Application and WC . TOWN OF YARMOUTH BOARD OF HEALTH I���o�����°
� � APPLICATION FOR LICENSE/PERMIT-2010
�.��I�{�,2. DEC � 7i •�9
* Please complete form and attach all necessary documents by Dece er �u tr � .
Failure to do so will result in the retum of your application pac
� NAME OF ESTABLISHMENT: �Mirlo�s" �LL�, TEL. # 5�13-.��/`7`-�P�D��
LOCATIONADDTZESS: Z3T k S�k4l. a mo.��., OZIp(o
MAILING ADDRESS: 3" am � A,tr'� oi
OWNERNAME: I-Fenr �.,� D FE or S • O - `��
CORPORATION NAME (IF APPLICABLE): �.M . t'��2-� In�.
MANAGER'SNAME: F�r1i-}x- �Goc.evo.- TEL. #
MAILING ADDRESS:
POOL CERTIFICATIONS: 1� I F4"
1'he 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 fofm.
1. 2.
Pool operators must list a minimum of two employees currently certified in basic water safety,standud 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.
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 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. �'lnrF�- ,kor �',r�- 2.
PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
1. ���a ,KoGeJF. 2.
HEIMLICH CERTIFICATIONS: N��'
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 nained in anti-chokmg procedures below and
attach copies of employee certificarions to this form. The Health Departroent will not use past years' records.
You must provide new copies and maintain a t"ile at your place of business.
i. 2.
3. 4.
RESTAURANT SEATING: TOTAL #
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIKED FEE PERMIT# LICENSE REQLIIRED FEE PERMIT#
_B&B $55 _CABIN $55 _,MO'IEL S55
_INN R55 �CPS?p QtS ��S:'.;IvL�Il;:G FOGi. 380ex.
_LODGE $55 �'CRAILERPARK $105 _WA[RLPOOL $80ee.
FOOD SERVIC£:
LICENSE REQUIltED FEE PERMIT# LICENSE REQiJIItED FEE PERMIT# LICENSE REQUIRED FEE PERMIT u
I 0-IOOSEATS S85 D��"U'I _CONTINENTAL S35 _NON-PROFIT S30
>I00 SEATS $160 COMMON V1C. S60 WHOLESALB S80
RETAIL SERVICE: —RESID.KITCHEN S80
LICENSE REQUIRED FEE PERMfi# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_<SOsq.ft. 850 >25,OOOsq.ft. 5225 _VENDING-FOOD 525
TQS,OOOsq.ft. $80 � t _FROZENDESSERT $40 T7'OBACCO S55
xnME cHnxeE: sts AMOIJNT DUE = S 85•Ge
"`•""PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM"*""*
ADMINISTRATION ° `
Under Chapter 152, Section 25C, Subsection 6,the Town ofYarmouth is now required to hold issuance or renewal
of any license or pernrit 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 t�es 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
TRANSIEN'i'OCCUPANG'I': For purposes of the limitations of Motel or Hotet 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 maurtain a principal place ofresidence 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 suf(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 ins
by the Health Department prior to opening. Contact the Health Departmem to schedule the inspection tLree( )days
pnor to opening.PLEASE NOTE: People aze NOT allowed to sit m the pool azea 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 quartecly
thereafter.
POOL CLOSING: Every outdoor in ground swimming pool 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 Depaztment by filing the required
Temporary Food Service Applicarion 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 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 Board ofHealth.
OUTDOOR COOHING:
Outdoor coQking,preparariona_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. TT IS YOUR RESPONSIBILII'I'TO RETURN
THE COMPLETED RENEWAL APPLICATION(5)AND REQUIltED FEE(S)BY DECEMBER 15, 2009.
ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY REQUTRE A SITE PLAN.
