HomeMy WebLinkAboutApplications, WC and Licenses Prior to 2010 , <� �J�� n� �,p�
' �` r'k� TOWN OF YARMOUTH BOARD OF HEALTH
;� � � APPLICATION FOR LICENSE/PERMTl'-2008 �
� . �9 .i
* Please complete form and attach all necessary documents by December'31, 2007
Failure to do so will result in the retum of your application packe� �=f' , , , i�� ?" t
NAME OF ESTABLISHMENT:�p�,�����np'C �'[yV��Tpb� TEL. #�T`-�"Z,(.,
LOCATIONADDRESS: \lS '(tiAvn : �e�C'��`a,��,p�N��cc� Vv�� p�.( 'j3
MAILING ADDRESS:_, MC �415 IL�CbV�
OWNER NAME:'(��mdnre 4 1cva�eLin 2�w��eeL�c TAX ID (FEIN or tv�� �-
CORPORATION NAME IF APPLICABLE):
MANAGER'S NAME: �er�jAm[n SU C(b TEL. # ��y,.3$3{�"124
MAILING ADDRESS: ly S'CECCac� C� �,(Yh�u YY1ia h2(o�J
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator,as required b��State law. Please list the desienated
Pool Operator(s) and attach a copy of the certification to this form.
1. 2.
Pool operators must list a minimuxn of two employees currently cenified in basic water safety, standard First Aid and
Community Cazdiopulmonary Resuscitation(CPR). Please list these employees below and attach copies ofemployee
certifications to this form. The Health Depertment will not use past years' records. I'ou 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 requ'ved to have at least one full-time employee who is certified as a Food
Protection Manager, as defined in the State Saiutary Code for Food Service Establishments, 105 CMR 590.000.
Please attach copies of certification to this application. The Health Department will not use past��ears'records.
You must provide new copies and maintain a file at,your establishment.
1. �� �1�\U,� Z. l`���'r]�,UC'_
PERS9N IN �HARGE:
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
1.__��`(h�� �fYl� 2. �CG� �\P�l�� _�C_��
k
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 yow employees trained in anti-choking procedures below and
attach copies of employeQ certifications to tlus 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. � �l 2.
3. � 4.
RESTAURANT SEATING: TOTAL # �_I g
OFFICE USE ONLY
LqDGING:
LICENSE�2EQUIRED FEE PER'�f17* LICENSE REQL`IRED FEE PER4f17� LICENSE REQL7RED FEE PERVS[T=
_B&B S50 _CABIN S50 _MOTEL SSO
_INN 550 _CA:4IP S�0 _S�4'IYI.vIINGPOOL575ea.
_LODGE S50 _TRAILERPARK 5100 R7-IIRLPOOL S75ra.
FOOD SERVICE: , � _,..
LICENSE REQUIRED FEE PER�fIT= LICENSE REQPIRED FEE PER4SIT= LICEtiSE REQti IRED FEE PER�fIT=
_0.100 SEATS S75 _CONTINENTAL S30 NO\-PROFI'I S25
I >100SEATS 5150 �jJg-188 �COVI.YfONVIC. 550 O(3�I _V1'HOLESALE 57i
RE7AIL SERVICE: � —RESID.KITCHEN 57i
LICENSE REQLnRED FEE PER'NIT= LICENSE REQL7RED FEE PER\4IT= LICENSE REQLIRED FEE PERbill'_
_<50 sq.ft. S45 _>25,000 sq.d. 5200 �'ENDING-FOOD S?0
_Q5,000 sq.8. S75 _FROZEN DESSERT S35 TOBACCO 550
vn.�caavice: sio AMOUITDUE _ $ a-�o .o0
**•"*PLEASE'IL'R.Y O\'ER��D CO�iPLE'IE 07'H£R SIDE OF FOR�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 COMPENSATION INSURANCE
AFFIDAVTI'MUST BE COMPLETED AND SIGNED, OR
CERT. OF INSURANCE ATTACHED �/
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth ta�ces and liens must be paid pri to renewal or issuance of your pemrits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES NO
MOTELS AND OTHER LODGING ESTABLISHMENTS
TRANSIENT OCCUPANCY': For purposes of the limitations of Motei 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 have and be abte to demonstrate that they maintain a principal place ofresidence elsewh�e.
Transiem occupancy shal( generally refer to conrinuous occupancy of not more than thirty (30) days, and an
aggregate of not more than ninety(90) days within any six(6)manth 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.
