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TOWN OF YARMOUTH BOARD OF A�:�H`� ; � . ���
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� APPLICATION FOR LICENSEIPEI�MI�� -��0� ` ���-��� '�`` �'"'
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�""� * =_. =������ TH DEP�• ;
Please complete form and attach a11 necessary do��tnen�s�`by Decembe 1 S t�8 �
Failure to do so will result in the return of your application packe . �� �
ESTABLISHMENT NAME: �"�� �TAX ID:
LOCATION ADDRESS: 3 L.�l�-i �S S�. TEL.#: � 6 • !�' �
MAILING ADDRESS: �i9�2 ,
OWNER NAME: �o '
CORPORATION NAME (ff PLICABLE): j `T �I G,L._C
MANAGER'S NAME: �c�S C71�r✓�i TEL.#: �`" • � - pp l
MAILING ADDRESS: t� `
POOL CERTIFICATIONS: '
The pool supervisor must be certified as a Pool Operator,as required by State IRw. Please list the designated '
Pool_Operator(s) and_attacll a copy of tl�c�rtification to tlais form. ____,_____ ___ __._�__� _ ;
1. 2.
Pool operators must list a minimum of two employees cun ently 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 Health Department wilt 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 Seivice Establishments, 105 CMR 590.D00.
Please attach copies of certification to tlus application. The Health Department will not use past years'records.
You must provide new copies and maintain a file at your establishment.
1. � � 2. �ob � �o ;
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PERSON IN CHARGE` f
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Each food establislunent must have at least one Person In Charge (PIC) on ite du ` g hours of operation, i
1.��e,�� ���.� l � ` ��� �
2. c �v�
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HEIMLICH CERTIFICATIONS: �
All food seivice 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 trauied in anti-choking procedures below and
attach copies of einployee certifications to this foi�n. The Health Department will not use pRst years' records. �
You must provide new copies and maintain a �le at vour place of business. �
-� 1. l'h��'LK.. �cJ4��eD2 2. �C i
3- 4.
RESTAURANT SEATING: TOTAL # �� ;
OFFICE USE ONLY
LODGI\G:
LICENSE REQUIRED FEE PER1bIIT?? LICENSE REQUIRED FEE PER�v1IT# LICENSE REQUIItED FEE PER1b1IT# �
B&B S55 CABIN S�� VIOTEL S5� '
____INN S55 _ _CAMP S55 _S�'4`T,ViMINGPpOL SSOe�.
_LODGE S�5 �TRAILERPARK S105 ��VHIRLPOOL S80ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT z LICENSE REQUIRED FEE PER��IT� LICENSE REQUIRED FEE PERMIT#
_0-100 SEATS S85 _CONTINENTAL S35 NON-PROFIT S30 '
J >100 SEATS S160 "O � I COMMON VIC. S60 ��[�� W�IOLESALE S80
RETAIL SERVICE: —RESID.KI?CHEN S80 '
�
LICENSE REQUIRED FEE PERIVII7# LICENSE REQUIRED FEE PERYIIr# LICENSE REQLTIRED FEE PER'�IIT�
,<50 sq.ft. S50 _>25,OQ0 sq.ft. S225 _VENDING-FOOD S2� �
_<25,000 sq.ft. S80 _FROZEN DESSERT S40 _TOBACCO S» k
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\�VIE CHA\GE: S15 AMOUNT DUE _ $ 2 2-0.oo '
*****PLEASE TtiR\OVER A\D COviPLETE OTHER SIDE OF FOR�Z***** ������� �
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ADML�TISTRATION
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. 1'HE 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 taxes and liens must be paid p or to renewal or issuance of your permits. PLEASE CHECK ,�
APPROPRIATELY IF PAID:,
YES NO
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1VIOTELS AND O�'HER LODGING�:STABi,ISHMENTS
TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shaU 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 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, sha11 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 prior to opening. Contact the Health De�artment to schedule the inspection three(3)days
pnor to openuig.PLEASE NOTE:People are NOT allowed to srt 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 standard plate count
by a State certified lab, and submitted to the Health Department three (3} days prior to opening, and quarterly
thereafter.
PO(�L CI.OS�NG:Every outdoor in ground swimming poal must be drained or covered within seven(7}days of �
closing.
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FOOD SERVICE `
SEASONAL FOOD SERVICE OPENING: �
All food service establishments must be ins�ected 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 obtamed at the
Health Department,or from the Town's website at www.yarmouth.ma.us under Health Departmer�t,Downloadable
Forms. l
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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 prnhibited.
;
NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILTI'Y TO RETLJRN
THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 15, 2010.
ALL RENOVATIONS TO ANY FOOD ESTABLIS�-IMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT, ETC.), MUST BE REPORTED TO AND APP OARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS M IT
DATE: �I��S`�� SIGNAT
PRINT NAME&TITLE: 6s t �„ �/LE�S _
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The Coinmonwealth ofMassachusetts '
Departn�ent of Indastrial Accidents �
NMfeiNi��fM� .
600 Washington Street, 7`"'Floor . `
Boston,Mas� 02111 �
Workers'Compen�atioe Ironr9nce Atiidavit;Baildiog/Plambieg/Ekctrieal CoatractoTs ,
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work site location f full addnssl_
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❑ I am a le proprietor and have no one wodcing in any capaci , �' ❑N�'Constnx,-tion�]Remodel
h'• ❑Building Addition �
am an employer�oviding workecs'compensadon for my employees wodciag on t(�is job.
