALE S80 RE'I:11L SER�ICE: —RESID.kITCHEN S30 LICENSE REQUIRED FEE PER�IIT� LICENSE REQUIRED FEE PER\-➢T= LICENSE REQIIIRED FEE PER�IIT� _<SOsq.ft. � S50 _>25.00Osq.ft. 5225 VENDING-FOOD S25 � _<�5,p00sq.ft. S30 _FROZENDESSERT 540 TOBACCO S55 �a�[E c��ce: sis AMOUNT DUE _ � 220 .�O "*'"*"PLEASE I'lR\O�"£R a\D CO\1PLE-IE OTHER SIDE OF FORJI*"w** y . . L i 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 COMPENSAT'ION 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 OTHEii LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes ofthe limitations ofMotel or 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 haue 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 Transier,t. 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 inspectionthree(3)days pnor to opening. PLEASE NOTE: People are NOT allowed to srt in the pool azea until the pool has been inspected and opened. POOL�'VATER 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. POUL CLUSli7V G: 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 Department to schedule the inspect�on three (3) days prior to opening. CATERING POLICY: Anyone who caters within the Town of Yannouth 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.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 ofHealth. OUTDOOR COOHING: 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 RESPONSIBII,ITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S) AND REQiIIltED FEE(S)BY DECEMBER I5, 2010. ALL RENOVATIONS TO ANY FOOD ESTABLISHD�N MOTEL OR POO e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND , OVED BY T OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS 1�1AY RE I� ITE PL DATF: �.Q 'a� (� SIGNATURE: PRINT NAME&TITLE: �V � r 10�0510 <uirqrtms� AGOkD.. CERTIFICATE OF LIABILITY INSURANCE °"TE,""'°°""n" 10/27/2070 rrsooucen ' THIS CERTIFICATE IS ISSUED AS A MATfER OF INFORMATION Dowling&O'Neil Insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE AgBnCy HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 973 lyannough Rd., PO Box 7990 Hyannis,MA 02601 INSURERS AFFORDING COVERAGE NAIC# INSUREO INSURER A: GUBfd if15U(af1CB GfOUP Calamari, Inc DBA DiParma Italian Table iNsuaeR a: AIO Tasty Tidbits Realty Trust �- 175 Main Street wsuaea c irvsuaeR o: West Yarmouth, MA 02673 INSURER E' COVERAGES ' THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANV CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLIpES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLIGES.AGGftEGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BV PAID CL41MS. INSR �0' POLICYEFFECTIVE POLIGYEXPIRATION LTR NSR TVPE OF INSURANCE POLICV NUMBER E MM M DD LIMITS GENERAL LIABILITV EAGH OCCl1RRENCE $ COMMEftGIAL GENERAL LIABILITV DAMAGE TO RENTED s CLAIMS MAOE ❑OCCUR MEO EXP(My one person) f PERSONAlBAOVINJURV E GENERALAGGREGATE $ GEN'LAGGREGATELIMITAPPLIESPER: PRODUCTS-COMPIOPAGG § POLICV PR� LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMR ANYAUTO (Eaaccideni) E ALL OWNED AUTOS 90DILV INJURY f SCHEDULE�AUTOS (Per person) HIRE�AUTOS BODILY INJURY f NON-OWNED AUTOS (Peraaidm�) PROPERTVDPMAGE f (Peraccitlan�) GARAGELIABILITY AUTOONLY-EAFCCIOENT E ANV AUTO OTHER THAN �pCC § AUTOONLV: qGG 5 E%CESSIIIMBRELLA LIABILITY - EqCH OCCURRENCE E OCCUR �CLAIMS MADE AGGREGATE E E oeoueTis�e g RETENTION $ j A WORKERSCOMPENSATIONANU CAWC131600 OB/O�I'IO OG/O'II�� X WCSTATU- OTH- EMPLOVERS'LIABILITY EL.EACH ACCIDENT ESOO OOO ANY PROPRIETOR/PARTNEfLE%ECUTIVE OFFICEWMEMBEREXCWDED? NO EL.DISEASE-EAEMPLOYEE SSOO�OOO If yes,tlescribe under SPEQAL PROVISIONS below EL.