* NOTE: En��osea Motel Census must be completed and returned w;tt,tt�s appli�at�on.
POOLS
POOL OPENING: All swimming,wading and wlurlpools which have been closed for the season must be ins ed
by the Health Department prior to opening. Contact the Health Department to schedule the inspection five(�ys
prior to opening.
POOL WATER T'ESTIlYG: The water must be tested for pseudomonas,total coliform and standard plate count
by a State certified lab, prior to opening, and quarterly thereafter.
POOL CLOSING: Every outdoor in ground swimming pooi must be drained or covered within seven(7)days of
closing.
FOOD SERVICE
CATERING POLICY:
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Departrnert 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.
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 urnil the
above terms have been met.
OUTSIDE CAFES:
Outside cafes(i.e., outdoor seating with waiter/waitress service),must haue prior approval from the Board ofHealth
OUTDOOR COOKING:
Outdoor cooking,prepazation, or display of any food product by a retail or food service establishmec�t is prohibited.
NOTICE:Permits run annually from January 1 to December 31. I'I'IS YOUR RESPONSIBII.ITY TO RETCTRN
THE COMPLETED APPLICATION(S)AND REQUIItED FEE(S)BY DECEMBER 31, 2007.
ALL RENOVATIONS TO ANY FOOD ESTABLISHIVIENT, MO'I'EL OR POOL (i.e., PAINTING, NEW
EQUIPMENT, ETC.), MUST BE REPOR'I'ED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR
TO COMMENCEMEVT. RENOVATIO:vS MAY REQUIRE A SITE PLA'.�t.
DATE: �UO$ SIG�IATURE: ,,��
PRI:�IT:VAh1E&TITLE: QQR�B'lh�� Scrc�O G Yh ,
io :o o�
1-877-532-8522 6/19/2008 6: 03 : 12 FM PAGE 2/002 Fax Server
sa.a�a ow:ow�uzooe Ecdeb Rep:JAMES D VILLANI Service Detei!Re R
TED ZAMBELIS p 9 �� ���
Tims-IN: 3:13 m Eeda�M r:MICHAELAZABATTA
VARI�UTMNOUSE Tima-OUT: �:15pm
335 MAIN ST —
Location:Kitchen Valued Custaner
WE8T YARMOUTH MA 02673 Since Mar-2003 �-8�3'.f�CLEAN
01 9 61 2 319 Routine Preventiva Mainlenance warewasning
c3=Repetitive Issue
Wh44 Inspecllon
Resuhs
Dishwsre C�ecketl-OK
Glassware Checketl-OK
Cups Checketl-OK
FlaRvere Checked-OK �
Machine
Arms ChecKetl-OK
Arm Entl Gaps C�ecKetl-OK
Door Checked-OK
Drain . Checketl-OK
Meaters Checketl-OK
Jets Checketl-OK
Nozbes Checketl-OK
Dispensing
Wareweshing Macnine Chacked-OK
Readings
Wash Temp 150 deg.F
Final Rinse Temp '150 tleg. F
Sanitizer-ppm 60 pDm
De[ergent Titretion-drops 12
Rinse Adtlitive 1.5 mis
�,sk me �b�aut other �cola� verv;ce,. Rest Elin�?in�tia�, �Sst��e��
E�uip �ervie� ar�d Fa�ad �af�ty ,4u�its
No Cberge(or Service
CODE NAME INV OTY CU9TOMER REVIEW
�. .�. �. . .�. � . :�. : : : . . . . . .�. .�. .�. .�. .�. .�. .�
Customer Acknowledpement
360°of ProtectionTM Page 1 of 7
Copyright�2008 ECOLAB All rights reserved.
1014743958
06/20l2008 10:57 5084772245 � SMC ASSOCIATES PAGE 01
C 2DEVIN
� ACORD CERTIFICATE QF LlABILITY INSURANCE ��,""'"'
���� TNIS CERTIFICATE I$ISBUED/13 A MATTER OF INFORMATION
DOWIIRg 3 O'NOII 111sYY911p ONLV AND CONFEN$NO R1pNTg UPON 7ME CERTIFlCATE
��� ALT�ER TM COVERAC�qFfORDED BYTTFIE pQUC1ES BE LONf.