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_ _ � WO�1l�RS COp3P8N6ATT�N AND ENlPLOYER.B LI]►BILIT_Y_INBLtRF�tCE CERTIPICATE—: --- __-_-_ ,
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. - � + �l �" IIJFORMATION PAGE . - RENEGTAL AGR£�MElJ? � •L't T .
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� Producer: AgeaL# 548 I
' � Nl� Retai�� Merchante WC Group Inc. � Thomas P 7Ceefe insuranee Agency, I . �
, t0 Hxitfsh �e'rican 81vd, = . � 51 Weec--Cencrai 5creet PO Box K
Latham, NY 2�21U f . . Franklin, MA �2038 . �
(Carrier Ccd�:' 34355l. ! . Certificate. #: �G24005030285110 . � "
: � . , .. •. ' . � � ' � � Prior Certificata #: 024005030285.109 . .
Z. The. Employer: ArBec � • . . . � ' ' �
South 8fde Tavern, LLC _ . � .
Maili�g Ad+�resa: 23V 4�hitts path � � ' ��� • I
South Yarn�ouch, MA 0266g . I
. _ , —. • __
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: � Fein: •
otlier Workplaceg not shawn above: Type ot 8uainess: Gimited Liabiltty Co . ,
' S6E 3CHEDULE .OF OPERATION� . Riak ID:
2. The certtficate peziod is. fra�s 12:01 a.m. on 110].{2010 to 12:01 a.m. aa . .
- . 1/o1I2021 at. che ineured�s mailing addreae. � � -
3. . A. Worker� Compensation Ceneicage: Part Ane oP the cercitiaate applies to the �
„ Worke�r,e Compeneatioa Law+ of the stateg 1lsted here: � • `
;Mj�. . �
8. Employers Liability Cover�ge: Part Twa af the ccrtificate applies. to wark in . �
each :etate listed fn Item 3.A. The limits of our liability under Part Two are: E
. ' , , ',i . . . . , I
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Bodily xnjury byAccideat • $ So0,o00. esch acciden� i
�Sbdily. Tnjury h�+ Disease $ 5b0,0�0 _. certiSicate limit I
Bodily. Injury by niBeese $ 500L,OOQ each employee , �
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C. o�hor States Coverage: . - . i
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D. Thie certl�lcate includes these endazsements ar�d scheduleg: . • �
• WCQOOOOOA,L04/92) W OQ4�08(OS/84) WCG004Q5�(OB 95 WCQ9_0__41_4(_07_�9G) � WC00042aA(09.�b8) �
WG200301tQ4/84}' WC200302(05/96)�, .WC2003038�09/49) WC2a0405(06/6I) WCZ06601(06J92) �
. � ;
I
4. The co�tributiaa for thf.s cert3fiaate will be determined by, our Manuale of Rules, �
' C2ae8ificatio�as, Rates and Rattng F2ans. Al2 in�ormation required below ie subjEc� -
to verificatioa and change by audit. .
� Classifications Code Contribution 8asi� Rate par E�timated .
_ _ _— -Nc- ' Totai Hatimace8 _ $100 of_ _-- -- -?�ual _ __
�_. — _ — _
Annual Remuneration RemuneYatioa CanCribution
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3EE 3CHED[2LE OB- OPBRATIONS •
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Rocal 8etimated Annual CcnCribution 23,335.00 ,�. ajC9� D,X/j'� �/3�$Q�
Minimum CnnCribution $ 268.00 E�enee Conetant $ .00
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WC.00 00 Oi A� � Iseue ]�ate: 1/11/2Q10. Counteraigried by - -
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SCNEDULE .OF OPERATION3 POR: ' FAG�: 1 � ,
� ���� ' . � . �' .� � Certi�icate� #: 014005030285.11� � ' .
__ Sauth Side Tavern,: LLC < . . � __ _ _ _ �ein:_ • __
23V Whites Path . � � � ; , �
South Yarmouth, MA 02664 ,
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OTHER WORKPLACES: . � I
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Ardeo . ! � � � . �
South 5ide Tavern, LI�C � . � . .
� Kings Way . . . ;
81 �:Kings Circuit , . .
� � Xarmauthport, MA 02675 �' . .
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� .�. �SCHEDUL� OF OPERATIONS FdR:Y . . . � . . PAGE: 2 , �
. ***''.* CFRTIFIC�ITE INFORMATION FOR MA *��,•• � �. , ' ' i
1�deo ' — .- � Certificate #: �14005030285110 . � � ,
South 5ide Tav�rzi, LI,C � Feiz�: � � �
23V Wh�tes Path . . '
South YarmQuth, MA Oa'664 , � ,
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Coc'Ie Clasafficatibn �. . payroll Rate : Contributian� �. �� .
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8810 CT�ERICAr, O�'FICE EMP7A'YEES NOC 49,400,. 00 .12 59.00 ,
9079 RESTAURANT NOC ; 8B2,9Z1. �0 1. 10 ' 9,707.00 � .
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Manual Cantribution ' 9,766.OQ � !
Rate Deviation 17,00� . 1,660.00 !
Incxeased Emplayers Liability. Limits 1.00O�C 81.00 � � ;
Experience Modi.fication - Listed belaw 10,479.00 �
Standard Contribution 10,479.Oq ,. �
Valume piecount _
AFAP Charge 1.2500 _ . 2,620.00 '
. Norc�al Contribution ' �
13,055.00�
Expense Corietant . . �
; Foreign_Terrarism ` -_ _ ; ' _ �
� ` Aninual Contribt�tion � 280.00 .
13,335.00 . . �
DIA A�seasment (00930). �2.QOOO�r / 2.0000� 253.00 � �
. ' � , . �
E:cperience Modifiers ' �
1.28QD 1�O1f2O10 . • �
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