DATE: �Z/�� I SIGNATURE: `/�j �
PRINT NAME&TITLE: I-I�evi wr �I3,Yew , d L�.n,,,�
09!25�09
� The Commo�nvea[d� ojMr�ssnchuset�s
Depai•[men!ojJndus(rial Accirlen[s
Ojfice of In ves�ign[ia�s
600 Wnsliineton Slreet
, Boslon, MA 02111
ivww innss.gov/din
Workers' Compensation Insurance Affidavit: General Businesses
Aoplicant Information Please Print Leaiblv
Business/OrganizationName: IIOMIh0�1 �ZZ;.
Address: �j������
City/State/Zip: �Yt� l�� 1 Phone #; S��- ���-`��2 �
Ar�e you an employer? Check the appropriate box: Business Type(required):
l.�v 1 am a employer with�_employees(full and/ 5. ❑ Retail
or part-time)." 6. ❑RestauranVBadEating Establishment
2.❑ 1 am a sole proprieror or partnership and have no 7, �Office and/or Sales(incl. real estate,auto,etcJ
employees working for me in any capaciry.
[No workers' comp. insurance required] 8. ❑Non-profit
3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment
their right of exemption per c. 152,§I(4),and we have �O.Q Manufacturing
no employees. [No workers' comp.insurance required]"
4.❑ We are a non-profit organization,staffed by volunteers, ��•�Health Care
with no employees. [No workers' comp. insurance req.] �Z•�Ower 2��- i✓
•Any applicent thet checks boa M I must�m fill out Ihe section below sho�ving Ihur workers compensation policy in(o(mation.
••If1he corporate offiars have ezempted themselvu,bu[ihe coryorerion hes olher employecs,a worf:ers'compensation policy is required and such on
organization sbould eheck boz NI. � � �
/nae a�r exrployer Ihul is proviAing ivorkers'cou�pensnliouF iusrrrance jor��ry eniployees. Belo�v is!de po(icy injornmfion.
InsuranceCompanyName: �6✓��/L +-�e�hah� /�u�n�/ �h<l.�nncL �-
InsurePsAddress: L2� A'YVtPS �0'-
Ciry/State/Zip: Pf��GWI � M/T d�/,�fo
Policy#or Self-ins. Lic. # �,l.j��7 9L'�.3 Z1�' Expiration Date: ��!{�
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to 51,500.00 and/or one-year imprisonment,as wefl as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day as�.ainst the violator. Be advised that a copy of this statement may be fonvarded to the Office of
lnvestigations of the DIA for insurance coverage verification.
/do hereby cer(' u �Aer lGe pnins nud pennlriu ojpe�jury d�nl Il�e injornialionpconided nbove is true and correc[
�ianature: ' �� � . Da[e•- �Z,��n9
Phone #: �/�-�f�' 7 7 Z�
Ojfcial nse on/y. Do no�ivri�e in Ihis nren,!o be co�uple/ed by cily or loivn o�cln/.
City or Town: Permit/License li
Issuing Authority(circle one):
1. Qoard of Wealth 2. 13uilding Department 3. City/1'o�vn Clerk 4:Licen3ine 6oard 5. Selectmen's Office
6. Other
Contact Person: Phone f!;
� www.inaSs.govPoia : . . .
12/3/2009 2:18 PM FROM: Risman Risman Insucance TO: +1 (508) 8�7�611 PAGE: 002 OF 003
ACORD�, CERTIFICATE OF LIABILITY INSURANCE iz�oizo 9
PRODUCER (7g1)396-2116 FAX (781)395-2300 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Risman Insurance Agency, Inc. ONLYANDCONFERSNORIGHTSUPONTHECERTIFICATE
HOLDER.THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
689 Fel l sway ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Medford, MA 02155
Michele Sarcia lNSURERSAFFORDINGCOVERAGE NAIC#
INSURED AM Pizza, Inc. iNsuaean� No�folk & Dedham Mutual Ins Co 23965
DBA: Danino's Pizza wsuaeRe: Arbella Protection Insurance C
384 Edgell Road wsuaeRc.
Framingham, MA 01701 wsuaeRo�
WSURER E.