�ISEASE-POLICV LIMIT §SOO OOO OTHER DESC2IPTION OF OPERATONS I LOGATIONS I VEHICLES/EXCL11510N5 ADDED BY ENOORSEMENT/SPECIAL PROVISIONS 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 coverege provided by the policy provisions. Members are included under the (See Attachnd Dexripiians) CERTIFICATE HOLDER CANCELLATION SHOULU ANY OF THE ABOVE DESCRIBEp POLIGIES BE CANCELLED BEFORE THE E%PIRAiION Town of Yarmouth DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL �Q_ DAYS WRITfEN Board of Health NOTICE TO THE CERTIFICATE HOLDEN NAMEO TO THE LEFf,BUT FAIW RE TO DO50 SHALL 1146 Route 28 IMPOSE NOOBLIGATION OR LIABIl1TY OF ANY KIND UPON THE INSURER,RS AGENTS OR South Yarmouth, MA 02664 REPRESENTATIVES. AUTHOR V cD R�PRESENTATIVE �w� �� ACORD 25(2001108)� of 3 #5741421M74147 LS1 a ACORD CORPORATION 1988 Client#:22600 2DIPARMA ACOhD,� CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY) 11/30/2010 rreooucen ' THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Dowling 8 O'Neil Insurance ONLY AND CONFERS NO RIGH7S UPON THE CERTIFICA7E A enc HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 9 Y ALTER THE COVERAGE APFORDED BY THE POLICIES BELOW. 973 lyannough Rd., PO Box 1990 Hyannis, MA 02607 INSURERS AFFORDING COVERAGE NAIC# wsurceo irvsuaeRa: Zurich Insurance Company Calamari,Inc DBA DiParma Italian Tabie INSURERB: A/O Tasty Tidbits Realty Trust INSURERC: 175 Main Street INSURER D: West Yarmouth, MA 02673 INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NO7WITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAV BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR DD' POLICY EFFECTIVE POLICV E%PIRATION LTR NSR 7VPE OF INSURANCE POLIGY NUMBER M D LIMRS A GENERALLIABILRV PPSO4179976 Qs��rJ�� O6/75/11 �CHOCCURRENCE $� QQQQQQ X COMMERCIAL GENERAL LIABILITV OAMAGE TO RENTED $]S OOO CLAIMS MADE �OCCUR � �- - � . ME�EXP(My one person) $S OOO � � • PERSONAL 8 A�V INJURV $'I OOO OOO � � GENERALAGGREGATE EZ OOO OOO GEN'LAGGREGATELIMRAPPLIESPER: � . . , � � PRO�UCTS-COMP/OPAGG E'I OOOOOO POLICV PR� LOC ' ' AUTOM081LE LIABILITY = .. ' � COMBINEO SINGLE LIMIT ANY AUTO � � - � �" (Ea accitlent) S ALL OWNED AUTOS BODILY INJURV SCHEDULEDAUTOS (Perperson) $ HIREO AUTOS BOOILVINJURV $ NONAWNED AUTOS (Per accitlen[) PROPERTY�AMAGE $ (Peraccident) GARAGELIABILITY AUTOONLV-EAACCIDENT $ ANVAUTO OTHERTHAN �ACC $ AUTOONLV: pGG $ EXGE55/UMBRELLALIABILffY EACHOCWRRENCE $ OCCUR �CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE $ RETENTION $ $ WCSTATU- OTH- WORKERS COMPENSATION AND EMPIOVERS'LIABILITY ANV PROPRIETOR/PARTNER/EXECUTNE E.L EACH ACCNENT $ OFFICERIMEMBEREXCLUDED? E.L.DISEASE-EAEMPLOVEE $ If yes.tlescri�e untler SPECIALPROVISIONSbelow E.L.DISEASE-POLICVLIMIT $ A OTHER LiquorLiab. PPSO4179976 06I75/70 06N5/11 $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I E%CLUSIONS ADDEO BV ENDORSEMENT/SPECIAL PROVISIONS Insurence coverage is limited to the terms,conditions,exclusions,other _ limitations and endorsements. Nothing contained in the certificate of insurence shall be deemed to have altered,waived, or extended the coverage provided by the policy provisions.Members are included under the (See Attached Descriptions) CERTIFICATE HOLDER CANCELLATION SHOULD ANV OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION TownofYarmouth DATETMEREOF,THEISSUINGINSURERWILLENDEAVORTOMAIL �_ DAVSWRfI'TEN Board of Health NOTICE TO THE CERTFIGATE HOLDER NAMEU TO THE LEFT,BUT FAILURE TO DO 50 SHALL 1146 Route 28 IMPOSE NO OBLIGATION OR LIABILRY OF ANV KIND UPON THE INSURER,RS AGENTS OR South Yarmouth, MA 02664 REPRESENTAlNE3. AUTHORIZ�PRESENTATNE ..�.J c C� .:� ACORD 25(2001I08)� of 3 #S75092/M75097 LS1 O ACORD CORPORATION 1988 IMPORTANT If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25S(2001I08) 2 of 3 #575092/M75091