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Home My WebLink AboutApplication and WC ., � TOWN OF YARMOUTH BOARD OF HEALTH ` ��'��d�D � APPLICATION FOR LICENSE/PERNIIT-2010 � Nov 2 ; �ros * Please complete form and attach all necessary do��ent s�b y Decemb H Utr i . Failure to do so will result in the return of your applicaUon pac NAME OF ESTA$LISHMENT: TEL. # SQ8-'�7 I-�7�{0 LOCATION ADDRESS: I�l5 '(Ylq,�,�n �-� i ,�c �elL�io, � ►�� , �,, r m�q p�c�-�3 MAILING ADDRESS: .�7lirn� OWNER NAME: �V T D FE or S N : - CORPORATION NAM�F ( APPLICABLE): C.Q�pur�p�.rw �,�, MANAGER'S NAME:�r,v,,,,n, r, S�,�rr�� TEL. #�5--171-1�7� lo MAILING ADDRESS:�e_ POOL CERTIFICATIONS: The pool supervisor must be certitied 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 Aealth Department will not use past years' records. You must provide new copies and maintain a file at your place of business. I. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTffICATIONS: 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 Aealth Department wiil not use past years' records. You must provide new copies and maintain a Cile at your establishment. i. i�x�m��n S.u.,r r c7 Z.��r i� '�Y1. � -�e��` � PERSON IN CHARGE: Each food establishment must have at least one Person In Chazge (PIC) on site during hours of operation. i. �i�e��r�,r,r, �',n �t.r � D z. ��r � c� r`�11 `�e� I 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 a11 times. Please list your employees trained in anti-chokmg procedures below and attach copies of employee certificarions to this form. The Health Department will not use past years' records. You must provide new copies and maintain a t"ile at your place of business. 1.� � O��rrl ��r� �l ��r fC� 2.�2.r1 � S� N.l�S1't�2,►'1QC�,`P 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 S55 _CAMP �55 ,SWIMMINGPOOL S80ea. _LODGE $55 _TRAILERPARK 5105 _WHIRLPOOL f80ea. FOOD SERVICE: LICENSE REQUIRED FEE P£RMI'C# LICENSE REQUIRED FEE PERMIT# LiCENSE REQUQtED FEE PERMiT 1! 0-100 SEATS S85 _CONTINENTAL %35 NON•PROFIT $30 1>1005EATS $160 ��3 1 COMMONVIC. S60 ��Q�ON� _WHOLESAL� 580 RETAII.SERVICE: —RESID.KITCH£N S80 LICENSE REQiJIRED FEE PERMIT t! LICENSE REQUIltED FEE PERMIT# LIC£NSE REQUIRED FEE PERMI I# _<SOsq.ft. $50 >25,OOOsq.ft. 5225 _VENDING-FOOD 825 �QS,OOOsq.ft. $80 _FROZENDESSERT $40 TTOBACCO � S55 - xa�c�vcE: sts AMOUNTDUE = S ,3�z �� "*•"•PLEA5E TURN OVER AND COMPLETE OTHER SIDE OF FORM*"�*• ADMIl�TISTRATION � Under Chapter 152, Section 25C, Subsection 6,the Town of Yazmouth is now required to hold issuance or renewal of any license or pemrit to operate a business if a person or company does not have a Certificaxe of Worker's Compensarion Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE . AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED V OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth t�es and liens must be paid prior to renewal or issuance of your pernrits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCl': For purposes of the limitations of Motel or Hotei use, Transieirt 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 ofresidence elsea+here. Transient occupancy sha11 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 dwelGng unit shall not be considered transient. Occupancy that is subject to the collecrion 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 inspecte3 by the Health Department prior to opening. Contact the Health Departmern to schedule the inspection U�(3)days pnor to opening.PLEASE NOTE: Peopie are NOT allowed to sit m the pool area untit 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 Depaztment 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)d�ys of closing. FOOD SERVICE CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmoufh Health Departrneat by filing the Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained ar�t tb Health Department. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent 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&om the Board ofHealth. OUTDOOR COOHING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishmetrt is prohibited. NOTICE:Pernuts run annually from January 1 to December 31. TT IS YOUR RESPONSIBII.TTY TO RETURN THE COMPLETED RENEWAL APPLICATION(5)AND REQUIRED FEE(S)BY DECEMBER 15, 2009. ALL RENOVATIONS TO ANY FOOD ESTABLISHIvIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIl'MENT, ETC.), MUST BE REPORTED TO AND APPRO BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUI I E AN. DATE:__Il�� SIGNATURE: PRINT NAME&TITLE: ��G�Ic�I r a_ �a.�Yl f�e I , t 0925109 . ' ' Client#:22600 2DIPARMA ACORDn CERTIFICATE OF LIABILITY INSURANCE ;;;;a,09' PROOIICER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Dowling&O'Neil Insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICA7E A enC HOLDER.THIS CERTIFICATE DOES NOT AMEND,EX7END OR 9 Y ALTERTHE COVERAGE AFFORDED BY THE POLICIES BELOW. 973 lyannough Rd., PO Box 1990 Hyannls,MA 02601 INSURERS AFFORDING COVERAGE NAIC# INSUREO INSURERA: GU3f(I If18Uf3fIGQ GfOUP Calamari,Inc DBA DiParma Italian Table INSURERB: A/O Tasty Tidbits Realty Trust INSURER C: 775 Main Street INSURERD: WestYarmouth,MA 02673 INSURERE: COVERAGES THE POLICIES OF INSURANCE LISTE�BELOW HAVE BEEN ISSUE�TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY RE�UIREMENT,TERM OR CONDITION OF ANV CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAV BE ISSUED OR MAV 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 RE�UCED BY PAID CLAIMS. INSR OD' POLICVEFFECTIVE POLICYE%PIRATION ��MRS LTR R TMPEOF�NSURANLE POLICYNUMBER M OD GENERAL LIABILItY E4CH OCCURRENCE S COMMERCIALGENERALLIHBILITV OAMAGETORENTED a CLAIMS MAOE ❑OCCUR MEO EXP(Anyone person) $ PERSONAL 8 A�V INJURV S GENERALAGGREGATE $ GEN'LAGGREGATELIMITAPPLIESPER: PRO�UCTS-COMP/OPAGG f POLICV PRO- LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANV AUTO (Ea acdtleni) f ALL OWNEO AUTOS BODILV INJURY SGHEDULEDPUTOS (Perperson) $ HIRED AUTOS BODILV INJURY NON-OWNEOAUTOS (Pe�accitlent) $ PROPERTV DAMAGE $ (PeracGtlent) GAFAGELIABILITY AUTOONIY-EAAGCIOENT $ ANVAUTO OTHERTHAN �ACC $ AUTO ONLY: qGG f E%CESSNMBRELLI�IIABILrtY EACHOCCURRENGE $ OCCUR �CLAIMS MADE AGGREGATE S 5 DEOUCTIBLE s RETENTION E 5 A WORKERSCOMPENSATIONAND CAWCOZZ7S9 OG/O�/O9 OBIO'I/�O X WGSTATU- OTH- EMFLOYERS'LNBILITY E.LEACHACCIDENT $SOOOOO ANV PROPRIETORIPARTNERIEXECUTNE OFFICEWMEMBEftEXCLUOE�T E.L.DISEASE-EAEM�IOYEE $SOO�OOO If yes,tleunbe untler SPECIAL PROVISIONS bebw E.L.DISEASE-POLICV LIMIT SSOO OOO OTHER DE9GRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS AUDEO BY ENUORSEMENT/SFECIAL PROVISIONS *"Workers Comp Infortnation** Experience Rating Modification Factor Endorsement Form#WC000403 Edt Date:04/07/84 Notification of Change in Ownership Endorsement Fortn#WC000414 (See Attached Descriptions) CERTIFICATE HOLDER CANCELLATION 10 Da s for Non-Pa ment SHOULO ANY OF THE ABOVE OESCRIBEO POIJCIES BE GNCELLE�BEFORE THE E%PIRATION TownofYarmouth OATETHEREOF,THEISSUINGINSURERWILLENDEAVORTOMAIL �p_ OAVSWRITfEN ��4B ROUSB ZS NOTCE TO THE CERTIFICATE MOLOER NAMEO TO TXE LEFf,6UT FAILURE TO 00 SO SXALL SouthYartnouth,MA 02664 IMV0.5ENOOBLIGATIONORLIABILRYOFANYKINOUGONTHEINSIIRER,RSAGENT50R REPRESENTATrvE3. 9UTXORIZEO REPRESENTATiVE ACORD 25(2001108)� pf 3 #S63259/M63258 JRS o ACORD CORPORATION 1988