$
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR hiE POLICY PERIOD INDICATED.NONJITHSTANDING
ANV REQUIREMEPfT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECTTO NhiICH THIS CERTIFICATE MAV BE ISSUED OR
MAV PERTAIN,THE INSURANCE AFFORDED BY iHE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL 7HE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAV HAVE BEEN REDUCED BV PAID CLAIMS.
INSR D' TypEOFINSURANCE POLICVNUMBER POLICVEFFECTNE POLICVE%PIRAl10N LIMRS
GENERALLIABILRV R0662751A 06/18/2009 �6�18�201� EACHOCCURRENCE $ 1 �00 0p
X COMMERCIAL GENERAL LIABILITY DAMAGE TO REMED $ SO�OO
i CLAIMS MHDE � OCNR � � � MED EXP(My one person� $ S�p�
q aERsorui a r�v iN�uar s 1 000 00
_. ... .... . _ . . ..._. .., . . ... . _. ._- . .cENERn�AGGREGAre $ 2,OOO�OO
GEMLAGGREGATELIMITPPPLIESP�R�. � � � � PRODUCTS-COMP/OPAGG $ Z�OOO�OO
POLICV jECT LOC . .�. �. ... . .
FIROMOBILELIABILT' 00984400004 06/18/2009 06/18/2010 COMBWEDSWGLELIMIT
� feeaoaaa�n $
rwr nuro � �� � � 1,000,00
ALL OWNEDAUTOS ' - ' ' ' �� BODILV INJURV
SCHEDULEDAlfr05 (Pa�pe�son� $
B X HIREDAIJrOS � BODILVINJURV
X NON-OWNED PAff05 . � IPer eccitleM� $
PROPERTY DANWGE $
. . .. . .. . .__ ._ . .._ _. _ . ......_ (PerdccitleM�
.__. __.. .__ __" _
GARAGELIABILRV� ". . .-.�.�. .. ... . ..-.�.. �. . . : .. AUTO.PNLV--EAACCIDEM $
PNY AllTO � . . . . . . .. .. . . . . . � OTHER THAN EA HCC $
. . . . . . . AUTOONLV�. AGG $
E%CESSNMBRELLALIABILRY _ . UOO213S 06/18/2009 06/18/2010� eo.cr+occuRaeNce a 2 000,00
X OCCUR .❑ CLAIMSDMDE � . - �. . ��_ AGGREGATE $
A . . s 2,000,00
DEDUQIBLE � � � 5
RETEMION � $ 8
WORKERSCOMPENSATIONANO ��� � WEO9GH32A DF1�18�2009 � 06��.5�2�1� W��TP'TI� �TM
EMPLOYERS'LIABILf1Y � � ELEACHACCIDEfJr $ SOO OO
A ANVPROPRIEfOR/PARTNER/EXECIJrIVE .
OFFlCER/MEMPEREHCWDE09 �. . � ' � E1.DISEASE-EAEMPLOVE $ SOO�OO
If yes,aascrl�e unaer . . . ..
SPEQALPROVISIONSbelow �:�� � -��� � � EL.DISEASE-POLiCYLIMIT $ SOO�OO
OTHER
DESLRIPTION OF OPERATONS I LOCAT10N5I VEHILLES I EXCLUSIONS PDDED BY ENOORSEMENT I SPECIAL PROVISIONS
. SHOULq ANY OFTHEqBOVE DESLRIBED POLIQES BE CANCELLED BEFORE hIE
� � E%PIRATIQN DAlE iHEREOF,iHE ISSUING INSURER WILL ENDEAVOR TO MNL
TOMRI Of YdTqUYFI -�AVS WRITTEN NOiiCE TO THE CERTIFICATE HOLDER NAMED TO iHE LEFf,
Board of Heal th BUT FAILURE TO MPIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILRY
1146 Route IS OF ANY KIND UPON THE INSURER,RS AGENTS OR REPRESENTATVES.
Yarnwuth� MA OZF)F)4 . AUTHORIZEDREPRESENTATNE . �� 0
�9u�
Michele Sarcia JS �
ACORD 25(2001/08) OOACORD CORPORATION 1988