8731ya�ough Rd.. PO Box 1890
Hy�nn4,MA 0$601 �wsuREkS AFFoaoING COVEawoe WnIC s
�� �Hsu,e�ati Guvd I�uursnu
Ghmerl,Inc DIB/A DeVino's RuLunM
MO Tasty Tldblb Rplty Trwt �"��&
17S Meln ShaN ��auaEw a
wssc rsrmann,MA OZ673 ���`°
�NBURER E
COVERA6E8
TME POLICIEB OF!N$URANCE USTED BE1pW MAVE BEEN ISSUED TO TME IN9URED NAMED ABOVE Fplt TNE POL�V PEPoOD INOIGTED.NOTWITH37ANqNG
M1Y REQU�REMEM.TERM OR CONO/TIIXi OF ANV Cp/l'q�Ct p(t OTMER OO(,UMENT WITM qE5pEC7 TO WMICN TN9 CERTIFlCA75 MAV$E ISSUED OR
MAY CERTNN,T/IE INSl1RANCE ACFpRpE�BY THE POLIdEH DESCR�BFA MEREM IS SUBJECT TO All TH�TEf{Mg,�(C1U610N8 PND CONDRION3 OF SUCM
DOLICIES.AGGREOA7E uM1T$$NpWN M/tY HAVE BEEN R£DUCED BY PAID CWMS.
T'YEOfMWIIiWCE ►OLILYIIIIYl6l WR7
o�nww�anv �ntnoccur�nce �
corn�ac�uae�ru�w�eiun roa f .
CLAIMB WOE ❑OCCUR MED IXP( aM i
PFA90N/iL 6�DV INlURV j
GENEMLAGGREGAIE �
OE�IlA00NEQnTeuMn�pvuEsven: v�ppyCTS-CANPlOPApO f
�icr �O �x
A�O�E��� CONBINW 91NpLE 11MlT
•M'NJ70 IEi�Maanq =
ALL OMiNEDAV10.4 BOOILV iWURY
SClIE�ULEDAU703 (PMoanM) f
HIREO AUT0.9 8004Y INIVRY
NON-0N?EOAVTOS (Pv�akwn) i
PFOPERT'OA�uOE _
(Pr amuenp
011RAOELMORITT AUTOONLY-EAAGCiOENT S
NA'Ml10 QiMER7MIN EIIACC S
Mrto otar. �oa 6
RCEOWYMEIUlLW1TM EAGNOCCUItl1ENGE j
OCCUR �CwMB MnDE AGGREGATE S
S
DEDUCIIBLE _
XET�+TION f
A waucots corvoropnoN u�p BINDER2875S6 OBq2�8 pg/p2py j( M'C BTAN- 01w
.w�m
aNv PRavaEranNulTr1ER�E%ECU*Nf E.L EACN AC b.��
o�icewweMeenaecwoEm NQ E.�.MBFABE-EFEMP�trrt i'.i��
�I ya ae.aB��ntl�
SPECIN. E.LD18E�SE.PoLILYLIMI� s500000
CTIFN
OFBCIO►fqN OF O►Fl1AlqN!/LOCATGMf/VEItlCLE6l OtCWlqN�AOOEO BYEMOORSFIENf/lPECNL►ROV WON!
Insurenu covqoga ia lImINd M tM qrms,eonditbna,�fcelualona,othar
Ilmlmtlons snd�ndorssmsnq. Nothing coMsinsd In ths prdficab of �
Inswsncs ahall M dssmsd W havs aR�rsd,watwd,or e�Mndsd ths
covorape provltled by the polky provlsio�».Manban aro Indudad under tha
(S�O AtlYChW DqCrIPWro)
CERTIF TE HOLDER CA�pyy�7�pN
MfoYID AMTOi TNE 11YOYE vEYCM1iED iOIICIEB OE C4MCElLED BEFdI!711E OfOMTON
Town of Yarmouth o�re rn�ncor,ne rwNo Msvnue nnu Eno�voam wu� _!� o�n w�meN
Boartl of Moalth rance ro n�cvmcs�n Hwoae ru�o ro n��rr,aut p�auae ro 00�p e�ut.�
1118 Routs 28 iwrwc�q oKwnnox oa wuMv Os u�v Nu/D WOn 7N!wWqEq,nf�plMf!q�
SeuM Yannouth�MA OZ660 av cwrw
wTMo�ven yyaserr�nve
-�✓!�� �
ACORD 25(2001l0lJ� p{3 f52281 �,g� o ACORD CORPORATION/9!B
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NUMBER: #08-188 FEE: $150.00
In accordance with re�1 ations promulgated under authority of Chapter 94, Section 305A and Chap[er
111,Section 5 of the(Ueneral Laws,a peiviit is hereby granted to:
Calamari, Inc., 175 Route 28 West Yazmouth, MA
Whose place of business is Tony Divinds Italian Table
Type of business: Food Service
To operate a food establishment in: Town of Yarmouth
Pemut expires: December 31. 2008 soARD oF�ni.1'x: 3nfQe—fe-�aa-S� �irlaL�c, `JZ..N., �a�nvnaQn_-_
SEATING: 1'71 �.fNA�.�o JG. �jr v(CC�,►[[iNrjnqn,
RESIRIC7TONS: Based on sewage plans,full china service only allowed ./t0�f. �MO[Illt� �
for 177 seats.P�esent seating of 171 detemtined by Building Depacfiient. Q/1!t�M4PIf�liU7fL� �..lv.
Monitor water resdings monUily,with repoR submitted to Health Deparhnent FItQ�ft �, ,�QljCb
by December 1 st.
Bmce G. Murphy,MPH,RS.,CHO
7une 20.2008 Director of Health
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
PERMIT NiJMBER: #08-114 F'EE: $50.00
This is to Certify that Calamari, Inc. d/b!a Tonv Divinds Italian Table
175 Route 28, West Yarmouth MA
IS HEREBY GRANTED A
COMMON VICTUALLER'S LICENSE
In said Town of Yarmouth and at that place only and expires December thirty-first 2008 unless
sooner suspended or revoked for violation of the laws of the Commonwealth respecting the
licensing of common victuallers. This license is issued in confomuty with the authority granted to
the licensing authorities by General Laws, Chapter 140, and amendments thereto.
In Testimony Whereof, the undersigned have hereunto affixed their official signatures.
BOARD OF HEALTH: 3Ee�eic SI�aR�, `JZ.rV., C'Rraixmaa
searm�c: 171 � `�, `,J(¢� ',(� v��n
RESTRICTTONS: Based on sewage plans,full china service only allowed �'�
for 177 seats.Present seating of 171 detertnined by Building Department. __ ,
Monitor water readings monUily,with report submitted to Healih Deparhnent ;�IX(�2d
by December 1 s[.
June 20.2008 Bruce G. Murphy,MPH,R.S.,CHO
Director of Health
TOWN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHMENT
PERMIT NUMBER: #OS-188 FEE: $150.00
In accordance with regulalious promulgated under authority of Chapter 94,Section 305A and Chapter
I I I, Section 5 of the Generat Laws,a pecmit is hereby gran[ed to:
Calamari Inc 175 Route 28 West Yazmout MA
Whose place of business is: Tony Divinds Italian Table
Type of business: Food Service
To operate a food establishment in: Town of Yarmouth
Permit expires: December 31_ 2008 BOnRD oF HEaI,TH: 3feP.ert $fur/i,, JZ„A/,, '�au�tary
Cl a��Pee .�E..'KeflilEe�c `Uice C'�aitunan
:J2aBent s. `,,ttrowx, C�
SEATtrrG: 178 (��(��� ��_
`^"^�"' �•�
Bruce G. Murphy,MPH,RS.,CHO
7une 20.2008 Director of Health
T'HE COMMONWEALTH OF MASSACHUSETTS
TOWN OF YARMOUTH
PERMIT NCJMBER: #08-ll4 F`EE: $50.00
This is to Certify that Calamari, Inc. d/b/a Tonv Divino's Italian Table
175 Route 28 West Yazmout MA
IS HEREBY GRANI'ED A
COMMON VICTUALLER'S LICENSE
In said Town of Yarmouth and at that place only and expires December thirty-first 2008 unless
sooner suspended or revoked for violation of the laws of the Commonwealth respecting the
licensing of common victuallers. This license is issued in confornvty with the authority granted to
the licensing auffiorities by General Laws, Chapter 14Q and amendments thereto.
In Testimony Whereof, the undersigned have hereunto af£xed their official signatures.
BOARD OF HEALTH: .�Eefen SR�aPt, J2.✓Y., C'P�aixman
SEArwG: 17$ (��� � rU���
t���!IL [[/►L�� .
7une 20.2008 Bruce G. Murphy,MPH,R.S.,CHO
Director of Health